After completing chapter 38, you will be able to: Identify the purpose of a general physical exam, describe the role of the medical assistant in a general physical exam, explain safety precautions used during a general physical exam, carry out the steps necessary to prepare the patient for an exam,...
CHAPTER 38 Assisting with General Physical Examination 38-2 Learning Outcomes (cont.) 38.1 Identify the purpose of a general physical exam 38.2 Describe the role of the medical assistant in a general physical exam 38.3 Explain safety precautions used during a general physical exam 38-3 Learning Outcomes (cont.) 38.4 Carry out the steps necessary to prepare the patient for an exam 38.5 Carry out positioning and draping a patient in each of the nine common exam positions 38.6 Apply techniques to assist patients from different cultures and patients with physical disabilities 38-4 Learning Outcomes (cont.) 38.7 Identify the six examination methods used in a general physical exam 38.8 List the components of a general physical exam 38.9 Describe follow-up steps after a general physical exam 38-5 Introduction • Physical examination – 1st step in the diagnosis or treatment process • The medical assistant – Make the client comfortable – Assist the physician A skilled medical assistant can create an atmosphere that results in a positive outcome for the patient during the physical examination 38-6 The Purpose of General Physical Exam • To confirm an overall state of health and provide baseline values • To diagnose a medical problem The Purpose of General Physical Exam (cont.) • Clinical diagnosis – Sign ~ objective – Symptom ~ subjective • Laboratory and diagnostic tests – Confirm clinical diagnosis – Help determine the differential diagnosis and prognosis – Formulation of treatment plan 38-7 38-8 Apply Your Knowledge Why does the physician perform a general physical examination? ANSWER: A physical examination is used to confirm the patient’s overall state of health or to diagnose a medical problem 38-9 The Role of Medical Assistant • To assist the licensed practitioner and the patient • Begins prior to the physical exam – Interview – Write an accurate history – Determine vital signs – Measure weight and height 38-10 The Role of Medical Assistant (cont.) • Responsibilities – Ensuring instruments and supplies are available – Ensuring patient comfort • Helping into position • Keeping them informed • Observing them for distress or need for assistance Components of the General Physical Examination (cont.) • Neurological system – Reflexes – Mental and emotional status – Sensory and motor functions – Intellectual assessment in children – Mental status and memory in elderly 38-44 38-45 Apply Your Knowledge In what order should the physician perform an abdominal examination and why? ANSWER: The physician will inspect, auscultate, percuss, and palpate the abdomen Auscultation should be done before percussion or palpation to avoid altering the bowel sounds 38-46 After the Examination • Assist patient to a sitting position • Allow the patient to perform any necessary self-hygiene measures • Allow patient to dress • Perform additional tests or procedures 38-47 Additional Tests and Procedures • Prior to dressing – Cold and heat therapy – Applying bandages – Collecting specimens Some medications should be administered before the patient dresses while others can be given after he is dressed 38-48 Additional Tests and Procedures • After dressing – Urine reagent strip tests – Pulmonary function tests – Eye or ear irrigation or medication administration 38-49 Patient Education • Assess needs – Risk factors for disease – Medication administration – Self-help or diagnostic techniques • Use proper language level • Ensure understanding • Give written instructions 38-50 Follow-Up • Scheduling appointments – Future office visits – Outside appointments • Helping plan for home nursing care • Helping the patient obtain assistance 38-51 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! 38-52 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 38-53 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 38-54 In Summary (cont.) 38.4 The medical assistant should prepare the patient for an exam emotionally, by using simple direct language; and physically, by providing for the patient’s comfort and privacy when positioning him or her according to the type of exam or procedure, and by modifying techniques to meet the needs of special patients 38-55 In Summary (cont.) 38.5 The nine common exam positions include sitting, supine, dorsal recumbent, lithotomy, 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 Assist patients who have physical disabilities with transfers and other tasks they cannot accomplish themselves 38-56 In Summary (cont.) 38.7 The six examination methods used in a general physical exam include inspection, auscultation, palpation, percussion, mensuration, and manipulation 38.8 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 38-57 In Summary (cont.) 38 In order to assist the patient with follow-up after the 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 38-58 End of Chapter 38 Health is the thing that makes you feel that now is the best time of the year ~ Franklin P Adams ... used in a general physical exam 38. 8 List the components of a general physical exam 38. 9 Describe follow-up steps after a general physical exam 38- 5 Introduction • Physical examination – 1st.. .38- 2 Learning Outcomes (cont.) 38. 1 Identify the purpose of a general physical exam 38. 2 Describe the role of the medical assistant in a general physical exam 38. 3 Explain safety... positions 38. 6 Apply techniques to assist patients from different cultures and patients with physical disabilities 38- 4 Learning Outcomes (cont.) 38. 7 Identify the six examination methods used in a general