Transcript Preparing the Exam Room and Examination

5
Assisting with Physical
Examinations
Lesson 1:
Preparing the Exam Room and
Examination Methods – Part 1
Lesson Objectives
Upon completion of this lesson, students should be able to …
 Define and spell the terms to learn for this chapter.
 Recognize pieces of equipment commonly used during a
physical examination.
 Describe the examination methods used by physicians.
 Discuss the steps to take in preparing a patient for a
physical examination.
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
Medical Assistant’s Role in the
Patient Physical Exam
 supplies
 safety
 Observing confidentiality
Cleaning the Examination Room
 used gowns in the
laundry receptacle
 Discard used
examination table paper
and drape
 Dispose of pillow cover
 Clean the exam table,
and recover with new
paper
Cleaning the Examination Room (cont)
 new cover on pillow
 Dispose of
equipment
 Clean and disinfect
equipment
 Disinfect all surfaces
Cleaning the Examination Room (cont)
 Close all biohazard
containers
 remove if full
 Ensure room is clean
and odor free
Features of the Examination Room
 Examination table
 Pillow
 Footstool
 Supply cupboard
 Trash can
 Hazardous waste and sharps
containers
 Rolling stool
 Chair
 Mayo tray stand
Preparing the Examination Room
 Ready instruments and equipment
 equipment is not within reach of the
patient
 exam light
 proper body mechanics
Ensuring Patient Comfort and
Privacy
 thermostat around 71 to 73 degrees F
 Provide blankets and sheets
 Explain clearly about exam gown
 Inform patients where to place clothes
Ensuring Patient Comfort and
Privacy (cont)
 Leave the room when patients are
undressing unless assistance is required
 Knock and receive permission when
reentering
Purpose of the Patient History
 assess general health status
 Helps determine a diagnosis
Fill out Patient History form activity
 Accuracy counts
 Spelling counts
WorkBook Page
 Neatness counts
17-19
Film Clip
 Saunders DVD
 Assisting w/physical exams
Contents of the Medical History
 Chief complaint (cc)
 Present illness
 Past medical history
 Family history
 Social or personal
history
 Review of systems
The Chief Complaint
 presenting problem
 consists of one or two symptoms
 documented using the patient’s own words
The Chief Complaint (cont)
 Subjective symptoms
 What the patient tells you
 Not directly observed
 Objective symptoms
 Signs you can see, hear, feel, smell
 Factual, measurable, observable
Do You Remember?
Objective vs. Subjective
 1. Mr. Brown states that he has a toothache
 2. Mrs. William’s urine appears to have
blood in it.
 3. Mrs. Smith’s respirations are very rapid
 4. Mr. Lee states that he is nauseated after
eating.
 5. Mrs. Bender’s dressing is dry & intact.
Do You Remember?
Objective vs. Subjective
 6. Mrs. Campbell complains of dizziness
after each respiratory treatment
 7. Mrs. Stark is jaundiced today.
 8. Mr. Runge has excessive bleeding every
time he has a tooth extracted
 9. Ms. Hime is perspiring, and her skin is
cold & clammy.
 10. Mr. Rue is experiencing some wheezing
with each breath.
Steps to Interviewing a Patient and
Preparing for an Exam
 Id the patient, greet, and id yourself
 Explain procedure
 Provide privacy
 Ask the patient to fill out form
Steps to Documenting a Chief
Complaint
 Maintain eye contact and actively
listen
 Gather information
 What makes the problem better or
worse?
 start?
 hurt?
 rate pain on a scale 0-10
Steps to Interviewing a Patient and
Preparing for an Exam (cont)
 Review
 ask questions
 Ask for the CC
 Chart the CC
Steps to Interviewing a Patient and
Preparing for an Exam (cont)
 observation skills
 Gather other information
 PH, FH, and SH
 Allergies –
 No allergies
 NKDA
 NKA
Steps to Interviewing a Patient and
Preparing for an Exam (cont)
 Correct any errors drawing one line through
the error and date and initial them – Record
the correct information
1/13/12 KG
BP 180/96----------K. Gers MA
Steps to Interviewing a Patient
and Preparing for an Exam (cont)
 Explain what procedures will follow
 Place the patient history in the
designated place
Obtaining the Past Medical History
 all past diseases and
medical problems
 Dates of major
illnesses
 Hospitalizations
 surgeries,
 current medications
including OTC meds
The Family Medical History
 Health problems of blood relatives
 current health, major health problems, and
cause of death, as well as age at death
 Family medical histories focus on diseases
that may be inherited
Information Contained on the
Personal History
 Lifestyle patterns Patient’s
occupation
 Marital status
 Sexual preferences
 diet choices
 exercise
 Sleep habits
Inspection of Physical Examination
 visually examining the exterior
surface of the body
Palpation of Physical Examination
 using the hands to feel the skin and
accessible underlying organs
Percussion of Physical Examination
 Use of the fingertips to tap the body to
gain information about underlying body
parts
Percussion Method of Physical
Examination
Auscultation Method of Physical
Examination
 listen to sounds that are found within
the body
 A stethoscope is used to amplify
body sounds
Mensuration Method of Physical
Examination
Use of special tools to measure the body or
specific parts
 Weight scale
 A tape measure
 A goniometer
 Calipers
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