Transcript The Profession of Medical Assisting

CHAPTER
38
Assisting with
General Physical
Examination
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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.
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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.
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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.
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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.
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38-6
The Purpose of General Physical Exam
• To confirm an overall state of health and
provide baseline values
• To diagnose a
medical problem
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38-7
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
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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.
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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
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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
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38-11
Apply Your Knowledge
What are your responsibilities when assisting with
a general physical exam?
ANSWER: Ensuring all supplies and instruments are
available for the physician and making sure the patient
is comfortable by
• Helping the patient into position
• Telling them what will happen
• Observing the patient for signs of distress or need
for assistance.
Hooray!
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38-12
Safety Precautions
• OSHA standards and guidelines
– Protect employees
– Make the workplace safe
• CDC guidelines – protect patients and
health-care workers
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38-13
Safety Precautions (cont.)
• Aseptic hand washing
– Before and after each
patient contact
– Before and after each
procedure
• Wear gloves if there may be contact with
– Blood
– Nonintact skin
– Body fluids
– Moist surfaces
– Also when handling specimens
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38-14
Safety Precautions (cont.)
• Respiratory hygiene/cough etiquette
• Wear a mask to prevent exposure to an
infectious disease transmitted by
airborne droplets
• Isolation precautions – personal protective
equipment
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38-15
Safety Precautions (cont.)
• Discard all disposable equipment and
supplies appropriately
• Clean and disinfect the exam
room after each patient
• Sanitize, disinfect, and sterilize
equipment appropriately
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38-16
Apply Your Knowledge
Impressive!
Mrs. Jefferson brings her daughter, Laura, to the office
because of what she describes as an upper respiratory
infection. Laura is coughing and the medical assistant
notices a blister-like rash on her arms. What actions
should the medical assistant take?
ANSWER: Laura and her mother should be moved away from
other patients in the waiting room to a private area. Since she is
coughing and could have an infection spread by droplet, the
medical assistant and physician should wear a mask and gloves
when in the room. In addition, the room should be cleaned and
sanitized following the appointment.
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38-17
Preparing the Patient for an Exam
• Emotional preparation
– Explain exactly what will occur and what they
will feel
– Use simple direct language
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38-18
Preparing the Patient for an Exam
• Physical
– Offer the bathroom
– Ask the patient to disrobe and put on an exam
gown or cover with a drape
– Be aware of
modesty and
comfort
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38-19
Apply Your Knowledge
What can you do to elicit the patient’s cooperation
during a physical exam?
ANSWER: Explain what she can expect to
happen during the examination and that her
cooperation will help the exam proceed
smoothly.
Way to go!
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38-20
Positioning and Draping
• Proper patient position facilitates the
examination
– Assist the patient to appropriate position
– Make as comfortable as possible
– Cover with appropriate drape
• Keep patient warm
• Maintain privacy/modesty
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38-21
Positioning and Draping (cont.)
• Sitting
• Supine/recumbent
– Symmetry
• Dorsal recumbent
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38-22
Positioning and Draping (cont.)
• Lithotomy
• Fowler’s
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38-23
Positioning and Draping (cont.)
• Prone
• Sims’
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38-24
Positioning and Draping (cont.)
• Knee-Elbow
• Proctologic
– Fenestrated drape
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38-25
Apply Your Knowledge
An elderly female patient needs her lower abdomen and
genitalia examined by the physician. What would be the
best position to place her in and why?
ANSWER: The dorsal recumbent position is recommended over
the lithotomy position because an elderly patient may have
difficulty placing her legs in stirrups.
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38-26
Special Patient Considerations
• Patients from different cultures
– Avoid stereotyping and making judgments
– Patients
• May not know what to expect
• May require more privacy
• May refuse a specific exam
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38-27
Special Patient Considerations
• Patients with disabilities – provide
assistance as needed
– Disrobing
– Moving to exam table
– Assuming exam
position
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38-28
Apply Your Knowledge
Why is it important to avoid stereotyping when
caring for patients from other cultures?
ANSWER: This can lead to making incorrect
judgment that may influence the care you
provide the patient.
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38-29
Examination Methods
• Inspection
– Visual exam
– Posture,
mannerisms, and
hygiene
• Auscultation
– Listening to body
sounds using a
stethoscope
– Size, shape, color,
position, symmetry
– Presence of
abnormalities
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38-30
Examination Methods (cont.)
• Palpation
• Percussion
– Touch
– Assess texture,
temperature, shape
– Presence of
vibration or
movements
– Tapping or striking
the body to hear
sounds or feel
vibrations
– Used to determine
location, size, or
density of structure
or organ
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38-31
Examination Methods (cont.)
• Mensuration –
process of
measuring
• Manipulation
– Systemic moving of
a patient’s body
parts
– Check for
abnormalities
– Determine range of
motion of joints
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38-32
Apply Your Knowledge
Jimmy Jones is complaining of abdominal pain. What types
of examination methods will the physician most likely use to
assess this complaint?
ANSWER: The physician will use inspection to
determine if there are any visual abnormalities of
Jimmy’s abdomen, palpation to feel for any
abnormalities, percussion to assess for vibrations, and
auscultation to assess bowel sounds. The medical
assistant may be asked to measure the abdominal girth.
Ole!
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38-33
Components of the General Physical
Examination
• Exams – performed in a certain order
– General appearance
– Specific body sections
• Become familiar with the standard order
for performing an exam
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38-34
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
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38-35
Components of the General Physical
Examination (cont.)
• General appearance • Head
– General state of
heath
– Distress or pain
– Abnormal
condition of scalp
or skin
– Puffiness
– Skin
– Nails and nail beds
– Abnormal growths
– Hair
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38-36
Components of the General Physical
Examination (cont.)
• Neck
• Eyes
– Lymph nodes,
thyroid glands, and
major blood
vessels
– Symmetry and
range of motion
– The presence of
disease or
abnormalities
– Pupils for light
response
– Muscles
– Internal structures
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38-37
Components of the General Physical
Examination (cont.)
• Ears
• Nose and sinuses
– Outer ear
– Infection or allergy
• Symmetry and size
• Lesions, redness,
or swelling
– Inner ear structures
– Nasal mucosa
– Tenderness in
sinuses
• Canals
• Eardrums
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38-38
Components of the General Physical
Examination (cont.)
• Mouth and throat
– Mouth ~ overall
health and hygiene
– Throat ~ swelling
or redness
• Chest and lungs
– Hyperventilation
– Inspection
– Auscultation
– Palpation and
percussion
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38-39
Components of the General Physical
Examination (cont.)
• Heart
• Breasts
– Percussion – size
of heart
– Auscultation
• Heart sounds
• Rate, rhythm,
intensity, and pitch
– Inspection
– Palpation
• Lymph nodes
• Breasts
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38-40
Components of the General Physical
Examination (cont.)
• Abdomen
– Inspection
– Auscultation
– Findings described
using system of
landmarks
– Percussion
– Palpation
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38-41
Components of the General Physical
Examination (cont.)
• Female genitalia
– Lithotomy position
– Assist to relax
• Male genitalia
– Inspection
• Penis and scrotum
• Groin
– Palpation
• Penis and scrotum
• Lymph nodes
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38-42
Components of the General Physical
Examination (cont.)
• Rectum
– Palpation using a digital exam
• Lesions or abnormalities
• Occult blood
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38-43
Components of the General Physical
Examination (cont.)
• Musculoskeletal system
– Posture ~ scoliosis
– Muscle strength
– Gait
– Body
measurements
– Range of motion
– Lesions,
deformities, or
circulatory
problems
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38-44
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
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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.
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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
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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.
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38-48
Additional Tests and Procedures
• After dressing
– Urine reagent strip tests
– Pulmonary function tests
– Eye or ear irrigation or medication
administration
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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
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38-50
Follow-Up
• Scheduling appointments
– Future office visits
– Outside appointments
• Helping plan for home nursing care
• Helping the patient obtain assistance
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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!
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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.
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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.
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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
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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.
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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.
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38-57
In Summary (cont.)
38. 9 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.
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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
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in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.