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

2. 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.

3. 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

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

5. 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

6. 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

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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. Purpose of the Patient History

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

17. 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

18. 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

19. 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

20. 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)

21. 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

22. 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

23. 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

24. 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

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

26. 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

27. 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

28. 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

29. 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

30. 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

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

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

33. 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

34. 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

35. Palpation Method of Physical Examination

36. 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

37. 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

38. Percussion Method of Physical Examination

39. 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

40. 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

41. Auscultation Method of Physical Examination

42. 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

43. 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

44. Mensuration Method of Physical Examination

45. 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

46. 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

47. Questions? 47