36 Assisting with Physical Examinations Lesson 1: Preparing the Exam Room and Examination Methods – Part 1

Lesson Objectives Upon completion of this lesson, students should be able to … Define and spell the terms to learn for this chapter. Recognize six pieces of equipment commonly used during a physical examination. Describe the six examination methods used by physicians. Discuss the steps to take in preparing a patient for a physical examination.

Medical Assistant’s Role in the Patient Physical Exam Interviewing the patient Documenting patient information Preparing the exam room prior to the patient’s visit Positioning and draping the patient Assisting the physician during the exam Cleaning the room after the visit Instrument care

Medical Assistant’s Role in the Patient Physical Exam Maintaining supplies Ensuring safety for patients and co-workers Observing confidentiality and patient privacy rules

Cleaning the Examination Room Place used gown in the laundry receptacle or waste container Discard used examination table paper and drape Dispose of pillow cover Clean the exam table, allow to dry, and recover with clean, new paper

Cleaning the Examination Room Place new cover on pillow Dispose of disposable equipment Clean and disinfect used equipment Disinfect all surfaces with cleanser Close all biohazard containers, seal, and remove if full Ensure room is clean and clutter and odor free

Features of the Examination Room Examination table Pillow Footstool Supply cupboard Trash can Hazardous waste and sharps containers Rolling stool Chair

Examination Room Safety Issues Width of doorways and hallways Placement of door handles Grab bars Handrails Spatial accommodations for patients in wheelchairs Floor surfaces Presence of clutter Condition of furniture Location of electrical cords and cables

Preparing the Examination Room Ready instruments and equipment for the physician Ensure equipment is not within reach of the patient Position exam light to provide correct illumination for the physician Ensure exam light is positioned so it does not tip over Use proper body mechanics when assisting with patient care

Critical Thinking Question As a medical assistant, how can you help ensure patient comfort and privacy while in the examination room?

Ensuring Patient Comfort and Privacy Keep thermostat around 71 to 73 degrees F Provide blankets and sheets as needed to keep patients warm Ensure examination room is well-ventilated to decrease odors Explain clearly how to put on examination gown Inform patients where to place clothes

Ensuring Patient Comfort and Privacy Leave the room when patients are disrobing unless assistance is required Knock and receive permission when reentering the examination room

Information Provided on the Patient Registration Form Demographic information Name and address Sex, age, and DOB Education and occupation Social security number Insurance information Racial or ethnic background Marital status Number of children and nearest relative HIPAA form Any financial agreements your facility needs for payment

Purpose of the Patient History Assists the physician in assessing the patient’s general health status Helps determine a diagnosis of the patient’s present problem or condition

Purpose of the Patient History

Contents of the Medical History Chief complaint Present illness Past medical history Family history Social or personal history Review of systems or systems assessment

The Chief Complaint Referred to as the presenting problem Usually consists of one or two symptoms Symptoms are either subjective or objective Subjective symptoms are felt by the patient but not apparent to an observer, such as vertigo or pain, and cannot be measured Objective symptoms are felt by the patient and are apparent to observers, such as a rash or fever, and can be measured Symptoms are usually documented using the patient’s own words

Steps to Interviewing a Patient and Preparing for an Exam Identify the patient, greet the patient warmly, and identify yourself Explain what you are going to do and what you want the patient to do and why Provide a private area to conduct the interview Ask the patient to fill in the patient data portion of the form consisting of demographic information

Steps to Interviewing a Patient and Preparing for an Exam Review the portion of the form completed by the patient and ask for any additional information necessary Ask for the reason why the patient has come to the physician’s office that day – the CC Record the CC in the patient’s own words as appropriate Ask the patient other open-ended questions to gather more information about the CC to record under PI

Steps to Interviewing a Patient and Preparing for an Exam Use observation skills during interview Gather other information on PH, FH, and SH and document in the patient’s record Ask the patient about allergies – Record in red ink as required by office policy (usually on the first page of the medical history) – If the patient states they do not have any allergies, record in red letters according to the office policy: NKA (no known allergies)

Steps to Interviewing a Patient and Preparing for an Exam Note any other observations or information you feel are relevant (such as illness at home or loss of a loved one) Record all information using correct charting guidelines Correct any errors drawing one line through the error and date and initial them – Record the correct information

Steps to Interviewing a Patient and Preparing for an Exam Ask the patient to provide a urine specimen if required, or ask the patient to empty the bladder Explain what clothes you wish the patient to remove; where you want the opening of the exam gown to be, and where you want the patient to sit and wait Explain what procedures will follow (physician will be in shortly, etc.) Place the patient history in the designated place for the physician to obtain

The Present Illness (PI) Provides a more complete, expansive description of the chief complaint Must contain a detailed description of the symptom(s), including the onset, duration, and intensity of each Each symptom should be documented as to its relationship to the chief complaint

Obtaining the Past Medical History Includes all diseases and medical problems the patient has experienced in the past Dates of major illnesses, hospitalizations, surgeries, and current medications including OTC, are noted whenever possible

Information Included on a Complete Past Medical History Childhood diseases Major illnesses Injuries Hospitalizations Surgeries Allergies Immunizations Current and past medications Last examination

The Family Medical History A record of the health problems of the patient’s blood relatives Information on blood relatives should include their current health, major health problems, and cause of death, as well as age at which the individual died Family medical histories focus on diseases that may be inherited such as diabetes mellitus, seizures, heart disease, hypertension, and some types of cancer

Information Contained on the Personal History Lifestyle patterns that could affect the health status of the patient, for example smoking, drinking, and using recreational drugs Patient’s occupation Marital status Sexual preferences Patient’s diet choices Frequency of exercise Sleep habits

Steps to Documenting a Chief Complaint Gather supplies including the medical record with problem list or progress note form Review briefly the patient’s medical history form before greeting the patient Greet and identify the patient and escort the patient into examination room Ask open-ended questions to gather information about why the patient is being seen today

Steps to Documenting a Chief Complaint Maintain eye contact and actively listen to patient responses Gather information about the PI by asking questions such as: What makes the problem better or worse? When did it start? Where does it hurt? Ask the patient to rate pain on a scale 0-10

Steps to Documenting a Chief Complaint Document CC and PI correctly on the correct form in the patient’s own words where necessary Thank the patient and explain that the physician will enter shortly to examine him or her Make sure the patient is comfortable before leaving the room

Exam Room Equipment and Supplies Flashlight or penlight Laryngeal or dental mirror Nasal speculum Opthlamoscope Otoscope Percussion hammer Stethoscope Sphygmomanometer Vaginal speculum Tape measure

Supplies Necessary for Exams Tuning fork Cotton applicators Disposable pads Gloves Lubricant Tongue depressor Various dressings and bandages Syringes and needles Alcohol pads

Inspection Method of Physical Examination Done by visually examining the exterior surface of the body Some interior portions of the body, including the throat, eyes, ears, vaginal wall, cervix, and rectum may be inspected using special instruments Notes are made of any unusual color, size, shape, position, or symmetry of the areas being inspected

Palpation Method of Physical Examination Performed by using the hands to feel the skin and accessible underlying organs Other areas examined by palpation include the axilla (armpits), neck, and chest Used to determine any unusual tenderness, size, shape, and texture Oftentimes, abnormalities and masses in the abdomen can be discovered through palpation

Palpation Method of Physical Examination

Percussion Method of Physical Examination Refers to use of the fingertips to tap the body lightly but sharply to gain information about the position and size of the underlying body parts To do this, two fingers of one hand are placed on the patient’s skin and then struck with the index and middle finger of the other hand

Percussion Method of Physical Examination The physician uses his or her fingers to percuss the chest wall and abdomen by gentle thumping or tapping, which produces a standard sound or vibrations An alteration of this sound or vibration aids in determining the presence of fluid or pus in a cavity

Percussion Method of Physical Examination

Auscultation Method of Physical Examination Means to listen to sounds that are found within the body Sounds made by the heart, lungs, stomach, and bowel are assessed for strength, presence or absence, and rhythm These sounds must be differentiated from normal body sounds by the physician

Auscultation Method of Physical Examination These sounds can be heard by using the auscultation method of examination A stethoscope is usually used to amplify body sounds; however, auscultation can also be performed by placing the ear directly over the body surface

Auscultation Method of Physical Examination

Mensuration Method of Physical Examination Use of special tools to measure the body or specific parts To determine a patient’s weight, a scale is used A tape measure would be used to determine a patient’s height, to measure an infant’s head and chest circumference and the abdomen, the diameter of a limb, the length of a limb, or the length and width of a wound

Mensuration Method of Physical Examination A goniometer is used to measure range of motion of a joint Calipers are used to determine the amount of body fat

Mensuration Method of Physical Examination

Manipulation Method of Physical Examination Passively assessing the range of motion of a joint When a physician is performing this examination method, he or she may palpate the joint for abnormalities and warmth Neurologists and orthopedists may use this method to evaluate patients who want to return to work after accidents or illness, or for insurance company’s records

The Adult Examination Done as part of each visit Length, extent and type determined by reason for the visit Purpose is to assess the body and determine diagnosis Often includes laboratory and diagnostic tests

Questions? 47