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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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 2 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 3 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 4 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 5 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 6 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 7 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 8 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 9 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 10 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 11 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 12 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 13 Preparation of the Examining Room 1. Important to properly prepare examining room a. Provides comfortable and healthy environment b. Facilitates the PE Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 14 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 15 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 16 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 17 Preparation of the Examining Room, cont. k. Clean and prepare items the physician will be using for examinations: • Equipment • Instruments • Supplies Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 18 Physical Exam Equipment and Supplies Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 19 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 20 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 21 Physical Exam Equipment and Supplies, cont. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 22 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 23 Identify the Patient Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 24 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 25 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 26 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 27 Identify the Patient Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 28 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 29 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 30 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 31 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 32 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 33 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 34 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 35 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 36 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 37 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 38 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 39 Balance the Scale Balance the Scale Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 40 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 41 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 42 Measuring Weight Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 43 Measuring Weight and Height, cont. • Interpret calibration markings accurately – Lower calibration bar: divided into 50-pound increments Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 44 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 45 Measuring Weight Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 46 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 47 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 48 Measuring Height Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 49 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 50 Measuring Height Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 51 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 52 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 53 Measuring Height Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 54 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 55 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 56 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 57 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 58 Sitting Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 59 Supine b. Supine: Examination of head, chest, abdomen, extremities • Not a comfortable position for patients with: – Respiratory problems – Back injury – Low back pain Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 60 Supine, cont. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 61 Prone c. Prone: Examination of back; assess extension of hip joint Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 62 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 63 Dorsal Recumbent Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 64 Lithotomy e. Lithotomy: Vaginal, pelvic and rectal examinations Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 65 Sims f. Sims: Used to examine the vagina and rectum, to measure rectal temperature, to perform a flexible sigmoidoscopy, an to administer an enema Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 66 Knee-Chest g. Knee-chest: Examine the rectum, perform a proctoscopic examination Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 67 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 68 Fowler’s, cont. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 69 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 70 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 71 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 72 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 73 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 74 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 75 Inspection, cont. • Observe patient for: – Color – Speech – Deformities – Skin condition – Body contour and symmetry – Orientation to the surroundings – Body movements – Anxiety level Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 76 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 77 Palpation, cont. • Used to determine: – Placement and size of organs – Presence of lumps – Pain – Swelling – Tenderness Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 78 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 79 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 80 Palpation, cont. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 81 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 82 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) Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 83 Percussion, cont. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 84 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 85 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 86 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 Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 87 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 88 What Would You Do? What Would You Not Do? Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 89 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 90 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. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 91