Chapter 25: Assisting with the Primary Physical Examination PDF

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Chapter 25: Assisting with the Primary Physical Examination Anatomy and Physiology 

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Cells (basic unit of life) o Plasma membrane o Intracellular environment o Nucleus Tissues o Epithelial (simple or stratified epithelium) o Connective (most widely distributed in body) o Muscle (skeletal, cardiac, smooth) o Nervous (neurons and neuroglia cells) Organs o May have one or many functions o Part of one or several systems Systems o Made up of organs and associated structures o Work together to perform specific functions Briefly explain the three parts of the cell. (The plasma membrane surrounds the cell; the intracellular environment houses the cytoplasm, which has living material to carry out cell function; and the nucleus contains the genetic code of the cell.) Epithelial tissue makes up skin, glands, and linings of organs and body cavities and can be considered squamous, cuboidal, columnar, or transitional. Connective tissue supports and binds other body tissues and includes collagen, bone, cartilage, adipose, ligaments, tendons, blood, and lymph. Muscle tissue produces movement. Nervous tissue conducts nerve impulses between the periphery and the central nervous system, effects rapid communication between body structures, and controls the body’s functions to maintain homeostasis. Each system has specific units in it, and each performs specific functions. Reference Table 25-1 for more information about the cells, organs, structures, and functions of each body system. Table 25-1 summarizes the body systems; their primary cells, organs, and structures; and the major functions of each.

Primary Care Provider       

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Treats patients of all ages Provides lifetime healthcare for families Primary care referral system Evaluates all healthcare needs Works with the medical assistant to give quality care What is primary care referral system? (This means that most patients are required to have a PCP as the gatekeeper in personal healthcare.) The PCP evaluates the patient’s total healthcare needs, provides personal medical care within one or more fields of medicine, and refers the patient to a specialist when an advanced or serious condition warrants additional expertise. The medical assistant’s clinical responsibilities in a primary care office include assisting with patients who may have problems in any of the body systems and with procedures in all age groups. Family practitioners

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Pediatricians Internists Obstetricians/gynecologists Nurse practitioners (NPs) and physician assistants (PAs) PCP professionals include these. The medical assistant’s clinical responsibilities in a PCP practice include assisting with patients who may have problems in any of the body systems and with procedures in all age groups.

Physical Examination 

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The medical assistant’s roles include: o Room preparation o Patient preparation o Assisting the provider As the physician examines the entire body, he or she interprets the findings, and by the time the examination has been completed, the physician has formed an initial diagnosis of the patient’s condition. Before the examination, the medical assistant has the opportunity to make sure that the patient feels comfortable during the examination process and that all the necessary medical information has been obtained. As part of patient preparation, the medical assistant should verify the patient’s insurance information and document current medications and allergies.

Room Preparation          

Stock with all equipment and supplies Check expiration dates, and discard expired materials Ensure the room is private, well lit, and a good temperature Clean and disinfect room between patients to avoid infection Be sure drapes, sheets, and gowns are ready to use Arrange equipment for easy access Observe Standard Precautions The room should always be as comfortable as possible and free of any potential dangers. The medical assistant must understand how to take care of and operate all equipment and instruments and should refer to operation manuals supplied by manufacturers as needed. What supplies and materials are needed for Standard Precautions? (Precautions include disposable gloves, a sink with an antibacterial handwashing agent, paper towels, biohazard waste containers, sharps containers, and impervious gowns and face guards.)

Patient Preparation      

Ensure medical record is complete and consent forms are signed Introduce yourself and address patient by preferred name Verify accuracy of insurance information by office policy Obtain any preordered specimens Measure height, body mass index, and vital signs If specimens have been preordered by the physician, the medical assistant will know.

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Explain to the patient what clothing should be removed and in what direction to put on the gown (open to the front or to the back, depending on the type of examination). If necessary, provide a drape to ensure the patient’s privacy. Assist the patient into and out of various examination positions as needed, explain what is happening, and consistently maintain the patient’s privacy and confidentiality. Place the patient’s medical record in the designated area for the physician, usually in a chart holder on the examination room door (if a written record) or update the EHR as needed. Maintain confidentiality and privacy. You may need to assist with patient dressing after the examination.

Assisting the Provider        

Hand out equipment and supplies as needed Alter position of lamp and turn lights on/off as needed Position the drape during phases of the examination Collect and properly label all specimens Perform follow-up diagnostic procedures as needed Alter the position of a gooseneck lamp to better illuminate the area being examined and turn lights off and on during specific phases of the examination. Conduct follow-up diagnostic procedures as ordered, including an electrocardiogram (ECG), eye or ear screening, urinalysis, and phlebotomy. Schedule post examination diagnostic procedures, such as mammography, x-ray examination, or colonoscopy.

Supplies and Instruments Needed for Examination       

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Figure 25-2 shows instruments for the physical examination. Supplies and instruments enable the physician to see, feel, inspect, and listen to parts of the body. All equipment must be in good working order, properly disinfected, and readily available for the physician’s use during the examination. Ophthalmoscope o For inspection of inner eye structures Tongue depressor o Holds tongue down during throat examination Otoscope o For examination of the external auditory canal and tympanic membrane How does an otoscope work? (The head of the otoscope has a light that is focused through a magnifying lens, should be covered with a disposable ear speculum, and can be used to see nasal passages and the throat.) When the handles of the nasal speculum are squeezed, the tips spread apart to dilate the nostrils, allowing the physician to visualize the internal aspects. Tuning fork o Tests auditory acuity, bone vibration Figure 25-3: A shows tuning forks. B shows a sound vibration test. C shows a bone vibration test.

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Tuning fork prongs produce a humming sound when they are struck with the hand. They are used to check the patient’s auditory acuity and bone vibration. Tape measure Stethoscope o Listening device when body parts are auscultated Reflex hammer o Used to test neurologic reflexes Gloves o Protection from microorganisms Additional supplies The stethoscope is used to listen mainly to the heart and lungs. A stethoscope is shown in Figure 25-4. According to Standard Precautions, gloves must be worn whenever the potential exists for contact with any bodily fluid, broken skin or wounds, or contaminated items. What are additional supplies that might be needed for the examination? (These supplies include gauze squares, cotton balls, cotton-tipped applicators, specimen containers, hemoccult packets, Pap smear supplies for female patients, lubricating jelly for vaginal and rectal examinations. Laboratory request forms should be easily accessible during the examination.)

Principles of Body Mechanics   

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Used consistently in work environment Proper alignment begins with good posture When reaching for object: o Don’t twist or turn o Turn feet toward object Don’t sit with legs crossed

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Proper body mechanics should be used when sitting or standing, lifting or carrying objects, pushing or pulling, or transferring patients. Good posture keeps the spine balanced and aligned while a person is sitting or standing. Do not cross the legs while sitting because this interferes with circulation to the legs and feet. When sitting, keep the popliteal area (behind the knees) free of the edge of the chair. Do a mental check of your posture regularly

Transferring a Patient      

Focus on correct body mechanics Provide support on the patient’s strong side Keep one hand under the axillary region and one on forearm Always bend at the knees Ensure the patient is safely positioned When bending, always bend at the knees and maintain the back’s three natural curves, allowing the leg muscles to help in lifting.

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You may need to remain with the patient until the examination has been completed to ensure the patient’s safety. Figure 25-7 shows the wheelchair at a 45-degree angle at the end of the examination table. How do you move a patient in a wheelchair? (If the patient is in a wheelchair, move the chair close to the examination table, lock the wheels, and lift the footrests of the wheelchair out of the way.) Refer to Procedure 25-1 to learn how to use proper body mechanics to safely transfer a patient from a wheelchair to an examination table.

Draping the Patient    

Drape the patient to protect privacy and keep the patient warm Position the sheet so that it allows complete visibility for examiner to conduct examination Expose one portion of body at a time during examination For gynecologic and rectal examinations, the sheet is positioned on the diagonal across the patient, or in a diamond shape, to provide maximum comfort for the patient while allowing the physician to perform the examination.

Positioning the Patient

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Fowler’s position Semi-Fowler’s position Supine (horizontal recumbent) position Dorsal recumbent position Lithotomy position Sims position In Fowler’s position, the patient simply sits at the edge of the table; for semi-Fowler’s position, the position is at a 45-degree angle. These positions are good for head, chest, neck, and postoperative examinations. In the supine position the patient lies flat with the face upward and the lower legs supported by the table extension and is useful for examining the front of the body. In the dorsal recumbent position, the patient is face upward with flexed knees; this position may be used for examination and/or inspection of the rectal, vaginal, and perineal areas. The lithotomy position is used primarily for vaginal examinations that require the use of a speculum and for Pap smears. Sims position is used for rectal examination, for instillation of rectal medication, and for some perineal and pelvic examinations. Procedure 25-2 describes how to prepare and position the patient using the Fowler’s and semiFowler’s positions. Procedure 25-3 describes how to prepare and position the patient using the horizontal recumbent and dorsal recumbent positions. Procedure 25-4 describes how to prepare and position the patient using the lithotomy position. Procedure 25-5 describes how to prepare and position the patient using the Sims position. Prone position Face down on ventral surface of the body Knee-chest position Difficult to maintain Rarely used in ambulatory care setting On a female patient, the drape should extend high enough to cover the breasts if the patient is to be turned over to the dorsal recumbent position during the examination. Explain the knee-chest position. (The patient rests on the knees and the chest with the head turned to one side. The arms can be placed under the head for support and comfort, or they can be bent and placed at the sides of the table near the head. The thighs are perpendicular to the table and slightly separated. The buttocks extend up into the air, and the back should be straight.) Procedure 25-6 describes how to prepare and position the patient using the prone position. Procedure 25-7 describes how to prepare and position the patient using the knee-chest position.

Trendelenburg Position   

Rarely used in ambulatory setting The Trendelenburg position, as shown in Figure 25-8, may be needed if a patient has severe hypotension or is going into shock. This position can be achieved only if the examination table separates so that the head can be tilted lower than the legs.

Methods of Examination         

Inspection Palpation Percussion Auscultation Mensuration Manipulation Healthcare providers use six methods to examine the human body. All six are part of a complete physical examination. What are some things that may be observed during inspection? (This part focuses on general appearance and mannerisms to body gait and deformities.) Mensuration is the act of measuring, and manipulation is the passive movement of a joint to determine the range of extension or flexion of a part of the body.

Palpation, Percussion, and Auscultation   

In palpation (Figure 25-9, A), a part of the body is felt with the hand to determine its condition or the condition of an underlying organ. Percussion (Figure 25-9, B) aids determination of the position, size, and density of an underlying organ or cavity. In auscultation (Figure 25-9, C), the provider uses a stethoscope to listen to sounds originating from the patient’s body.

Examination Sequence            

General appearance o Disorientation, gait, posture, nourishment Nutrition and stature o Record height, weight, body mass index Speech o Could reveal pathologic condition Breath odors o Poor oral hygiene or dental care The presenting appearance includes signs of disorientation or undernourishment and vice versa. The patient’s gait should also be observed. Sometimes abnormalities in height or body proportion may be caused by hormonal imbalances. What are some basic speech defects? (They include aphonia, aphasia, dysphasia, and motor aphasia.) Acidosis produces a strong odor of acetone, which is sweet and fruity, and may result from diabetes mellitus, starvation, or renal disease. Skin o Note fingernails and toenails Head o How patient handles stress and illness Eyes and ears o PERRLA Nose and sinuses

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o Mucosa examined for color/texture Mouth and throat o Oral hygiene and dental care The condition of the skin can be a good reflection of the patient’s nutritional status and hydration level. The skull, scalp, and face are palpated for size, shape, and symmetry. The distribution or lack of hair and the hair texture may indicate hormonal changes. As the head is palpated, the physician assesses possible nodules, masses, or signs of trauma. If the pupils constrict equally and smoothly to a light stimulus, the physician documents "PERRLA" (which means the pupils are equal, round, respond to light, and adjust and focus on objects). The ears are checked with an otoscope for inflammation and earwax. Dental hygiene includes the condition of the teeth, how the patient cares for the teeth and gums, and whether the teeth of the upper and lower jaws meet properly (occlude) for chewing. Neck o Examined for range of motion (ROM) Chest o Examine heart, chest, lungs Abdomen o Relaxation of abdominal muscles Reflexes o Checked in high Fowler’s and supine positions During neck examination, the carotid artery and lymph nodes are palpated. While the patient is sitting, the biceps are checked with the patient’s arm flexed and supported by the examiner. The knee jerk (patellar reflex) and the ankle jerk (Achilles reflex) are checked using tapotement (a tapping or percussing movement) with either the fingers or the reflex hammer. With the stethoscope to the patient’s back, the examiner auscultates lung sounds. The patient is asked to take deep, regular breaths. The abdomen is examined with the patient in the dorsal recumbent position. Breasts and testicles o Examined visually and by palpation o Testicular examination Rectum o Maintain comfort and dignity o Examination gloves and lubricating jelly needed Breast cancer is the most common malignancy in women, and early detection is the key to successful treatment. It is important for all males to perform a testicular self-examination each month because testicular carcinoma is a major health risk. Hemoccult test specimens often are collected at the time of the digital rectal examination. If this is a procedure the physician performs, be sure to include the necessary collection folder with the examination equipment.

Role of the Medical Assistant   

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Never consider the examination to be routine Have the room, supplies, and equipment ready Patient prepared o Vitals o Weight, height, body mass index Diagnostic procedures completed Restock supplies and disinfect the area During the examination, the medical assistant should be prepared to hand the physician needed equipment or to assist in any other way necessary. Assist in the patient’s discharge; answer the patient’s questions or complete patient education. Refer to Procedure 25-8 for the steps in how to assist the provider with a patient examination.

Patient Education 

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Consider the following: o What information the patient needs to know o How to convey the information so that the patient understands it o How the patient will use the information o Whether any community resources are available that might help o Whether the patient understands and will learn more about health problems or treatment protocols Develop a plan to teach the patient. Think about the different modalities available, such as pamphlets, pictures, DVDs, demonstrations, and community resources.

Legal and Ethical Issues 

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HIPAA applications o Guard patient confidentiality during all parts of a visit o If paper records are used, place medical records facing the door o If EHRs are used, safeguard patient information by closing patient files and locking computers when you are out of the room o Place physician’s schedule away from patient areas Information gained during the physical examination is confidential and must remain that way....