1 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Assisting with the Primary Physical Examination Chapter 32

2 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Learning Objectives  Define, spell, and pronounce the terms listed in the vocabulary.  Apply critical thinking skills in performing patient assessment and care.  Describe the structural development of the human body.  Differentiate among the functions of the 11 body systems and the major organs and structures in each.  Outline the medical assistant’s role in preparing for the physical examination.

3 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Learning Objectives  Summarize the instruments and equipment typically used by the physician during a physical examination.  Describe the six methods of examination, and give an example for each.  Outline the basic principles of properly gowning and draping a patient for examination.  Compare and contrast the various positions that may be used during an examination, and identify the purpose of each.  Position and drape a patient in six different examining positions while remaining mindful of patient privacy and comfort.

4 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Learning Objectives  Demonstrate proper body mechanics in transferring a patient from a chair to the examination table and back.  Outline the sequence of a routine physical examination.  Prepare for and assist in the physical examination of a patient, correctly completing each step of the procedure in the proper sequence.  Summarize the role of the medical assistant in the physical examination process.  Determine the role of patient education during the physical examination.  Discuss the legal and ethical implications of the physical examination.

5 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Anatomy and Physiology  Anatomy is the study of how the body is shaped and structured. – structural development – levels of organization – relationships among microscopic parts – the interrelationship of structure and function  Physiology is the study of body functions.

6 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Structural Development  Cells  Intracellular  Intercellular  Tissues – cells of similar structure and function  Epithelial  Connective  Muscle  Nervous  Organs – two or more types of tissues; may have more than one function in more than one system

7 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Systems  A body system is composed of several organs and their associated structures, which work together to perform a specific function.  Of 11 systems in the human body, each system has specific units, and each performs specific functions.  Refer to Table 32-1 for the structures that make up the body systems and their functions.

8 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Primary Care Physician  The primary care physician (PCP) treats patients of all ages for a broad range of diseases and complaints.  A PCP is qualified to provide continuing healthcare services for the entire family, from birth to old age.  The PCP evaluates a patient’s total healthcare needs, provides personal medical care within one or more fields of medicine, and refers the patient to a specialist when an advanced or serious condition warrants additional expertise.

9 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Physical Examination  The purpose of a physical examination is to determine the overall state of well-being of the patient.  Frequently, laboratory and other diagnostic tests are ordered to supplement the physician’s initial diagnosis.

10 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Preparing for the Physical Examination  The medical assistant’s duties include:  preparing and maintaining the examination room and equipment  preparing the patient  assisting the physician during the physical examination

11 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Room Preparation: Procedure 32-1  Check the area at the beginning of each day and between patients to make sure that it is completely stocked with equipment and supplies.  Check expiration dates on all packages and supplies.  Room should be private, well lit, and at a comfortable temperature.  Clean and disinfect the area daily and between patients.  Arrange drapes, gowns, and any other patient supplies before the patient enters the room.  Prepare instruments and equipment needed for examination, and arrange these items for easy access before the physician enters.  Room should contain all required materials for standard precautions.

12 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Preparation for the Physical Examination

13 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient Preparation  Make sure the medical record is complete.  Gather insurance information.  Obtain specimens if preordered by physician.  Measure and record height, weight, BMI, and vital signs.  Conduct initial investigation into reason for the visit and explain the examination procedure.  Have the patient empty the bladder before the examination.  Gown and drape patient as needed.  Assist patient into and out of examination positions as needed.  Throughout the procedure explain what is happening, answer questions, and consistently maintain patient privacy and confidentiality.  Document patient data in the medical record.

14 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Assisting the Physician  Hand instruments, equipment, supplies as requested.  Provide appropriate light, adjusting as needed.  Position and drape the patient.  Collect and label specimens.  Perform diagnostic procedures as ordered.  Schedule postexamination diagnostic procedures.

15 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Supplies and Instruments Needed for the Physical Examination  Instruments typically are used during the physical examination to inspect, palpate, and auscultate parts of the body.  All equipment must be in good working order, properly disinfected, and readily available.

16 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Supplies and Instruments Needed for the Physical Examination From Bonewit-West K: Clinical procedures for medical assistants, ed 6, Philadelphia, 2004, Saunders.

17 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Ophthalmoscope  Ophthalmoscope: Instrument used to inspect the inner structures of the eye.  The stainless-steel handle contains batteries, onto which a head is attached, equipped with a light and magnifying lenses and an opening through which the eye is viewed.

18 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Supplies and Instruments  Tongue depressor: Flat, wooden blade used to hold down the tongue when examining the throat.  Reflex hammer: Sometimes referred to as a percussion hammer, this has a hard rubber head used to test neurological reflexes of the knee and elbow by striking the tendons.

19 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Percussion Hammer

20 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Otoscope  Otoscope: Instrument used to examine the external auditory canal and tympanic membrane.  The stainless steel handle containing batteries, onto which a head is fastened.  The head contains a light focused through a magnifying lens and a disposable ear speculum.

21 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Nasal Speculum  Nasal speculum: Stainless-steel instrument used to inspect the lining of the nose, nasal membranes, and internal septum.  Spreads apart to dilate the nostrils.

22 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Nasal Speculum

23 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Tuning Forks  The tuning fork is used to check a patient's auditory acuity and to test bone vibration.  Consists of a handle and two prongs that produce a humming sound when the physician strikes the prongs.

24 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Tuning Forks

25 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Measuring Devices  Tape measure: Flexible ribbon ruler usually printed in inches and feet on one side and in centimeters and meters on the opposite side.  Used to assess infant length and head circumference, patient wound size, and so on.

26 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Stethoscope  Stethoscope: Listening device used to auscultate certain areas of the body, particularly the heart and lungs.  Two earpieces are connected to flexible rubber or vinyl tubing. At the distal end of the tubing is a diaphragm or bell (many have both) that enables the physician to hear internal body sounds.

27 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Stethoscope Modified from Seidel HM: Mosby’s guide to physical examination, ed 6, St Louis, 2006, Mosby.

28 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Disposable Gloves  Gloves: Disposable examination gloves protect the physician and the patient from microorganisms.  Under Standard Precautions, gloves are to be worn whenever there is a possibility of contact with body fluids, broken skin or wounds, or contaminated items.

29 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Methods of Examination  Inspection is use of observation to detect significant physical features or objective data. Focus on the patient's general appearance (the general state of health, including posture, mannerisms, grooming) then on more detailed observations, including body contour, gait, symmetry, visible injuries and deformities, tremors, rashes, and color changes.

30 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Palpation  Palpation is the use of touch to determine the body’s condition or that of an underlying organ. Palpation may include touching the skin or the more firm feeling of the abdomen for underlying masses and involves a wide range of perceptions: temperature, vibrations, consistency, form, size, rigidity, elasticity, moisture, texture, position, and contour.

31 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Palpation From Zokus SM: Mosby’s clinical skills for medical assistants, ed 4, St Louis, 2001, Mosby.

32 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Percussion  Percussion involves tapping or striking the body, usually with the fingers or a small hammer, to elicit sounds or vibratory sensations, to determine the position, size, and density of an underlying organ or cavity.

33 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Percussion From Zokus SM: Mosby’s clinical skills for medical assistants, ed 4, St Louis, 2001, Mosby.

34 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Auscultation  Auscultation uses a stethoscope to listen to sounds arising from the body and distinguish between normal and abnormal sounds.

35 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Auscultation From Zokus SM: Mosby’s clinical skills for medical assistants, ed 4, St Louis, 2001, Mosby.

36 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Measurements  Mensuration is the process of measuring.  Measurements are recorded of the patient’s height and weight, the length and diameter of an extremity, the extent of flexion or extension of an extremity, the uterus during pregnancy, the size and depth of a wound, or the pressure of a grip.

37 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Manipulation  Manipulation is assisted passive movement of a joint to determine its range of extension or flexion.

38 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Positioning and Draping for Physical Examinations  The medical assistant instructs the patient about, and assists the patient into, these positions with as much ease and modesty as possible and helps the patient to maintain the position during the examination with as little discomfort as possible.  Draping with an examination sheet protects the patient from embarrassment and keeps the patient warm.  Refer to Procedures 32-2 to 32-7.

39 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Fowler’s Position

40 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Semi-Fowler’s Position

41 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Supine Position

42 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Dorsal Recumbent Position

43 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Lithotomy Position

44 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sims’ Position

45 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Prone Position

46 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Knee-Chest Position

47 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Trendelenburg Position

48 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Principles of Body Mechanics  Maintain good posture whether sitting or standing.  Avoid twisting or turning; move feet to face the object.  Do not cross legs.  Keep back of knees away from chair edge when sitting.  Do not reach for heavy items.  To lift, bend knees, keep back straight, and bring item as close as possible to the body while lifting. Reverse these steps when lowering a heavy item.  Push rather than pull heavy items.

49 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Principles of Body Mechanics

50 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Transferring a Patient  Good body mechanics principles include maintaining balanced posture, bending knees while keeping the back straight, and using leg muscles to help lift.  Move the wheelchair close to the examination table, lock wheels, and lift the foot rests.  Support patient close to your body on the patient's strong side.  Place step stool in front of the chair next to the side of the examination table, grasp the patient, anchor step stool with one foot, and help the patient step up onto the stool with the strong leg.  Pivot the patient into a sitting position on the table.

51 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Transferring a Patient

52 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Examination Sequence  Presenting appearance  Nutrition and stature  Speech  Breath odors  Skin  Head  Eyes, ears, nose, and mouth

53 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Examination Sequence  Neck  Reflexes  Chest  Abdomen  Breast and testicular examinations  Rectum

54 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. Patient Education  The physical examination process is an excellent time for the medical assistant to assess the need for patient education. The MA should consider:  The information that the patient needs to know  How to convey the information so that the patient will understand  How the patient will use the information once he or she has it

55 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. HIPAA Applications  Prevent others from overhearing patient conversations.  Keep privacy glass at front desk closed; turn your back away from the waiting room when talking on the phone; avoid any conversation that might be overheard.  Place medical records on the examination room door with identifying information facing the door or if using electronic medical records close patient files and lock computers when not in use.  Keep physician’s schedule away from patient areas.  Must completely block previous patient names if sign-in sheets are used.