Felicia Grand, a newly hired certified medical assistant (CMA, AAMA), works for Dr. Anna Kosto, who is a member of a busy multiphysician primary care practice. One of Felicia’s chief responsibilities is to assist Dr. Kosto with physical examinations. Her duties include preparing and maintaining the examination room and equipment; getting the patient ready for specific physical examinations; and gowning, draping, and positioning the patient as needed. Because Felicia will be assisting with examinations, she must become familiar with the physical examination procedure and the order in which the physician needs various pieces of medical equipment. It also is important that Felicia protect herself from possible injury by using appropriate body mechanics throughout her day in the office.

While studying this chapter, think about the following questions:

• What equipment does Felicia need to gather before the physician enters the examination room to make sure the examination goes smoothly and without interruption?

• With what examination and treatment positions should Felicia be familiar, and when should the various positions be used?

• What measures can Felicia take to protect herself from injury when lifting heavy items or assisting with the transfer of patients?

To promote health maintenance, healthcare professionals must understand the anatomy and physiology of the body, the role each part plays, how each component functions, and what happens to the body when disease occurs in body systems.

Anatomy and Physiology

Anatomy is the study of how the body is shaped and structured. It encompasses a wide range of subjects, including structural development, levels of organization, relationships among microscopic parts, and the interrelationship of structure and function.

Physiology is the study of body functions. This field is subdivided into areas of study; some physiologists spend their entire lives studying only one function, such as how cells work or how a single organ, such as the small intestine, is interrelated in function with the stomach and the large intestine.

Separating these two sciences is almost impossible, because one continuously influences the other. Function affects structure, and structure affects function; for example, an infant can suck effortlessly because of the lack of teeth in the mouth. Once teeth appear, sucking becomes more tiresome, and the child begins to chew and bite. Phenomena in structure and function affect the interrelationships of all body systems.

Structural Development

Cells

The basic unit of life is the cell. Cells determine the functional and structural characteristics of the entire body. Cells are microscopic in size, have a variety of shapes, and perform a vast array of functions. It is estimated that the human body is composed of approximately 100 trillion living, functioning cells. A cell is made up of three primary parts: the plasma membrane that surrounds the cell, creating an outer covering; the intracellular environment, which includes the cytoplasm that contains the living material that carries on the cell’s function; and the nucleus of the cell, which contains the genetic code of the cell that determines the cell’s function.

Tissues

When cells with similar structure and function are placed together, they form tissues. The study of tissues is known as histology. All of the body tissues are grouped into four types. The types of tissues distributed throughout the body and where they are located are as follows:

• Epithelial tissue: This type of tissue makes up the skin, glands, and linings of body cavities and organs; is packed closely together with little or no intercellular material; and is classified according to shape as squamous (flat), cuboidal (square), columnar (long and narrow), or transitional (varying shapes that can stretch). Epithelial cells may be arranged in a single layer of cells of the same shape, called simple epithelium, or in many layers of cells named according to the shape of the cells in the outer layer; this is called stratified epithelium.

• Connective tissue: This tissue supports and binds other body tissues. Types of connective tissue include collagen, bone, cartilage, adipose, ligaments, tendons, blood, and lymph. Connective tissue is the most frequently occurring tissue in the body and has the widest distribution.

• Muscle tissue: This tissue produces movement. It is classified as skeletal muscle (striated, voluntary), which is attached to bones and produces voluntary body movements when contracted; cardiac muscle (striated and involuntary), which forms the heart muscle wall; or smooth muscle (nonstriated and involuntary), which lines the walls of blood vessels and hollow organs and causes such actions as peristalsis and vasoconstriction.

• Nervous tissue: This type of tissue conducts nerve impulses between the periphery and the central nervous system. It also effects rapid communication between body structures and controls the body’s functions to maintain homeostasis. Nervous tissue is made up of neurons and supportive structures called neuroglial cells.

Organs

An organ is composed of two or more types of tissue bound together to form a more complex structure for a common purpose or function. An organ may have one or many functions; for example, the pancreas has an endocrine function because it produces the hormone insulin, and a digestive function because it produces digestive enzymes. Organs also may be part of one or several systems. For example, in the male system, the urethra is part of both the urinary and the reproductive system.

Systems

A body system is composed of several organs and their associated structures. These structures work together to perform a specific function in the body. Each system has specific units in it, and each performs specific functions. Table 32-1 summarizes the body systems; their primary cells, organs, and structures; and the major functions of each.

TABLE 32-1

Organization of Body Systems

BODY SYSTEM	CELLS, ORGANS, AND STRUCTURES	FUNCTIONS
Blood	Arteries, arterioles, veins, venules, white blood cells, red blood cells, platelets, plasma	Transports materials and collects wastes throughout the body; white blood cells fight infection; red blood cells carry oxygen; platelets help form clots; plasma carries dissolved nutrients and other materials
Cardiovascular	Heart, valves, arteries, arterioles, veins, venules	Circulatory system transports materials in the blood throughout the body; veins return deoxygenated blood to the heart, which pumps it into the lungs; oxygenated blood is pumped into the aorta and branching arteries to cells throughout the body
Endocrine	Pituitary, pineal gland, hypothalamus, thyroid, pancreas, adrenal cortex and medulla, parathyroid, thymus, ovaries, testes	Produces hormones that circulate in the blood to target tissue that stimulates a particular action
Integumentary	Skin, subcutaneous tissue, sweat and sebaceous glands, hair, nails, sense receptors	Protection, temperature regulation; senses organ activity
Gastrointestinal	Mouth, tongue, teeth, pharynx, esophagus, stomach, small intestine, large intestine, liver, gallbladder, pancreas, appendix	Mastication, swallowing, digestion, absorption of nutrients, excretion of waste materials
Lymphatic and immune	Lymph, lymph vessels, lymph nodes, thymus, tonsils, spleen, lymphocytes, antibodies	Maintains fluid balance; protects internal environment; defends against foreign cells and disease; provides immunity to some diseases
Musculoskeletal	Bones, joints, muscles, tendons, ligaments, cartilage	Movement, posture, heat production, support, protection, mineral storage, hematopoiesis
Nervous	Brain, spinal cord, neurons, neuroglial cells, peripheral nerves, autonomic nerves	Controls body structures to maintain homeostasis; higher-order thinking and reflex centers that control autonomic processes; carries sensory stimulus to the brain and motor impulses to the periphery
Reproductive	Female: Estrogen and progesterone, ovum, ovaries, fallopian tubes, uterus, vagina, vulva, mammary glands Male: testosterone, sperm, epididymis, vas deferens, prostate gland, testes, scrotum, penis, urethra	Produces hormones; reproduction
Respiratory	Nose, sinuses, pharynx, larynx, trachea, bronchi, lungs, bronchioles, alveoli	Responsible for inhalation of oxygen and exhalation of carbon dioxide externally and exchange of oxygen and carbon dioxide internally at the cellular level; acid-base regulation
Sensory	Eyes, ears, taste buds, olfactory receptors, sensory receptors	Helps sense changes in the external and internal environments through vision, hearing, balance, taste, and smell
Urinary	Nephron unit, bilateral kidneys, ureters, urinary bladder, urethra	Filters waste material from the blood; reabsorbs fluid and electrolytes as needed; excretes waste in the urine; maintains electrolyte, water, and acid-base balances; regulates blood pressure; activates red blood cells

Primary Care Physician

Primary care physicians (PCPs) treat patients of all ages for a broad range of diseases and complaints. A PCP is qualified to provide continuing healthcare for the entire family, from birth to old age. Most health insurance programs have converted to the primary care referral system. This means that most patients are required to have a PCP as the gatekeeper in personal healthcare. Therefore, the PCP must be contacted first, before the patient can be referred to specialty physicians for care.

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. With such a diversified scope of practice, the physician and medical assistant must work as a team to use their time efficiently and still provide quality, patient-centered healthcare.

Physical Examination

The purpose of a physical examination is to determine the patient’s overall state of well-being. All major organs and body systems are checked during a physical examination. 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. Often laboratory and other diagnostic tests are ordered to supplement the physician’s initial diagnosis. The results of these tests are used to refine the patient’s diagnosis, to help the physician plan or revise treatment for the patient, to evaluate and maintain current drug therapy, and/or to determine the patient’s progress.

Preparing for the Physical Examination

Role of the Medical Assistant in the Physical Examination

Assessment of the patient begins with the first contact in the office. 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. The medical assistant’s duties include preparing and maintaining the examination room and equipment, preparing the patient, and assisting the physician during the physical examination.

Room Preparation.

The medical assistant is responsible for making sure the examination room is ready for any procedure that might be performed during the physical examination. The area should be as comfortable as possible for the patient and free of any potential dangers (Procedure 32-1). The examination room is prepared as follows:

• The area should be checked at the beginning of each day and between patients to make sure it is completely stocked with equipment and supplies and that all equipment is functioning properly. 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.

• Expiration dates must be checked regularly on all packages and supplies, and expired materials should be discarded.

• The room should be private, well lit, and at a comfortable temperature for the patient during the physical examination.

• The area should be cleaned and disinfected daily and between patients as needed to prevent the spread of infection and to ensure patients’ comfort. All potentially contaminated surfaces, including the examination table, are disinfected between patients, with an appropriate disinfectant. After cleaning the table, change the examination paper by unrolling a new piece.

• Drapes, gowns, and all other patient supplies are arranged before the patient enters the room so that they are ready for use.

• To save time, the instruments and equipment needed for the examination are prepared and arranged for easy access before the physician enters the room.

• The examination room should contain all materials required for observing Standard Precautions, including disposable gloves, a sink with an antibacterial hand-washing agent, paper towels, biohazard waste containers, sharps containers, and impervious gowns and face guards. Sharps containers are replaced when they are two-thirds full, as indicated by Standard Precautions (see Chapter 27).

Procedure 32-1

Prepare and Maintain the Examination and Treatment Areas

GOAL: To prepare an examination room for a patient procedure, maintain equipment and supplies needed for the physical examination, and demonstrate maintenance of the room after a patient visit.

EQUIPMENT and SUPPLIES

• Scale with height measurement bar

• Otoscope with disposable speculum

• Biohazard container

• Laboratory request forms

• Specimen bottles/lab requisitions

• Thermometer

• Cotton-tipped applicators

• Hemoccult supplies

• Table paper

• Spray disinfectant

Procedural Steps

1. Check the examination room at the beginning of each day and between patients to make sure it is completely stocked with equipment and supplies and that the equipment functions properly.
PURPOSE: The room must be ready for patient services.

2. Check all equipment and instruments to make sure they are operational; refer to manuals supplied by the manufacturers as needed.

3. Check expiration dates on all packages and supplies regularly and discard expired materials.
PURPOSE: To maintain the patient’s safety.

4. The room should be private, well lit, and at a comfortable temperature for the patient during the physical examination.
PURPOSE: To maintain confidentiality and the patient’s safety and comfort.

5. Prepare the examination room before and between patients according to acceptable medical rules of asepsis.
PURPOSE: The room must be aseptically clean to prevent the spread of infection.

6. After each patient use: Don disposable examination gloves, spray the table and any other contaminated surface with a disinfectant, and clean the area with disposable towels; discard waste and the gloves in an appropriate biohazard container and put clean paper on the table.

7. Sanitize your hands.
PURPOSE: To ensure infection control and to prevent the transmission of pathogens from one patient to another.

8. Inventory the supplies needed after each patient visit and restock as needed.
PURPOSE: The room must be maintained and ready for each examination.

Patient Preparation.

Getting the patient ready for the examination includes taking care of paperwork before the patient enters the examination room and performing related clinical skills.

• Make sure the medical record is complete and that any needed consent forms have been signed. The medical assistant is not responsible for obtaining informed consent, but he or she should review the paperwork to make sure that informed consent forms were reviewed by the physician and that the patient signed the forms.

• Introduce yourself and address the patient by his or her preferred name, making sure to maintain respect at all times. Pay close attention to the patient’s nonverbal language to make sure the patient understands what to expect.

• Verify the accuracy of the insurance information according to office policy. In most facilities, the policy is to make a copy of the patient’s insurance card when the patient first enters the office or, if the patient has been to the office recently, to ask whether any of the insurance information has changed.

• Obtain specimens (e.g., urine, blood) if they have been preordered by the physician, or if this practice is part of the office policy.

• Measure and record the patient’s height, weight, body mass index (BMI), and vital signs.

• Conduct the initial investigation into the reason for the visit and explain the examination procedure to the patient. Be prepared to answer the patient’s questions and allay any fears.

• Ask the patient whether he or she needs to empty the bladder before the examination, because a full bladder may interfere with the examination and may be uncomfortable for the patient.

• Help the patient physically prepare for the examination. 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), and provide a drape to ensure the patient’s privacy. Offer assistance as needed.

• Assist the patient into and out of various examination positions as needed.

• Throughout this entire sequence of events, explain what is happening, and consistently maintain the patient’s privacy and confidentiality.

• Document patient data in the medical record, completing all forms required.

• Place the patient’s medical record in the designated area for the physician, usually in a chart holder on the examination room door; make sure that no identifiable patient information is visible, in accordance with regulations established by the Health Insurance Portability and Accountability Act (HIPAA).

• Help the patient with dressing as needed after the examination.

Assisting the Physician.

The medical assistant should be prepared to help the physician complete the physical examination as comprehensively and efficiently as possible. You have already prepared the room, so all equipment and supplies are available and in good working order; you also have prepared the patient by gathering the needed information and measuring and recording vital signs. During the examination, the physician may expect the medical assistant to do the following:

• Hand him or her instruments and equipment as requested and provide supplies 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.

• Position and drape the patient during different phases of the examination.

• Assist in collecting and properly labeling specimens such as urine, Pap smear specimens, and throat cultures.

• Conduct follow-up diagnostic procedures as ordered, including an electrocardiogram (ECG), eye or ear screening, urinalysis, and phlebotomy.

• Schedule postexamination diagnostic procedures such as mammography, x-ray examination, or colonoscopy.

32-1

Critical Thinking Application

Felicia’s first patient for the day is Harry Garcia, a 51-year-old truck driver who is scheduled for a complete physical examination. Mr. Garcia’s insurance has changed since his last visit. The physician ordered an ECG and a complete blood panel to be drawn before the physical. What does Felicia need to complete before Dr. Kosto sees the patient?

Supplies and Instruments Needed for the Physical Examination

The instruments typically used during the physical examination are shown in Figure 32-1. They 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. The instruments most frequently used for a physical examination are described in the following paragraphs. Physical examinations typically are performed from the head to the feet; the instruments are listed in the order in which the physician typically would request them.

FIGURE 32-1 Instruments for the physical examination. (From Bonewit-West K: *Clinical procedures for medical assistants,* ed 7, St Louis, 2008, Saunders.)

Ophthalmoscope.

An ophthalmoscope is used to inspect the inner structures of the eye. It consists of a stainless-steel handle containing batteries and an attached head, which has a light, magnifying lenses, and an opening through which the eye is viewed. Examination rooms usually are equipped with wall-mounted electrical units for the ophthalmoscope and otoscope, a dispenser for disposable speculums, and a wall-mounted sphygmomanometer.

Tongue Depressor.

A tongue depressor is a flat, wooden blade used to hold down the tongue when the throat is examined.

Otoscope.

An otoscope is used to examine the external auditory canal and tympanic membrane. It has a stainless-steel handle containing batteries or is part of a wall-mounted electrical unit. The head of the otoscope has a light that is focused through a magnifying lens and should be covered with a disposable ear speculum. The light also may be used to illuminate the nasal passages and throat.

Nasal Speculum.

A nasal speculum is a stainless-steel instrument used to inspect the lining of the nose, nasal membranes, and internal septum (Figure 32-2). 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. An otoscope with a special attachment may also be used for nasal visualization.

Tuning Fork.

Tuning forks are aluminum fork-shaped instruments that consist of a handle and two prongs (Figure 32-3, A). The prongs produce a humming sound when the physician strikes them against his or her hand. Tuning forks are available in different sizes, and each size produces a different pitch level. A tuning fork is used to check the patient’s auditory acuity (Figure 32-3, B) and to test bone vibration (Figure 32-3, C). This aluminum instrument consists of a handle and two prongs that produce a humming sound when the physician strikes the prongs against his or her hand.

Tape Measure.

A tape measure is a flexible ribbon ruler that is usually printed in inches and feet on one side and in centimeters and meters on the opposite side. Measurements may be used to assess length and head circumference in infants, wound size, and so on.

Stethoscope.

A stethoscope is a listening device used when certain areas of the body are auscultated, particularly the heart and lungs. This instrument is available in many shapes and sizes. All have two earpieces that are connected to flexible rubber or vinyl tubing (Figure 32-4). At the distal end of the tubing is a diaphragm or bell (many have both), which, when placed securely on the patient’s skin, enables the physician to hear internal body sounds.

Reflex Hammer.

A reflex hammer is sometimes called a percussion hammer. This stainless-steel instrument has a hard rubber head that is used to strike the tendons of the knee and elbow to test the neurologic reflexes.

Gloves.

Disposable examination gloves protect the healthcare worker and the patient from microorganisms. According to Standard Precautions, gloves must be worn whenever the potential exists for contact with any body fluid, broken skin or wounds, or contaminated items.

Additional Supplies.

Gauze squares, cotton balls, cotton-tipped applicators, specimen containers, hemoccult packets, Pap smear supplies for female patients, lubricating jelly for vaginal and rectal examinations, and laboratory request forms should be easily accessible during the examination.

Assisting With the Physical Examination

Methods of Examination

Examinations are performed as both a routine confirmation of the absence of illness and a means of diagnosing disease. Healthcare providers use six methods to examine the human body. All six are part of a complete physical examination.

Inspection.

During inspection, the examiner uses observation to detect significant physical features or objective data. This method of examination ranges from focusing on the patient’s general appearance (general state of health, including posture, mannerisms, and grooming) to more detailed observations, including body contour, gait, symmetry, visible injuries and deformities, tremors, rashes, and color changes.

Palpation.

In palpation, the examiner uses the sense of touch (Figure 32-5, A). A part of the body is felt with the hand to determine its condition or the condition of an underlying organ. Palpation may involve touching the skin or performing a firmer exploration of the abdomen for underlying masses. This technique involves a wide range of perceptions, including temperature, vibration, consistency, form, size, rigidity, elasticity, moisture, texture, position, and contour. Palpation is performed with one hand, both hands (bimanual), one finger (digital), the fingertips, or the palmar aspect of the hand. A pelvic examination is done bimanually, whereas an anal examination is performed digitally. Do not confuse palpation with palpitation, which is a throbbing pulsation felt in the chest.

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Apr 6, 2017 | Posted by admin in MEDICAL ASSISSTANT | Comments Off

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Assisting with the Primary Physical Examination