CHAPTER 38 Assisting with a General Physical Examination © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-2 Learning Outcomes 38.1 Identify the purpose of a general physical examination 38.2 Describe the role of the medical assistant in a general physical examination 38.3 Explain safety precautions used during a general physical examination 38.4 Carry out the steps necessary to prepare the patient for an examination © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-3 Learning Outcomes (cont.) 38.5 Describe how to position and drape a patient in each of the ten common examination positions 38.6 Describe how to assist patients from different cultures, patients with disabilities, and pediatric patients during a physical examination 38.7 Identify the six examination methods used in a general physical examination 38.8 List the components of a general physical examination © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-4 Learning Outcomes (cont.) 38.9 Perform the procedures for vision screenings 38.10 Perform the procedures for hearing screenings 38.11 Explain the special needs of the elderly for patient education 38.12 Identify ways to help a patient follow up on a doctor’s recommendations © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-5 Introduction • You must make the • Physical client comfortable examination is the and assist the first step in the physician during process for the the physical physician examination A skilled medical assistant can create an atmosphere that results in a positive outcome for the patient during the physical examination © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-6 Purpose of General Physical Examination • To confirm an overall state of health • To diagnose a medical problem – Focuses on an organ system – Based on patient’s chief complaint © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d Purpose of General Physical Examination 38-7 (cont.) • Clinical diagnosis – Based on signs and symptoms of a disease • Sign – objective information that can be detected • Symptom – subjective information from the patient – Laboratory and diagnostic tests • • • • Confirm clinical diagnosis Aid in forming differential diagnosis Aid in developing a prognosis Formulate a treatment plan and/or drug therapy © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-8 Role of Medical Assistant • Enable the doctor to perform an effective examination • Contribute to patient confidence in care – Physical and emotional comfort • Tasks – Interview – Write an accurate history – Determine vital signs and measure weight and height – Assist with examination Your responsibilities include ensuring that all instruments and supplies are readily available to the doctor during the examination © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-9 Apply Your Knowledge What are two purposes for a general physical examination? Describe the role the medical assistant plays in this exam ANSWER: A physical examination is used to confirm the patient’s overall state of health or to diagnose a medical problem The medical assistant’s role includes putting the patient at ease, performing the initial interview, documenting the patient history, taking vital signs and body measurements, assisting the physician in the exam, and making sure instruments and supplies are available for the exam © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-10 Safety Precautions • Occupational Safety and Health Administration (OSHA) standards and guidelines – Protect employee – Make workplace safe • Centers for Disease Control and Prevention (CDC) guidelines – Protect patients and health-care workers © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-37 Apply Your Knowledge What is the medical assistant’s role in a general physical examination? ANSWER: The medical assistant should be familiar with the components of the examination, know equipment and supplies used, ensure the patient’s comfort, and protect the patient’s modesty © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-38 Completing the Examination • Assist patient to a sitting position • Allow the patient to perform any necessary self-hygiene measures • Perform additional tests or procedures © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-39 Completing the Examination (cont.) • Screening for visual acuity – Snellen chart – distance – Jaegar chart – near vision – Ishihara book – color vision – Special considerations • Children • Patients with dementia or Alzheimer’s disease • Auditory acuity – audiometer © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-40 Completing the Examination (cont.) • Patient education – Assess needs – Topics • Risk factors for disease • Medication administration • Self-help or diagnostic techniques – Do not talk down to patient – Ensure understanding – Give written instructions © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-41 Completing the Examination (cont.) • Special problems of the elderly – Greater need for patient education – Common problems: • Incontinence • Depression • Lack of information on preventive medicines • Poor patient compliance when taking medications – Involve family members when possible © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-42 Completing the Examination (cont.) • Follow-up – Scheduling the patient for future visits – Making outside appointments for diagnostic tests – Helping the patient and patient’s family plan for home nursing care – Helping the patient obtain help from community or social services © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-43 Apply Your Knowledge What is important to remember when providing patient education? ANSWER: You should provide information in a way the patient can understand it, but you should not talk down to the patient In addition, you need to verify that the patient understands what you taught Super! © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-44 In Summary 38.1 A general physical exam is done either to confirm an overall state of health or to examine a patient to diagnose a medical problem 38.2 The medical assistant assists the patient and physician during an exam Making the patient physically and emotionally comfortable as well as providing materials and assistance to the physician are essential to a successful exam © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-45 In Summary (cont.) 38.3 During an exam, the medical assistant should perform hand hygiene, wear gloves and other personal protective equipment, ensure respiratory hygiene/cough etiquette, use isolation precautions, dispose of biohazardous waste, and clean and disinfect the exam room as necessary to provide for safety 38.4 The medical assistant should prepare the patient for an exam emotionally, by using simple, direct language; physically, by providing for the patient’s comfort and privacy and by positioning him or her according to the type of exam or procedure; and by modifying techniques to meet the needs of special patients © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-46 In Summary (cont.) 38.5 The ten common exam positions include sitting, supine, dorsal recumbent, lithotomy, Trendelenburg, Fowler’s, prone, Sims’, knee-chest, and proctologic 38.6 When assisting with the physical exam, avoid judging and stereotyping patients from different cultures, and obtain a translator for proper communication if necessary © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-47 In Summary (cont.) 38.7 Assist patients with physical disabilities with transfers and other tasks they cannot accomplish themselves 38.8 Involve the child in the exam process and assist him based upon his age and ability to cooperate © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-48 In Summary (cont.) 38.9 The six examination methods used in a general physical exam include inspection, palpation, percussion ,auscultation, mensuration, and manipulation 38.10 A general physical exam typically includes an evaluation of the general appearance, head, neck, eyes, ears, nose and sinuses, mouth and throat, chest and lungs, heart, breasts, abdomen, genitalia, rectum, musculoskeletal system, and neurological system © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-49 In Summary (cont.) 38.11 Vision screening procedures include using the Snellen chart for distance visual acuity, the Jaegar chart for screening for near vision, and the Ishihara book for color vision screening 38.12 An auditory acuity test is done before or after the exam using some type of audiometer © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-50 In Summary (cont.) 38.13 Patient education for the elderly requires ensuring compliance when taking medications, providing preventative medicine education tools, and recognizing problems related to incontinence and depression 38.14 In order to assist the patient with follow-up after his or her exam, you may schedule future visits, schedule visits outside of the office, help plan for home care, and if within your scope of practice provide education related to the patient’s condition © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38-51 End of Chapter 38 Health is the thing that makes you feel that now is the best time of the year ~ Franklin P Adams © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d [...]... Inc A ll rights reserv e d 38- 36 Components of the General Physical Examination (cont.) • Musculoskeletal system – – – – – – Posture Gait Range of motion Muscle strength Body measurements Development and coordination in children • Neurological system – Reflexes – Mental and emotional status – Sensory and motor functions – Intellectual assessment in children – Mental status and memory in elderly © 2011... position – Palpation – fluid or foreign mass in lungs – Auscultation – listen for abnormalities © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 34 Components of the General Physical Examination (cont.) • Heart and vascular system – Percussion – size of heart – Auscultation • Heart sounds • Rate, rhythm, intensity, and pitch – Pulses • Breasts – Palpation for abnormalities • Abdomen – – –. .. 38- 17 Positioning and Draping (cont.) • Positions – Sitting – Supine (recumbent) – Dorsal recumbent – Lithotomy – Trendelenburg’s – Fowler’s – Prone – Sims’ – Knee-chest – Proctologic © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 18 Positioning and Draping (cont.) • Sitting • Supine/recumbent • Dorsal recumbent © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 19... d 38- 30 Components of the General Physical Examination (cont.) • General appearance • Head – Skin – a good indicator of overall health – Abnormal condition of scalp or skin – Nails and nail beds – Puffiness – Hair – pattern of growth and texture – Abnormal growths © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 31 Components of the General Physical Examination (cont.) • Neck – Lymph... Eardrums • Nose and sinuses – Nasal mucosa – Structures of nose – Palpation to check for tenderness in sinuses © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 33 Components of the General Physical Examination (cont.) • Mouth and throat – Mouth – impression of overall health and hygiene – Throat • Common site of infection • Tonsils – swelling or redness • Chest and lungs – Inspection... Chest and lungs, heart, breasts – Abdomen, genitalia, and rectum – Musculoskeletal and neurological systems © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 29 Components of the General Physical Examination (cont.) • Medical assistant – Be familiar with the components of the examination – Know equipment and supplies used – Ensure the patient’s comfort – Protect the patient’s modesty... disabilities – Provide extra assistance as needed – Ask for assistance with patient transfers © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 22 Special Considerations (cont.) • Children – Modify techniques based on age and ability – Emotional • Involve child in the examination • Approach infants and toddlers slowly, with a smile and gentle voice • Perform procedures quickly – Physical... nodes, thyroid glands, and major blood vessels – Symmetry and range of motion • Eyes – The presence of disease or abnormalities – Pupils for light response – Muscles – Internal structures © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 32 Components of the General Physical Examination (cont.) • Ears – Outer ear • Symmetry and size • Presence of lesions, redness, or swelling – Inner ear... rights reserv e d 38- 24 Examination Methods • Inspection – Visual examination – Assesses posture, mannerisms, and hygiene – Size, shape, color, position, symmetry • Palpation – Touch texture, temperature, shape – Presence of vibration or movements – Superficial or with additional pressure – Presence of abnormalities © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 25 Examination Methods.. .38- 11 Safety Precautions (cont.) 1 Hand washing – Before and after each patient contact – Before and after each procedure 1 Wear gloves if there is probability of contact with – Blood – Body fluids Nonintact skin Moist surfaces © 2011 The McGraw -Hill Com panies, Inc A ll rights reserv e d 38- 12 Safety Precautions (cont.) 3 Wear a mask if there