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CHAPTER 5
THE PHYSICAL EXAMINATION
PRETEST
True or False
1. A complete patient examination consists of a physical
examination and laboratory tests.
2. Arthritis is an example of a chronic illness.
3. An otoscope is used to examine the eyes.
4. A patient should be identified by name and date of
birth.
5. The reason for weighing a prenatal patient is to
determine the baby's due date.
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PRETEST, CONT.
True or False
6.
The height of an adult is measured during every
office visit.
7.
The lithotomy position is used to examine the vagina.
8.
Inspection involves the observation of the patient for
any signs of disease.
9.
Measuring blood pressure is an example of
auscultation.
10. The supine position is used to examine the back.
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Content Outline
Introduction to the Physical Examination
1. Complete patient examination
consists of:
a. Health history
b. Physical examination (PE)
c. Laboratory and diagnostic tests
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Introduction to the Physical
Examination, cont.
2. Results used by physician to:
a. Determine patient's state of health
b. Arrive at a diagnosis and prescribe
treatment
c. Observe any change in patient's illness
after treatment has been instituted
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Introduction to the Physical
Examination, cont.
3. MA has an important role in assisting the
physician with a PE
4. Purpose of PE
a. To detect early signs of illness
•
Helps prevent serious health problems
b. Prerequisite for employment
c. Participation in sports
d. Attendance at summer camp
e. Admission to school
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Definition of Terms
1. Final diagnosis: scientific method of
determining and identifying a patient's
condition through evaluation of the health
history, PE, laboratory tests, and diagnostic
procedures
a. Often simply called the diagnosis (dx)
b. Provides a logical basis for treatment and
prognosis
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Definition of Terms, cont.
2. Clinical diagnosis: intermediate step in the
determination of a final diagnosis
a. Obtained through evaluation of health
history and PE (without laboratory and
diagnostic tests)
b. Outside laboratories provide space on
laboratory request: to specify clinical
diagnosis
•
Assists laboratory in correlating clinical data
with the physician's needs
c. Once physician has analyzed test results:
final diagnosis can usually be established
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Definition of Terms, cont.
3. Differential diagnosis: two or more diseases
may have similar symptoms
a. Determines which disease is causing the
symptoms so that a final diagnosis can be
made
b. Example: “Strep” throat and pharyngitis
have similar symptoms
•
Differential diagnosis is made by strep test
4. Prognosis: probable course and outcome of a
patient's condition and the patient's prospects
for recovery
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Definition of Terms, cont.
5. Risk factor: physical or behavioral condition
that increases the probability that an individual
will develop a particular condition
a. Includes:
•
Genetic factors
•
Habits
•
Environmental conditions
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Definition of Terms, cont.
c. Does not mean the disease will develop
•
Only that chance is greater of developing it
•
Example: Smoking is a risk factor for lung
cancer and heart disease
6. Acute illness: characterized by symptoms
that have a rapid onset
a. Usually severe and intense
b. Subside after a short time
•
Example: influenza
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Definition of Terms, cont.
7. Chronic illness: characterized by symptoms
that persist for more than 3 months
a. Patient shows little change over a long time
•
Examples: diabetes, hypertension, emphysema
8. Therapeutic procedure: a procedure
performed to treat patient's condition with the
goal of eliminating it or promoting as much
recovery as possible
a. Example: administration of medications
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Definition of Terms, cont.
9. Diagnostic procedure: performed to assist
in the diagnosis of a patient's condition
a. Examples: electrocardiography, x-ray
examination
10.Laboratory testing: the analysis and study of
specimens obtained from patient to assist in
diagnosis and treatment of disease
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Preparation of the Examining Room
1. Important to properly prepare examining
room
a. Provides comfortable and healthy
environment
b. Facilitates the PE
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Preparation of the Examining Room,
cont.
2. Guidelines:
a. Should be free from clutter and well lit
b. Check daily for ample supplies; restock as
needed
c. Empty waste receptacles frequently
d. Replace biohazard containers as necessary
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Preparation of the Examining Room,
cont.
e. Room should be well ventilated
f. Maintain room temperature
•
Should be comfortable for both clothed and
unclothed patients
g. Clean and disinfect daily:
•
Examining tables
•
Countertops
•
Faucets
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Preparation of the Examining Room,
cont.
h. Remove dust and dirt from furniture and
towel dispensers
i. Change examining table paper after each
patient; restock gowns and drapes as
needed
j. Patient's privacy should be ensured
•
Keep examining room door closed during
patient examination
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Preparation of the Examining Room,
cont.
k. Clean and prepare items the physician will
be using for examinations:
•
Equipment
•
Instruments
•
Supplies
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Physical Exam Equipment and
Supplies
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Physical Exam Equipment and
Supplies, cont.
l. Check equipment and instruments
frequently for proper working condition
•
Protects patient from harm caused by faulty
equipment
m. Have equipment and supplies ready for
examination
•
Arrange for easy access by physician
•
Type varies based on:
– Type of examination
– Physician's preference
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Physical Exam Equipment and
Supplies, cont.
n. Know how to operate and care for
equipment
•
Refer to the operating manual
– Read carefully
– Keep available for reference
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Physical Exam Equipment and
Supplies, cont.
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Preparation of the Patient
1. MA's responsibility: prepare the patient
for PE:
a. After escorting patient to examining room
•
Identify the patient by name and date of birth
– Purpose:
1) To avoid mistaking one patient for
another
2)
(a) Could be held liable if perform
procedure on wrong patient by mistake
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Identify the Patient
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Preparation of the Patient, cont.
b. Take vital signs
c. Measure height and weight
d. Explain purpose of examination and offer to
answer questions
e. Apprehension can be reduced by:
•
Address patient by name of choice
•
Have a friendly and supportive attitude
•
Speak clearly, distinctly, and slowly
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Preparation of the Patient, cont.
f. Ask patient if he needs to empty the bladder
before examination
•
Makes examination easier for physician to
perform
– Makes examination more comfortable for
patient
•
If urine specimen is needed: patient is asked to
void
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Preparation of the Patient, cont.
g. Instructions for disrobing should be
specific
•
Clothing that should be removed
•
Where to place clothing
– Instructions for putting on gown and
location of gown opening
– MA should offer assistance if needed
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Identify the Patient
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Preparation of the Patient, cont.
h. Disrobing facility should be comfortable
and private
•
Helpful to have a place for patient to sit
•
Should have hooks and hangers for clothing
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Preparation of the Patient, cont.
i. MA should have patient's medical record
available for review by the physician
•
Use designated location for medical record
a. Shelf next to examining room door
b. Chart holder on outside of door
•
Follow HIPAA privacy rule to protect patient's
health info
– Patient-identifiable info should not be visible
j. Help patient on and off the examining table
for safety
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Measuring Weight and Height
1. Mensuration: process of measuring
the patient
2. Change in weight may be significant in:
a. Diagnosis of patient's condition
b. Prescribing treatment
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Measuring Weight and Height, cont.
3. Underweight and overweight patients on
diet therapy program:
a. Should have weight taken regularly to
determine progress
4. Prenatal patients weighed at each
prenatal visit to:
a. Assess fetal development
b. Assess mother's health
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Measuring Weight and Height, cont.
5. Adult weight is measured at each office
visit
6. Adult height usually only measured:
a. First office visit
b. Complete PE
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Measuring Weight and Height, cont.
7. Children weighed and measured at each
office visit to:
a. Observe pattern of growth
b. Calculate and determine medication
dosage
8. Height and weight are compared against
a standardized chart:
a. Determines if patient falls within normal
limits
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Height and Weight
From Report of the Dietary Guidelines Advisory Committee on the dietary guidelines for Americans, Washington, DC 1995,
U.S. Department of Health and Human Services.
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What Would You Do?
What Would You Not Do?
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What Would You Do?
What Would You Not Do?
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Measuring Weight and Height, cont.
9. Guidelines for Measuring Weight
and Height
a. Weight: Using an upright balance scale
•
Locate scale to provide privacy for patient
– Many patients are self-conscious about
having weight measured
– Be careful not to make weight-sensitive
comments during procedure
1) Especially important for patients with
weight control problems (obesity,
eating disorders)
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Measuring Weight and Height, cont.
•
Balance scale
– If scale not balanced: measurement will be
inaccurate
– Scale is balanced:
1) When upper and lower weights are on
zero
2) Indicator point comes to a rest at center
of balance area
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Balance the Scale
Balance the Scale
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Measuring Weight and Height, cont.
•
Assist the patient
– Assist patient on and off the scale platform
– Platform moves slightly: may cause patient
to become unsteady
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Measuring Weight and Height, cont.
•
Obtain an accurate weight
– Ask patient to remove shoes
– Measure weight with patient in normal
clothing
– Ask patient to remove heavy outer clothing:
1) Sweater
2) Jacket
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Measuring Weight
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Measuring Weight and Height, cont.
•
Interpret calibration markings accurately
– Lower calibration bar: divided into 50-pound
increments
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Measuring Weight and Height, cont.
– Upper calibration bar is divided into pounds
and quarter pounds
1) Longer calibration lines: indicate pound
increments
2) Shorter calibration lines indicate
quarter-pound and half-pound
increments
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Measuring Weight
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Measuring Weight and Height, cont.
•
Determine patient's weight correctly
– Add the measurement on lower scale
to measurement on upper scale
– Round results to nearest quarter
pound
– Occasionally weight may need to be
converted to kilograms (metric unit)
1) May be required to determine
medication dosage
2) 1 kg = 2.2 pounds
3) To convert pounds to kg: Divide
the number of pounds by 2.2
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Measuring Weight and Height, cont.
b. Height: Using an upright balance scale
•
Provide for patient's safety
– Do not place patient on scale in a forward
position
1) Measuring bar could fall into patient's
face when patient steps off scale: could
cause a facial injury.
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Measuring Height
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Measuring Weight and Height, cont.
•
Determine the calibration markings accurately
– Calibration markings are divided into either:
1) Inches
2) Feet and inches
– Calibration rod is also calibrated into
centimeters (metric unit)
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Measuring Height
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Measuring Weight and Height, cont.
•
Read the measurement correctly
– Read the measurement at the junction of the
stationary calibration rod and the movable
calibration rod
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Measuring Weight and Height, cont.
– If patient's height is less than the top value
of the stationary calibration rod
1) Read the measurement directly on the
stationary rod
a) On most scales: highest calibration
on stationary rod is 50 inches
b) Patients with a height of 50 inches
or less will have their height read
directly on stationary rod
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Measuring Height
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Measuring Weight and Height, cont.
•
Record the height measurement correctly.
– Record height measurement in feet and
inches.
– If the scale is calibrated in inches:
1) Convert the reading to feet and inches:
divide the number of inches by 12
2) Example: Height measurement of 60
inches is recorded as 5 feet (60 inches
divided by 12 equals 5)
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What Would You Do?
What Would You Not Do?
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What Would You Do?
What Would You Not Do?
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Positioning and Draping
1. Correct positioning of the patient
facilitates the examination
a. Permits better access to part being
examined
2. Basic positions and use of each:
a. Sitting: Examination of the head, neck,
chest, upper extremities; measure vital
signs
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Sitting
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Supine
b. Supine: Examination of head, chest, abdomen,
extremities
•
Not a comfortable position for patients with:
– Respiratory problems
– Back injury
– Low back pain
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Supine, cont.
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Prone
c. Prone: Examination of back; assess extension of
hip joint
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Dorsal Recumbent
d. Dorsal recumbent: Vaginal and rectal
examinations, insertion of urinary catheter, examine
the head, neck, chest and extremities of patients
who have difficulty maintaining supine position
•
Bending of legs is more comfortable for some
patients
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Dorsal Recumbent
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Lithotomy
e. Lithotomy: Vaginal, pelvic and rectal
examinations
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Sims
f. Sims: Used to examine
the vagina and rectum,
to measure rectal
temperature, to perform
a flexible sigmoidoscopy,
an to administer an
enema
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Knee-Chest
g. Knee-chest: Examine the rectum, perform
a proctoscopic examination
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Fowler’s
h. Fowler's:
•
Examine upper body of patients with
cardiovascular and respiratory problems
(congestive heart failure, emphysema, asthma)
– Easier for these patients to breathe in this
position
•
Draw blood from patients likely to faint
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Fowler’s, cont.
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Positioning and Draping, cont.
3. Position used depends on type of
examination being performed
a. More than one position may be used to
examine the same body part
b. Explain position to patient and assist them
into it
c. Take patient's endurance and degree of
wellness into consideration
•
Weak or ill patient may not be able to assume a
position
•
May require special assistance in attaining it
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Positioning and Draping, cont.
d. Do not keep patient in uncomfortable
positions longer than necessary
e. Let the patient rest before getting off the
examining table
•
Some positions cause patient to become dizzy
f. Assist patient off table to prevent falls
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Positioning and Draping, cont.
4. Draping provides modesty, comfort, and
warmth
a. Only part being examined should be
exposed
5. Gowns and drapes are made of paper or
cloth
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Assessment of the Patient
1. Extent of assessment during PE
depends on:
a. Purpose of examination
b. Patient's condition
2. Complete PE: Thorough assessment of all
body systems
a. Physician uses an organized and systemic
approach:
•
Starts with head and proceeds toward the feet
•
Facilitates the examination process
•
Requires fewest position changes
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Assessment of the Patient, cont.
3. Results are charted by physician in
patient's medical record
a. See Figure 5-6
4. Patients who exhibit symptoms of illness:
a. Do not require a complete PE
b. Physician examines body system
associated with symptom
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Inspection
5. Assessment techniques
a. Inspection: The process of observing a patient to
detect the signs of disease
•
Assessment technique most frequently used
•
Good lighting is required
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Inspection, cont.
•
Observe patient for:
– Color
– Speech
– Deformities
– Skin condition
– Body contour and symmetry
– Orientation to the surroundings
– Body movements
– Anxiety level
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Palpation
b. Palpation: The process of feeling with the hands to
detect the signs of disease
•
Helps verify data obtained from inspection
•
Patient's verbal and facial expressions are
observed
– Assists in detection of abnormalities
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Palpation, cont.
•
Used to determine:
– Placement and size of organs
– Presence of lumps
– Pain
– Swelling
– Tenderness
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Palpation, cont.
•
Examples of palpation
– Breast examination
– Measuring radial pulse
•
Types of palpation
– Light: to determine areas of tenderness
1) Fingertips are placed on the body part
2) Gently depressed ½ inch
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Palpation, cont.
– Deep: to examine condition of organs
1) Two hands are used
a) One to support the body from
below
b) Other to press over the area
– Example: bimanual pelvic examination
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Palpation, cont.
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Percussion
c. Percussion: The process of tapping body and
listening to the sounds produced to detect the signs
of disease
•
Used to determine:
– Size of organs
– Density of organs
– Location of organs
•
Example: examination of lungs and abdomen
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Percussion, cont.
•
Technique
– Fingertips used to produce sound
– Nondominant hand: placed over area with
fingers slightly separated
– Dominant hand: strike the joint of middle
finger placed on patient to produce a sound
1) Dense structures: produce a dull sound
(liver)
2) Empty or air-filled structures: produce a
hollow sound (lungs)
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Percussion, cont.
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Ausculatation
d. Auscultation: The process of listening with a
stethoscope to the sounds produced within the body
to detect the signs of disease
•
Used to:
– Listen to heart and lungs
– Measure blood pressure
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Auscultation, cont.
•
Guidelines
– Minimize environmental noise
1) Interferes with effective listening
– Diaphragm chestpiece: used for highpitched sounds (lung and bowel)
– Bell chestpiece: used for low-pitched
sounds (heart and vascular system)
– Clean chestpiece with an antiseptic and
warm it before placing on the patient
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Assisting the Physician
1. The MA is responsible for:
a. Helping patient change positions
b. Handing physician instruments and supplies
c. Reassuring patient
d. Assisting patient off the examining table
after the PE
e. Providing patient with additional information
if needed
•
Scheduling a return visit
•
Patient education
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What Would You Do?
What Would You Not Do?
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What Would You Do?
What Would You Not Do?
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POSTTEST
True or False
1.
2.
3.
4.
5.
The prognosis is what is wrong with the patient.
A risk factor means that a patient will develop a
certain disease.
A CT scan is an example of a therapeutic procedure.
The function of a speculum is to open a body orifice
for viewing.
The process of measuring the patient is called
mensuration.
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POSTTEST, CONT.
True or False
6.
A reason for weighing a child is to determine drug
dosage.
7. The purpose of draping a patient is to make it easier
for the physician to examine the patient.
8. Sims position is used for flexible sigmoidoscopy.
9. Measuring pulse is an example of percussion.
10. BMI is the abbreviation for body mass index.
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