1. Assisting with the Physical
Chapter 20:
Assisting with the Physical
Examination

2. Learning Outcomes Cognitive Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
1. Spell and define the key terms
2. Identify and state the use of the basic and specialized instruments and supplies used in the physical examination
3. Describe the four methods used to examine the patient
4. State your responsibilities before, during, and after the physical examination
5. List the basic sequence of the physical examination
6. Describe the normal function of each body system

3. Learning Outcomes (cont'd.)
Psychomotor Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
1. Assist with the adult physical examination (Procedure 20-1)
2. Assist provider with a patient exam
3. Coach patients appropriately considering cultural diversity, developmental life stages, and communication barriers
4. Document accurately in the patient record

4. Learning Outcomes (cont'd.)
Affective Domain
Note: AAMA/CAAHEP 2015 Standards are italicized.
1. Incorporate critical thinking skills in performing patient assessment
2. Show awareness of a patient’s concerns related to procedure being performed
3. Explain to a patient the rationale for performance of a procedure
4. Demonstrate empathy, active listening, and nonverbal communication
5. Demonstrate respect for individual diversity, incorporating awareness of one’s own biases in areas including gender, race, religion, age, and economic status
6. Protect the integrity of the medical record

5. Learning Outcomes (cont'd.)
ABHES Competencies
1. Prepare and maintain examination and treatment area
2. Prepare patient for examinations and treatments
3. Assist physician with routine and specialty examinations and treatments

6. Introduction
New patients usually receive a complete physical examination, which gives the physician baseline information about the patient. This baseline information is valuable for future comparison and can aid the physician in diagnosis. Routine examinations are performed thereafter at regular intervals to help maintain the patient’s health and prevent disease.
The purpose of the complete physical examination is to assess the patient’s general state of health and detect signs and symptoms of disease.
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7. Introduction (cont’d.)
diagnosis: identification of a disease or condition by evaluating physical signs and symptoms, health history, and laboratory tests; a disease or condition identified in a person
clinical diagnosis: record containing a diagnosis based only on the patient’s clinical symptoms
differential diagnosis: a diagnosis made by comparing the
patient’s symptoms to two or more diseases that have similar symptoms
As a medical assistant, you are responsible for assisting with taking the medical history, preparing the patient for the examination, and assisting the physician during the examination so that a clinical or differential diagnosis can be made as accurately as possible.
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8. Basic Instruments and Supplies
Physician uses instruments and supplies, but medical assistant must be familiar
Basic:
Gloves
Applicators
Tongue depressors
Tape measure
Common supplies used in the adult physical examination: tape measure, gloves, tongue depressor, and cotton-tipped applicator.
Instruments used during the physical examination enable the examiner to see, hear, or feel areas of the body being assessed.
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9. Checkpoint Question
Jackie works in a general surgery physician office. Instruments and supplies in her office may be different from those found in a pediatric office. Why is there variation in the types of instruments and supplies used in each medical office?
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10. Checkpoint Answer
Although there are some basic instruments and supplies found in most medical offices, the exact equipment used from one office to the next may vary according to the preference and specialty of the physician.
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11. Basic Instruments and Supplies (cont’d.)
Percussion Hammer
Test neurologic reflexes at tendons (ankle, knee, wrist, elbow
Babinski reflex — sole of foot
A reflex hammer.
Babinski reflex: reflex (dorsiflexion of the great toe and extension and fanning of the other toes upon stroking the sole of the foot) exhibited normally by infants. This reflex
is abnormal in children and adults
The percussion hammer is used to test neurologic reflexes.
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12. Basic Instruments and Supplies (cont’d.)
Tuning Fork
Test hearing
Strike prongs against hand, place end against bony part of skull next to ear
A tuning fork.
The tuning fork is used to test hearing.
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13. Basic Instruments and Supplies (cont’d.)
Nasal Speculum
View inside of nose, membranes, septum
A nasal speculum.
speculum: instrument that enlarges and separates the opening of a cavity to expose its interior for examination
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14. Basic Instruments and Supplies (cont’d.)
Otoscope and Audioscope
Otoscope — examine ear canal, tympanic membrane
Audioscope — test hearing
tympanic membrane: thin, semitransparent membrane in the middle ear that transmits sound vibrations; the eardrum
The otoscope permits visualization of the ear canal and tympanic membrane.
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15. Basic Instruments and Supplies (cont’d.)
(A) A portable otoscope. (B) Wall-mounted examination instruments. From left: sphygmomanometer with cuff, ophthalmoscope, otoscope, and dispenser for disposable otoscope speculum covers.
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16. Basic Instruments and Supplies (cont’d.)
An audioscope.
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17. Basic Instruments and Supplies (cont’d.)
A portable ophthalmoscope.
Ophthalmoscope
Examine interior of eye
The ophthalmoscope is used to examine the interior structures of the eyes.
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18. Basic Instruments and Supplies (cont’d.)
Examination Light and Gooseneck Lamp
Improve visualization of body parts being examined
Gooseneck — flexible
An examination light.
You have the responsibility to make sure all examination lights are in proper working order and to direct the light toward the area of the body as indicated by the physician.
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19. Basic Instruments and Supplies (cont’d.)
Stethoscope
Hear body sounds: heart, lungs, intestines
Measure blood pressure
A stethoscope.
The stethoscope is used for listening to body sounds.
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20. Basic Instruments and Supplies (cont’d.)
Penlight or Flashlight
Better visualization of specific area
Eyes, nose, throat
A penlight.
A common flashlight may be used if a penlight is not available.
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21. Checkpoint Question
Dr. Rowe would like to check the hearing of a preoperative patient. Which instruments should Jackie make available for Dr. Rowe to test the ears and hearing?
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22. Checkpoint Answer
The tuning fork and audioscope are used to test hearing. The otoscope is used to assess the internal structures of the ear.
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23. Instruments and Supplies Used in Specialized Examinations
A head light.
Head Light or Mirror
Light attached to mirror and placed on head
Ear, nose, and throat physician
An ear, nose, and throat specialist (otorhinolaryngologist) may wear a headlight or head mirror during the examination of these structures.
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24. Instruments and Supplies Used in Specialized Examinations (cont’d.)
A laryngoscope handle and blades (straight and curved).
Laryngeal Mirror and Laryngoscope
Mirror — on long handle, allows view of threat and larynx
Laryngoscope — blade and small light allows view deeper into throat
The laryngeal mirror is a stainless steel instrument with a long, slender handle and a small, round mirror.
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25. Instruments and Supplies Used in Specialized Examinations (cont’d.)
Vaginal Speculum
Stainless steel or plastic
Allows examination of vagina and cervix
Allows sampling of cervical cells with Ayre spatula/cervical scraper for Pap smear
Allows sampling of cells with histobrush for Papanicolau (Pap) smear
Papanicolaou (Pap) test or smear: smear of tissue cells examined
for abnormalities including cancer, especially of the
cervix; named for George N. Papanicolaou, a physician, anatomist, and cytologist
To obtain the cells for a Pap smear, or to visually examine internal female
reproductive structures, the vaginal speculum is inserted into the vagina to expand the opening.
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26. Instruments and Supplies Used in Specialized Examinations (cont’d.)
Cotton-tipped applicator (left), Ayre spatula (center), and histobrush (right). Cotton-tipped applicators of this size are frequently used to remove excess vaginal secretions or to apply medications during the gynecologic examination.
Vaginal specula.
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27. Instruments and Supplies Used in Specialized Examinations (cont’d.)
Lubricant
Facilitates bimanual exam — insertion of gloved, lubricated fingers of one hand into vagina, other hand on abdomen
Rectal exam
lubricant: agent that reduces friction
bimanual: pertaining to the use of both hands; an examination performed with both hands
Lubricant is a water-soluble gel used to reduce friction and provide easy insertion of an instrument in the physical examination.
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28. Instruments and Supplies Used in Specialized Examinations (cont’d.)
The anoscope with the obturator.
Anoscope, Proctoscope, and Sigmoidoscope
All come with obturator — tip that allows instrument to be easily inserted
Anoscope — short stainless steel instrument to visualize anal canal
Proctoscope — longer, visualizes anus and rectum
obturator: smooth, rounded, removable inner portion of a hollow tube, such as an anoscope, that allows for easier insertion
The anoscope is a short stainless steel or plastic speculum that is inserted into the rectum to inspect the anal canal.
The proctoscope is another type of speculum that is used to visualize the rectum and the anus.
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29. Instruments and Supplies Used in Specialized Examinations (cont’d.)
A flexible sigmoidoscope.
Sigmoidoscope — long, flexible, visualizes rectum and sigmoid colon
A longer instrument used to visualize the rectum and the sigmoid colon is the sigmoidoscope.
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30. Checkpoint Question
What are the uses of the anoscope, proctoscope, and sigmoidoscope? How would Jackie explain the function of an obturator?
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31. Checkpoint Answer
The anoscope is the shortest and is used to inspect the anal canal. The proctoscope is longer than the anoscope and is used to visualize the rectum and the anus. The sigmoidoscope is the longest of the three and is used to inspect the rectum and sigmoid colon. The obturator is a smooth, rounded, removable inner portion of a hollow tube that allows for easier insertion
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32. Examination Techniques
inspection: visual examination
palpation: technique in which the examiner feels the texture,
size, consistency, and location of parts of the body with the hands
percussion: striking with the hands to evaluate the size, borders, consistency, and presence of fluid or air
auscultation: act of listening for sounds within the body, usually
with a stethoscope, such as to evaluate the heart, lungs, intestines, or fetal heart tones
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33. Examination Techniques (cont’d.)
Inspection
Visual examination of the body:
General appearance
Movement
Skin/membranes
Symmetry and asymmetry
Smells
symmetry: equality in size or shape or position of parts on
opposite sides of the body
asymmetry: lack or absence of symmetry; inequality of size
or shape on opposite sides of the body
Inspection is looking at areas of the body to observe physical features.
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34. Examination Techniques (cont’d.)
Palpation
Touching body parts with hands or fingers:
Pulse
Growths/swellings
Organ shape/size
Tenderness/pain
Temperature, moisture, texture, elasticity of skin
Bimanual — both hands
Digital — fingers
Manipulation — moving body parts to test range of motion (ROM)
manipulation: skillful use of the hands in diagnostic procedures
range of motion (ROM): range in degrees of angle through which a joint can be extended and flexed
Palpation is touching or moving body areas with the fingers or hands.
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35. Examination Techniques (cont’d.)
Percussion
Tapping of body with hand or instrument to produce sound:
Direct — tapping body with a finger
Indirect — place finger on body, then tap with finger of other hand to determine presence of air inside body
Percussion is tapping or striking the body with the hand or an instrument to produce sounds.
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36. Examination Techniques (cont’d.)
Auscultation
Listening to sounds of body
Stethoscope or direct with ear:
Heart
Lungs
Abdomen
Blood vessels
Auscultation is listening to the sounds of the body.
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37. Checkpoint Question
Jackie is assisting Dr. Rowe with physical examinations today. Which of the examination techniques used by Dr. Rowe require the use of the hands and fingers to feel organs or structures?
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38. Checkpoint Answer
The examination technique that requires the use of the hands or fingers is palpation.
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39. Responsibilities of the Medical Assistant
Room Preparation
Clean
Comfortable temperature
Adequate light and ventilation
Exam table disinfected and covered with fresh paper
Supplies stocked
Equipment working
Medical assistants are usually responsible for preparing the examination rooms, equipment, and supplies in the clinical area.
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40. Responsibilities of the Medical Assistant (cont’d.)
Patient Preparation
Call patient in
Escort to room
Be supportive and caring — develop rapport
Treat as individual
Speak clearly and confidently
Obtain history if appropriate
Instruct for undressing and putting on gown, drape legs
Leave room unless helping
Obtain urine specimen if needed
Place chart outside room
Notify physician
Before the physician sees the patient, it may be your responsibility to obtain and record the patient’s history, chief complaint, and vital signs.
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41. Checkpoint Question
Each morning, Jackie prepares the examination rooms by making sure there are adequate supplies and equipment is ready to use. What would be the advantage of checking the working condition of equipment at the beginning of each work day?
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42. Checkpoint Answer
The working condition of equipment that may be used during patient examinations should be checked at the beginning of each work day to increase efficiency and improve patient care.
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43. Responsibilities of the Medical Assistant (cont’d.)
Assisting the Physician
Hand physician instruments, supplies
Direct light
Remain in room if male physician with female patient or female physician with male patient
Help patient into positions if necessary
Support and reassure
Always assess the patient’s facial expression and level of anxiety by noting verbal and nonverbal behavior during the examination.
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44. Responsibilities of the Medical Assistant (cont’d.)
The Erect or Standing Position: The patient stands erect facing forward with the arms at the sides.
Body Part
Instrument Used
Male genitalia and hernia
Gloves
Legs
Percussion hammer
Spine, posture, gait, coordination, balance, strength, flexibility
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45. Responsibilities of the Medical Assistant (cont’d.)
Body Part
Instrument Used
General appearance
Head, neck
Stethoscope
Eyes
Ophthalmoscope, penlight
Ears
Otoscope, tuning fork
Nose
Nasal speculum, penlight, odors
Sinuses
Penlight
Mouth
Glove, tongue blade, penlight
Throat
Glove, tongue blade, penlight, laryngeal mirror, laryngoscope
Axilla, arms
Chest
Breasts
Upper back
Reflexes
Percussion hammer .
Sitting Position: The patient sits erect at the end of the examination table with the feet supported on a footrest or stool.
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46. Responsibilities of the Medical Assistant (cont’d.)
The Supine Position: The patient lies on the back with arms at the sides. A pillow may be placed under the head for comfort.
Body Parts
Instruments Needed
Chest
Stethoscope
Abdomen
Breasts
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47. Responsibilities of the Medical Assistant (cont’d.)
Body Parts
Instruments Needed
Female genitalia and internal organs
Gloves, vaginal speculum, Ayre spatula, histobrush, lubricant
Male genitalia and hernia
Gloves
The dorsal recumbent position. The patient is supine with the legs separated, knees bent, and feet flat on the table.
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48. Responsibilities of the Medical Assistant (cont’d.)
The lithotomy position is similar to the dorsal recumbent position but with the patient’s feet in stirrups rather than flat on the table. The stirrups should be level with each other and about 1 foot out from the edge of the table. The patient’s feet are moved into or out of the stirrups at the same time to prevent back strain.
Body Parts
Instruments Needed
Female genitalia and internal organs
Gloves, vaginal speculum, Ayre spatula, histobrush, lubricant
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49. Responsibilities of the Medical Assistant (cont’d.)
Body Parts
Instruments Needed
Female genitalia and internal organs
Gloves, vaginal speculum, Ayre spatula, histobrush, lubricant
Male rectum
Gloves, lubricant, fecal occult blood test
Prostate
Gloves, lubricant
The Sims position. The patient lies on the left side with the left arm and shoulder behind the body, right leg and arm sharply flexed on the table, and left knee slightly flexed.
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50. Responsibilities of the Medical Assistant (cont’d.)
The prone position. The patient lies on the abdomen with the head supported and turned to one side. The arms may be under the head or by the sides, whichever is more comfortable.
Body Parts
Instruments Needed
Back, spine, legs
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51. Responsibilities of the Medical Assistant (cont’d.)
Body Parts
Instruments Needed
Rectum
Glove, lubricant, anoscope, proctoscope, or sigmoidoscope, fecal occult blood test
Female genitalia
Glove, lubricant, vagial speculu, Ayre spatula, histobrush
Prostate
Glove, lubricant
Knee-chest position. The patient kneels on the table with the arms and chest on the table, hips in the air, and back straight.
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52. Responsibilities of the Medical Assistant (cont’d.)
Fowler position. The patient is half-sitting with the head of the examination table elevated 80 degrees to 90 degrees.
Body Parts
Instruments Needed
Head, neck, chest
Stethoscope
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53. Responsibilities of the Medical Assistant (cont’d.)
Semi-Fowler position. The patient is in a half-sitting position with the head of the table elevated 30 degrees to 45 degrees and the knees slightly bent.
Body Parts
Instruments Needed
Head, neck, chest
Stethoscope
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54. Responsibilities of the Medical Assistant (cont’d.)
Trendelenburg position. The patient lies on the back with arms straight at either side, and the head of the bed is lowered with the head lower than the hips; the legs are elevated at approximately 45 degrees.
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55. Responsibilities of the Medical Assistant (cont’d.)
Postexamination Duties
Assist patient in sitting and dressing if necessary
Instruct patient on what to do after
Reinforce physician instructions
Educate patient
Escort patient to front desk, assist with appointments or other processes as needed
Clean room, disinfect and re-paper table, restock supplies
Ensure room is ready for next patient
After the physical examination, you should perform any follow-up treatments and procedures as necessary or as ordered by the physician.
Check the medical record to be sure that all data have been accurately documented before releasing the record to the billing department.
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56. Checkpoint Question
When assisting Dr. Rowe with performing physical examinations, what are her four basic responsibilities?
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57. The clinical medical assistant is responsible for:
Checkpoint Answer
The clinical medical assistant is responsible for:
Preparing the examination room
Preparing the patient
Assisting the physician
Cleaning the examination room and equipment after the examination
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58. Physical Examination Format
To begin:
Seat and drape patient
Observations throughout exam — appearance, behavior, speech, posture, hair distribution, nutritional status, skin
The physician usually progresses through the examination in an orderly,
methodical sequence.
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59. Physical Examination Format (cont’d.)
Head and Neck
Examine skull, scalp, hair, face
Look for nodules, masses, injuries, lesions
Examine lymph nodes, thyroid, trachea for size and symmetry
Carotid artery — bruit
bruit: abnormal sound or murmur in the blood vessels during
auscultation
The patient’s skull, scalp, hair, and face are inspected and palpated for size, shape, and symmetry.
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60. Physical Examination Format (cont’d.)
Eyes and Ears
Visual acuity before physical exam
Sclera — color
Pupils — PERRLA
Extraocular eye movement — EOM
Peripheral vision
Ophthalmoscope:
Interior of eye
Retina
Vasculature
Using the ophthalmoscope, the physician visualizes the interior of the
eye and evaluates the condition of the retina and any pathology of the interlobular blood vessels.
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61. Physical Examination Format (cont’d.)
PERRLA: abbreviation used in documentation to denote pupils equal, round, reactive to light, and accommodation if all findings are normal; refers to the size and shape of the pupils, their reaction to light, and their ability to adjust to distance extraocular: outside the eye, as in extraocular eye movement peripheral vision: side vision while looking straight ahead sclera: white fibrous tissue that covers the eye
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62. Physical Examination Format (cont’d.)
Palpate ears — size, symmetry, lesions, nodules
Otoscope:
Ear canal
Cerumen — ear wax
Tympanic membrane — normal is pearl gray and concave, infected is discolored and bulging
Tuning fork — auditory test
A normal tympanic membrane.
Cerumen: yellowish or brownish waxlike secretion in the external ear canal; earwax
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63. Physical Examination Format (cont’d.)
Nose and Sinuses
External — abnormalities
Internal — color, discharge, lesions, polyps, obstructions, tenderness, swelling, position of nasal septum
Sense of smell
Transilluminate for view of sinuses — penlight in darkened room
nasal septum: wall or partition dividing the nostrils
transillumination: passage of light through body tissues for the purpose of examination
The external nose is palpated for abnormalities and inspected using a nasal speculum and light.
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64. Physical Examination Format (cont’d.)
Mouth and Throat
Mucous membranes
Teeth, gums, dental hygiene
Tongue
Throat, tonsils
Salivary gland function
The physician inspects the mucous membranes of the mouth, gums, teeth, tongue, tonsils, and throat using clean gloves, a light source, and a tongue blade.
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65. Checkpoint Question
What is the tympanic membrane, and how does infection affect its appearance?
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66. Checkpoint Answer
The tympanic membrane, also called the eardrum, is a thin membrane between the outer and middle ear that transmits sound waves to the inner ear. Normally, it is a pearly gray and concave. However, in the presence of an infection and fluid behind it, it may be discolored and bulge outward.
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67. Physical Examination Format (cont’d.)
Chest, Breasts, and Abdomen
General appearance
Respiratory rate and rhythm
Masses or swelling
Palpate chest and axillary lymph nodes
Auscultate lungs:
Lung and heart sounds, apical pulse
The physician observes the general appearance and symmetry of the chest and breast area, the respiratory rate and pattern, and any obvious masses or swelling.
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68. Physical Examination Format (cont’d.)
Back and spine
Auscultate posterior lung sounds
Palpate breasts, nipples, tissue to clavicle, axilla, bottom of rib cage:
Women — supine
The supine position is preferred for palpation of the breasts because the breast tissue flattens out, making any abnormalities easier to feel.
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69. Physical Examination Format (cont’d.)
Inspect, palpate, and percuss abdomen
Auscultate bowel sounds
Palpate inguinal lymph nodes
Check for hernia
inguinal: pertaining to the regions of the groin
hernia: protrusion of an organ through the muscle wall of the cavity that normally surrounds it
The abdomen is inspected for contour, symmetry, and pulsations
from the aorta, a large artery that extends from the heart down the center of the thoracic and abdominal cavities.
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70. Checkpoint Question
Jackie assists a patient into position for a breast examination. Why is the patient supine for palpation of the breasts?
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71. Checkpoint Answer
When the patient is supine, the breast tissue flattens out, making it easier for the examiner to feel any abnormalities.
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72. Physical Examination Format (cont’d.)
Genitalia and Rectum
Men:
Scrotum — size, contour, consistency
Transilluminate contents
Inguinal area — hernia exam
Anus — lesions, hemorrhoids
Rectum — sphincter tone, prostate size, consistency, masses
Stool specimen for occult blood test
occult blood: blood hidden or concealed from observation
The male genitalia are inspected to note symmetry, lesions, swelling, masses, and hair distribution.
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73. Physical Examination Format (cont’d.)
Women:
External genitalia —lesions, edema, cysts, hair distribution
Internal — vagina, cervix
Pap smear
Bimanual exam — two fingers of dominant hand in vagina, nondominant hand on abdomen, palpate internal reproductive organs
Rectovaginal exam — index finger in vagina, middle finger in rectum to palpate for lesions, hemorrhoids, sphincter tone, stool specimen
rectovaginal: pertaining to the rectum and vagina
The female genitalia and rectum are usually examined with the patient in the lithotomy position and with one corner of the drape extending over the genitalia and
the other corner covering the patient’s chest.
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74. Physical Examination Format (cont’d.)
Legs
Inspect
Palpate peripheral pulse — supine and standing
Reflexes
Percussion hammer — biceps, triceps, patella, Achilles and plantar tendons
Patient usually sitting
The legs are inspected and the peripheral pulse sites palpated with the patient supine.
The examiner uses the percussion hammer to test the patient’s reflexes by striking the biceps, triceps, patellar, Achilles, and plantar tendons.
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75. Physical Examination Format (cont’d.)
Posture, Gait, Coordination, Balance, and Strength
Inspect posture, spine — standing
Inspect gait, coordination — walking
Inspect balance — stand, feet together, eyes closed
Arm range of motion, strength
Gait: manner or style of walking
The general posture of the patient and the spine may be inspected with the patient standing.
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76. Checkpoint Question
Why would Dr. Rowe perform rectovaginal and bimanual pelvic examinations?
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77. Checkpoint Answer
The rectovaginal examination is done to palpate the posterior uterus and vaginal wall.
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78. General Health Guidelines and Checkups
Patient education step
Ages 20 to 24 years, physical exam every 1 to 3 years
Over age 40 years, every year
1st Pap no later than 21 years, the every 2 years
Breast exam every 3 years at 20 to 40 years old
Baseline mammogram at 35 years old, yearly after age 40
For patients aged 20 to 40 years, physical examinations are scheduled about
every 1 to 3 years.
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79. General Health Guidelines and Checkups (cont’d.)
Baseline ECG at age 40 years
Rectal exam and fecal occult blood at age 40 years
Colonoscopy at age 50 years:
Every 3–5 years
Men PSA and DRE at age 50 years
All patients should have a baseline electrocardiogram (ECG) at age 40 and follow-up ECGs as necessary.
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80. General Health Guidelines and Checkups (cont’d.)
CDC-recommended immunizations:
Tdap once
Tetanus every 10 years, sooner if have open wound
MMR: one or two doses between ages of 19 and 49 years
Varicella (chicken pox) two doses between ages 19 and 49 years
Seasonal flu each year for everyone over 6 months of age
Pneumococcal at age 65 years
Hepatitis B series for adults
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81. Checkpoint Question
Dr. Rowe asks Jackie to explain the procedure to perform a self-breast examination to a young female patient. Why are monthly breast self-examinations important for women aged 20 to 40 years?
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82. Checkpoint Answer
Monthly breast self-examinations are important in women ages 20 to 40 years to detect abnormal lumps or thickenings that may be malignancies. Cancers are most likely to be cured if detected and treated early.
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