1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 18 Patient Exams

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The national exams often require you to identify instruments and equipment from a picture. Practice recognizing various instruments and their medical uses. Also, study the body positions described in this chapter, since they usually are incorporated in the exams. Review Tip

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The medical assistant, from the moment of contact, observes the patient for baseline behaviors, changes, and signs and symptoms. This first observation begins the patient exam, and observations continue throughout the patient visit. Specific medical record forms are used to record the information. The medical assistant should note the data from previous visits as a comparison to the newly obtained information. Appropriate asepsis should be followed throughout procedures (refer to Chapter 17). Overview

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The interview process discussed in this chapter incorporates the knowledge, techniques, and skills from previous chapters—including medical terminology, anatomy and physiology, communication, law and ethics, patient education, medical records, and microorganisms and asepsis. Professionalism and confidentiality are expected standards. ■ Chief complaint—a summary of the patient’s words explaining why he or she is seeking health care; best determined by asking an open-ended question such as “What brings you here today?” ■ Symptoms—subjective descriptions of altered health indicators (e.g., nausea, headache); complaints that cannot be seen or measured ■ Medical-related histories—accounts of past health status or practices and exposures that affect health status Patient Interview

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Family history—medical history of the patient’s close biological relatives (e.g., grandparents, parents, siblings) Patient medical history—the patient’s past health status; usually conducted by a review of body systems Social and environmental history—the patient’s past and current personal habits and exposures that influence health Screen for abuse and domestic violence—a history-type questionnaire recommended by many professional organizations and mandated in some jurisdictions to assist in determining the presence of abuse in the patient’s life Patient Interview, cont’d.

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obtaining assessment measurements is also known as anthropometry. Anthropometry comprises signs, functions, and capacities that can be objectively determined by the senses (e.g., sight, hearing, smell, touch) or by specific equipment and tests. Medical asepsis is maintained in preparing, performing, and following all common assessment functions. Common Assessment Measurements

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Vital Signs Vital signs are measurements of body temperature, pulse rate, respirations (TPR), and blood pressure (BP). ■ Body temperature—measured by a thermometer using one of two scales, degrees Fahrenheit (F) or degrees Celsius (C), also referred to as centigrade; the normal range for infants, children, and adults is the same, but infants and small children are more sensitive to external temperature changes Common anatomic locations to obtain temperature - Oral (temperature taken in the mouth) adult norm is 98.6ºF or 37ºC - Rectal (temperature taken in the rectum) norm is 1 degree higher than oral; adult norm is 99.6ºF or 37.5ºC Common Assessment Measurements, cont’d.

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins - Axillary (temperature taken in the armpit) norm is 1 degree lower than oral; adult norm is 97.6ºF or 36.4ºC - Aural, otic, or tympanic (temperature taken in the ear) norm is the same as oral; adult norm is 98.6ºF or 37ºC Thermometer—instrument used to measure temperature - Mercury—a glass thermometer with a mercury column. No longer used due to mercury danger - Electronic—a thermometer with a power source used for all sites (special type is used for the ear); displays the temperature digitally; converts from ºF to ºC or vice versa by flipping a small switch; stylus is covered by a disposable sheath - Tympanic—electronic thermometer resembling an otoscope that is used in the ear - Disposable—one-time-use plastic thermometer strips, dots, or probes used on the skin or orally; considered least reliable Common Assessment Measurements,cont'd.

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Pulse—“beat” caused by expansion and relaxation of the artery wall, expressed in beats per minute; the adult norm is 60 to 100 beats per minute (bpm) in a regular rhythm, usually the same rate and rhythm as the heart; the infant norm is 100 to 160 bpm; and the norm of children to age 10 is 70 to 120 bpm Anatomic sites—the pulse may be taken using any artery lying over bone; the most common follow in the order of frequency of use - Radial—pulse located on the thumb side of the wrist; most common site used for adults - Brachial—pulse located medially on both arms anterior to the elbow; most common site used for children - Apical—pulse located at the fifth intercostal space midclavicular; common site used for infants; requires a stethoscope Common Assessment Measurements,cont'd.

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins -Dorsalis pedis—pulse located medially on the top of both feet, often used to assess circulation to the extremities -Carotid—pulse located on both sides of the neck, lateral to the trachea -Femoral—pulse located bilaterally in groin -Popliteal—pulse located posterior to both knees, also used to assess circulation to the extremities -Temporal—pulse located bilaterally over temporal bone Methods to obtain pulse -Manual—light compression of the artery with index and middle finger; count beats for 30 or 60 seconds, multiplying beats by 2 if 30-second count is used Common Assessment Measurements,cont'd.

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins -Doppler—ultrasonic device used to locate, audibly transmit, and sometimes record pulse -Electronic sphygmomanometer—device used to measure pulse and blood pressure simultaneously using a blood pressure cuff ■ Respiration—measurement of the number of respiratory cycles per minute, usually done by observation; a respiratory cycle consists of inspiration and expiration; the adult norm is 12 to 20 respiratory cycles per minute in a regular rhythm; the younger the infant or child, the more rapid the normal respiratory rate; 0- to 1-year norm is 20 to 40; 2- to 6-year norm is 20 to 30 Common Assessment Measurements,cont'd.

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ BP—measurement of the force of blood on the artery walls during contraction (systole) and relaxation (diastole) of the heart; recorded as a fraction with systole as the numerator and diastole as the denominator; the adult norm is 120/80; BPs are not commonly taken in children younger than 4 years; the most accurate position for taking a blood pressure is placing the arm at the level of the heart Korotkoff sounds—sounds heard through the stethoscope during the measurement of blood pressure; there are five phases: 1. Phase I—faint tapping sounds heard as the cuff deflates (systole) 2. Phase II—soft swishing sounds 3. Phase III—rhythmic, sharp, distinct tapping sounds 4. Phase IV—soft tapping sounds that become faint 5. Phase V—disappearance of sound (diastole) Common Assessment Measurements,cont'd.

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulse pressure—the difference between the systolic and diastolic pressures; the adult norm is 40; the difference should be approximately one third of systole Orthostatic pressure—blood pressure taken in all three positions (supine, sitting, and standing) at least 1 to 2 minutes apart Sphygmomanometer—the instrument used to measure BP; composed of a cuff for the arm, thigh, wrist, or finger, and a measurement device; the correct size and cuff fit influence the accuracy of the readings Common Assessment Measurements,cont'd.

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins - Mercury sphygmomanometer—no longer in use because of mercury danger - Aneroid sphygmomanometer—a blood pressure cuff with a numeric gauge to measure readings; stethoscope required - Electronic sphygmomanometer—blood pressure cuff with an electronic device to measure blood pressure and pulse readings; no stethoscope required Stethoscope—the instrument’s diaphragm or bell is placed at the artery to be used to hear the sounds that compose the BP Common Assessment Measurements,cont'd.

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Other Measurements Height Height or length is commonly measured by a rod attached to a weight scale or fixed bar on a wall; a measuring tape is used for measuring the length of neonates and also the head circumference. Measurements are recorded in feet (ft) and inches (in), or centimeters (cm); conversion is 2.5 cm per inch. Weight Weight is commonly measured in the medical office using a balance beam or an electronic scale. Measurements are recorded in pounds (lb) or kilograms (kg); conversion is 2.2 lb per kg. Common Assessment Measurements,cont'd.

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Comparisons of Height and Weight Using the height and weight in formulas and charts provides the practitioner with an approximation of the patient’s size related to normal standards. These methods are used to determine the patient’s health risk for various diseases and conditions. ■ Body mass index—a health risk assessment tool for adults and children to estimate the percentage of body fat by using a formula based on the individual’s height and weight; calculations are found online. Normal range = 18.5 to 24.9 Underweight = <18.5 Overweight = 25 to 29.9 Obese = 30 and above Common Assessment Measurements,cont'd.

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Pediatric growth chart—supplied by the Centers for Disease Control and Prevention (CDC); the form is specific to the current age and sex of the child and contains the height, weight, and head circumference; the individual’s measurements are compared by percentile to an established reference group Common Assessment Measurements,cont'd.

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Figure 18-1. Centers for Disease Control and Prevention (CDC) growth chart for U.S. males, birth to 36 months of age. Common Assessment Measurements, cont’d.

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Vision Visual acuity is the measurement of how well a person can see at specified distances; the Snellen chart method is used with various letters of the alphabet for adults; the E chart is commonly used for preschoolers. The right eye and the left eye are measured individually, and then both eyes are measured together. The adult norm is 20/20: the numerator indicates the distance the chart is placed from the patient, usually 20 feet; the denominator indicates the distance at which people with normal acuity could read the last line read by the patient—for example, 20/30 vision indicates that the patient sees at 20 feet what someone with normal vision sees at 30 feet. Common Assessment Measurements,cont'd.

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Figure 18-2. Snellen eye chart for those who know the alphabet. Common Assessment Measurements, cont’d.

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Figure 18-3. Snellen “E” eye chart for preschoolers. Common Assessment Measurements, cont’d.

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Ishihara color vision test—used to determine color vision deficiencies (color blindness); consists of a series of pages or plates with imbedded numbers of various colors; depending on the degree of the deficiency, the person would not see the number or would see it in a different color ■ Tonometer—an instrument used to measure the intraocular pressure of the eye to diagnose glaucoma; the procedure is called tonometry ■ Ophthalmoscopy (funduscopy) exam—an examination of the interior eye with an instrument that reflects light through the pupil to determine the health of the interior of the eye; the abbreviation PERRLA is used to document the normal finding of “pupils equal round and reactive to light and accommodation” Common Assessment Measurements,cont'd.

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Hearing All measurements of hearing should be preceded by a visual exam of the auditory canal and eardrum using an otoscope. Hearing measurements may be gross or highly defined. ■ Startle—gross measurement used with neonates; a loud noise such as a clap will be initiated; the expected result is that the infant will react with a jerk or a cry ■ Whisper—gross measurement; the health care provider will whisper to the patient and the patient repeats what is said; each ear is done separately Common Assessment Measurements,cont'd.

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Tuning fork—gross measurement; instrument is activated by striking it with a hand and is then placed on top of the patient’s head, beside each ear, and on each side of the patient’s mastoid bone; determines hearing and conduction ■ Audiometry—a hearing test using an audiometer with earphones that measures the patient’s response to tones; it is recorded in decibels (db) and frequencies ■ Impedance audiometry—a hearing test using an audiometer and an ear probe that measures tympanic membrane and ossicle mobility ■ Tympanometry—a test that uses a tympanometer (air pressure) to measure tympanic membrane mobility Common Assessment Measurements,cont'd.

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Respiratory Tests Part of the physical exam is to determine how well the lungs are functioning. The practitioner performs an initial evaluation by listening for normal breath sounds with a stethoscope. Other common respiratory tests are performed by the medical assistant. ■ Pulse oximetry—a test using a pulse oximeter on the patient’s digit to measure the percentage of oxygen (O 2 ) in the blood; this is a common test done with vital signs when visiting the medical office ■ Pulmonary function test (PFT)—used to diagnose and measure the severity of lung problems by evaluating how well the lungs work: the amount of air the lungs can hold and how quickly the lungs move air in and out; measurements also include the efficiency of oxygenating the blood and removing carbon dioxide Common Assessment Measurements,cont'd.

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Spirometry—the most common lung function test; measures how much and how quickly air is moved in and out of the lungs by breathing into a mouthpiece attached to a recording device (spirometer); a graph with the results (spirogram) is produced Peak flow meter—a handheld device used to measure the peak expiratory flow rate (PEFR) to monitor asthmatics; the ranges are established by the practitioner; height may be used as a factor. Common Assessment Measurements,cont'd.

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The type of examination scheduled for the health care provider to perform determines how the medical assistant prepares the patient and the supplies and tools used. Ensure privacy is maintained, requesting that the patient undress to facilitate access to the body areas that will be examined; provide gowns and draping accordingly. Consideration for the patient’s comfort includes room temperature, lighting, sound, and physical position while waiting and during the exam. ■ Common supplies and instruments—the medical assistant is responsible for ensuring all supplies and equipment are readily available for the physical exam Physical Exam Preparation

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Assessment Measurements, cont’d.

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Figure 18-4. Select tools for routine physical exam. Common Assessment Measurements, cont’d.

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Patient positions Supine—patient lies on back with arms to the sides; commonly used for abdominal exams Dorsal recumbent—patient lies on back with knees bent and feet flat on the exam table; commonly used to check progress of labor Lithotomy—patient lies on back with buttocks on edge of exam table, legs elevated and resting in stirrups; commonly used for pelvic exams Sims’—patient lies on left side with left leg slightly flexed and left arm behind body as comfortable; right leg is flexed toward chest and right arm is over the chest; commonly used for rectal exams Prone—patient lies on stomach; commonly used for exam of posterior and administration of intramuscular injections on adults Physical Exam Preparation, cont’d.

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Knee-chest position—patient rests on knees with chest and arms on table and arms flexed over the head; commonly used for rectal and sigmoidoscopic exams Fowler’s—patient lies face up on table with upper body elevated to a 45º to 90º angle; commonly used for patients short of breath and for head and neck exams Semi-Fowler’s—the Fowler’s position at a 45ºangle is sometimes referred to as semi-Fowler’s Physical Exam Preparation, cont’d.

32. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Figure 18-5. Patient positions for exams and procedures. Common Assessment Measurements, cont’d.

33. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Examination techniques Observation—visual review of the body, inspecting for symmetry, abnormalities, and skin color and conditions Palpation—use of fingertips and hands to feel for sizes and positions of specific organs, masses, and other abnormalities; texture and firmness; skin temperature and moisture; and flexibility of joints Percussion—process of determining density of specific internal structures by the sound (e.g., dull, hollow) produced by external tapping, usually with fingers or with a percussion hammer for testing neurologic reflexes Auscultation—use of an instrument, usually a stethoscope, to listen to internal body sounds for abnormalities Manipulation—passive movement of body joints to determine the extent of movement Mensuration—measurement of height or length and weight Physical Exam Preparation, cont’d.