Define and turn in (chapter 5): Audiometer Auscultation Clinical diagnosis Inspection Ophthalmoscope Otoscope Palpation Percussion Speculum Symptom

5 5 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 pieces of equipment commonly used during a physical examination. Describe the 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 supplies safety Observing confidentiality

Cleaning the Examination Room used gowns in the laundry receptacle Discard used examination table paper and drape Dispose of pillow cover Clean the exam table, and recover with new paper

Cleaning the Examination Room (cont) new cover on pillow Dispose of equipment Clean and disinfect equipment Disinfect all surfaces

Cleaning the Examination Room (cont) Close all biohazard containers remove if full Ensure room is clean and odor free

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

Preparing the Examination Room Ready instruments and equipment equipment is not within reach of the patient exam light proper body mechanics

Critical Thinking Question 1. As a medical assistant, how can you help ensure patient comfort and privacy while in the examination room?

Ensuring Patient Comfort and Privacy thermostat around 71 to 73 degrees F Provide blankets and sheets Explain clearly about exam gown Inform patients where to place clothes

Ensuring Patient Comfort and Privacy (cont) Leave the room when patients are undressing unless assistance is required Knock and receive permission when reentering

Purpose of the Patient History assess general health status Helps determine a diagnosis

Fill out Patient History form activity Accuracy counts Spelling counts Neatness counts WorkBook Page 17-19

Film Clip Saunders DVD Assisting w/physical exams

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

The Chief Complaint presenting problem consists of one or two symptoms documented using the patient’s own words

The Chief Complaint (cont) Subjective symptoms What the patient tells you Not directly observed Objective symptoms Signs you can see, hear, feel, smell Factual, measurable, observable

Do You Remember? Objective vs. Subjective 1. Mr. Brown states that he has a toothache 2. Mrs. William’s urine appears to have blood in it. 3. Mrs. Smith’s respirations are very rapid 4. Mr. Lee states that he is nauseated after eating. 5. Mrs. Bender’s dressing is dry & intact.

Do You Remember? Objective vs. Subjective 6. Mrs. Campbell complains of dizziness after each respiratory treatment 7. Mrs. Stark is jaundiced today. 8. Mr. Runge has excessive bleeding every time he has a tooth extracted 9. Ms. Hime is perspiring, and her skin is cold & clammy. 10. Mr. Rue is experiencing some wheezing with each breath.

Steps to Interviewing a Patient and Preparing for an Exam Id the patient, greet, and id yourself Explain procedure Provide privacy Ask the patient to fill out form

Steps to Documenting a Chief Complaint Maintain eye contact and actively listen Gather information What makes the problem better or worse? start? hurt? rate pain on a scale 0-10

Steps to Interviewing a Patient and Preparing for an Exam (cont) Review ask questions Ask for the CC Chart the CC

Steps to Interviewing a Patient and Preparing for an Exam (cont) observation skills Gather other information PH, FH, and SH Allergies – No allergies NKDA NKA

Steps to Interviewing a Patient and Preparing for an Exam (cont) Correct any errors drawing one line through the error and date and initial them – Record the correct information 1/13/12 KG BP 180/ K. Gers MA

Steps to Interviewing a Patient and Preparing for an Exam (cont) urine specimen if required or ask the patient to empty the bladder Explain about undressing and gown opening

Steps to Interviewing a Patient and Preparing for an Exam (cont) Explain what procedures will follow Place the patient history in the designated place

Obtaining the Past Medical History all past diseases and medical problems Dates of major illnesses Hospitalizations surgeries, current medications including OTC meds

Information Included on a Complete Past Medical History

The Family Medical History Health problems of blood relatives current health, major health problems, and cause of death, as well as age at death Family medical histories focus on diseases that may be inherited

Information Contained on the Personal History Lifestyle patterns Patient’s occupation Marital status Sexual preferences diet choices exercise Sleep habits

Exam Room Equipment and Supplies Read List on page 176 (table 5-1) Be prepared to answer questions!

Lets go to the lab: Gather supplies for an exam

Inspection of Physical Examination visually examining the exterior surface of the body

Palpation of Physical Examination using the hands to feel the skin and accessible underlying organs

Palpation Method of Physical Examination

Percussion of Physical Examination Use of the fingertips to tap the body to gain information about underlying body parts

Percussion Method of Physical Examination

Auscultation Method of Physical Examination listen to sounds that are found within the body A stethoscope is used to amplify body sounds

Auscultation Method of Physical Examination

Mensuration Method of Physical Examination Use of special tools to measure the body or specific parts Weight scale A tape measure A goniometer Calipers

goniometer

Calipers

Let’s clean up 1/10 bleach solution Gloves towels

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