Specialty Examinations and Procedures

Colon Procedures, Male Reproductive Health, and Radiology and Diagnostic Imaging

LEARNING OBJECTIVES	PROCEDURES
Fecal Occult Blood Testing
1. Explain the purpose of a fecal occult blood test.	Instruct a patient in the preparation and procedure for a fecal occult blood test (guaiac slide test).
2. Describe the patient preparation for fecal occult blood testing (guaiac slide method).	Develop a fecal occult blood test.
3. Explain the purpose of each type of preparation for fecal occult blood testing (guaiac slide method).
Sigmoidoscopy
4. Explain the purpose of a digital rectal examination before a sigmoidoscopic examination.	Instruct a patient in the preparation required for a sigmoidoscopy.
5. Explain the purpose of a sigmoidoscopy.	Assist the physician with sigmoidoscopy.
6. Describe the patient preparation for a sigmoidoscopy.
Colonoscopy
7. Explain the purpose of a colonoscopy.	Instruct a patient in the preparation required for a colonoscopy.
8. List the conditions that can be detected and assessed during a colonoscopy.
9. Describe the patient preparation for a colonoscopy.
Male Reproductive Health
10. List the symptoms of prostate cancer.	Assist the physician with a digital rectal examination.
11. Explain the purpose of the digital rectal examination (DRE).	Instruct a patient in the preparation for a PSA test.
12. Explain the purpose of the prostate-specific antigen (PSA) test.
13. State the risk factors for testicular cancer.	Teach a patient how to perform a testicular self-examination (TSE).
14. Describe the TSE schedule.
Radiology
15. State the function of radiographs in medicine. 16. Explain the importance of proper patient preparation for a radiographic examination. 17. Explain the function of a contrast medium. 18. Describe the purpose of a fluoroscope. 19. Explain the purpose of each of the following types of radiographic examinations: Mammography Bone density scan Upper gastrointestinal radiography Lower gastrointestinal radiography Intravenous pyelography	Instruct a patient in the proper preparation necessary for each of the following types of radiographic examinations: Mammography Bone density scan Upper gastrointestinal radiography Lower gastrointestinal radiography Intravenous pyelography
Diagnostic Imaging
20. Explain the purpose of each of the following diagnostic imaging procedures: Ultrasonography Computed tomography Magnetic resonance imaging Nuclear medicine 21. Explain how nuclear medicine is used to produce an image of a body part or organ. 22. State the guidelines that may be required for nuclear medicine.	Instruct a patient on the purpose and advance preparation for each of the following diagnostic imaging procedures: Ultrasonography Computed tomography Magnetic resonance imaging Nuclear medicine
Digital Radiology
23. Explain the advantages of digital radiology.

Colon Procedures

Introduction to Colon Procedures

Colon procedures are performed in the medical office or clinic and include the fecal occult blood test (FOBT), sigmoidoscopy, and sometimes colonoscopy, which are presented in this chapter. The FOBT is a screening test used to detect blood in the stool for the early detection of colorectal cancer. Stool specimens must be collected by the patient at home. Some patients initially may be reluctant to comply with the FOBT patient preparation requirements and collection of the stool specimens. The medical assistant can help by explaining the purpose of the test to the patient. If the patient understands the benefits to be derived from the test, he or she is more likely to participate as required.

Medical assistants are often responsible for explaining to a patient the preparation required for a sigmoidoscopy and colonoscopy. The medical assistant should make sure the patient thoroughly understands the instructions. If the patient does not prepare properly, the procedure must be cancelled, which requires the patient to go through the preparation procedure again. The medical assistant assists the physician during a sigmoidoscopy, and he or she should have a thorough knowledge of the responsibilities accompanying this procedure.

Blood in the Stool

Blood in the stool can indicate a number of gastrointestinal conditions, including hemorrhoids, diverticulitis, polyps, colitis, upper gastrointestinal ulcers, and colorectal cancer. Some of these conditions (e.g., hemorrhoids) produce visible red blood on the outside of the stool, making it easy to detect. Blood entering the stool in an amount of 50 mL or greater from conditions affecting the upper gastrointestinal tract (e.g., peptic ulcers) causes the stool to exhibit melena, meaning it is black and tarlike. The dark color is a result of oxidation of the iron in the blood (heme) by intestinal and bacterial enzymes. If a minute quantity of blood is present, however, it is not possible to detect it with the unaided eye. This hidden, or nonvisible, blood is termed occult blood, and its presence can be determined by testing the stool for blood.

Colorectal cancer is one of the most common forms of cancer in individuals older than the age of 50 years (see Highlight on Colorectal Cancer). During the early asymptomatic stages, almost all lesions (e.g., benign and malignant tumors) of the colon and rectum bleed a small amount on an intermittent basis, and this is usually in the form of occult blood. Discovery of occult blood in the stool does not mean that a patient has colorectal cancer. It does, however, warrant further diagnostic procedures, such as a colonoscopy, to determine if colorectal cancer is present. Early diagnosis and treatment of colorectal cancer increase the patient’s survival rate. In most cases, when more pronounced symptoms of colorectal cancer start to appear (e.g., visible bleeding from the rectum, a change in bowel habits, abdominal pain), the cancer has reached an advanced stage.

Fecal Occult Blood Test

Putting It All into Practice

My name is Megan Baer, and I work in a large clinic that includes the specialties of family practice, gastroenterology, allergies, and dermatology. I am the clinical supervisor and oversee all of the clinical medical assistants and our “in-house” laboratory. I work closely with all physicians to meet the growing needs of the clinic.

Working with a gastroenterologist has been interesting and educational. When preparing a patient for a sigmoidoscopy, you must help the patient feel relaxed. This is an embarrassing situation for the patient, so you need to make him or her feel as comfortable as possible and maintain the patient’s privacy and modesty. During the procedure, I talk to patients about the weather, their pets, and other interests to make them feel more relaxed and comfortable. This can help take their mind off the procedure.

One day I was assisting with a sigmoidoscopic examination, and a few minutes into the procedure the look on the physician’s face told me something was wrong. When the examination was finished, the physician and I left the room and went back to his office. He informed me that what he saw on his examination was colorectal cancer, and at this stage, not much could be done for the patient. The worst thing a physician has to do is give unpleasant news to a patient and see the look on the patient’s face. Going into the room of a patient who has just received life-threatening information is something you don’t forget. All you can do is be sympathetic and understanding and be a good listener. You have to be strong and not show your emotions even though your heart is breaking for the patient and the family. Always let patients know you are there for them.

Being with a patient who receives bad news about his or her health can make you think about your own life, and how it affects not only you, but also your family and friends. I often think of how I would feel about receiving such news. I try to put myself in the patient’s place and to be sincere and understanding and willing to lend an ear.

Certain medications irritate the gastrointestinal tract, which may result in a small amount of bleeding, and thus could result in a false-positive result on the guaiac slide test. Medications that should be avoided include ibuprofen (Motrin, Advil), naproxen (Aleve), and more than one adult aspirin per day. In addition, an iron supplement may cause a false-positive result, and a vitamin C supplement (greater than 250 mg per day) can cause a false-negative result. All of these substances should be discontinued before testing. Table 28-1 lists the specific patient preparation requirements for fecal occult blood testing using the guaiac slide test.

Table 28-1

Patient Preparation for the Fecal Occult Guaiac Slide Test

Dietary and Medication Guidelines
Beginning 3 days before obtaining the first stool specimen, the patient should follow certain diet and medication modifications. These modifications should be followed until all three slides have been prepared.
Meats	Eat no red or rare meat (beef and lamb) or liver. Small amounts of well-cooked pork, poultry, and fish are permitted. Red meat contains animal blood that could cause a false-positive test result.
Vegetables	Eat moderate amounts of raw and cooked vegetables. Especially advised are lettuce, spinach, corn, and celery. Do not consume horseradish, turnips, broccoli, cauliflower, and radishes. These foods contain peroxidase, which sometimes can cause a false-positive test result.
Fruits	Eat moderate amounts of apples, bananas, oranges, peaches, pears, and plums. Avoid vitamin C in excess of 250 mg a day from citrus fruits and juices. Do not consume melons, because they contain peroxidase.
Miscellaneous high-fiber foods	Eat moderate amounts of whole-wheat bread, bran cereal, and popcorn. Foods high in fiber provide roughage to promote bowel elimination and encourage bleeding from “silent” lesions that bleed only occasionally.
Medications	Do not take medications or vitamin supplements that contain iron or vitamin C in excess of 250 mg for 3 days before and during the collection period. In addition, based on the patient’s medication therapy, the physician may stipulate additional medication restrictions. Certain medications cause irritation of the gastrointestinal tract, which may result in a small amount of bleeding. Nonsteroidal antiinflammatory drugs (NSAIDs) and more than one adult aspirin a day should be avoided for at least 7 days before and continuing through the test period. Examples of NSAIDs include ibuprofen (Advil, Motrin) and naproxen (Aleve). Acetaminophen (Tylenol) can be taken as needed.
Special guidelines	Inform the physician, and do not consume any of the food items listed previously if you know, from past experience, that they cause you severe gastrointestinal discomfort or serious diarrhea. Ensure that the diet modifications have been followed for 3 days before collecting the first stool specimen. Do not initiate the test during a menstrual period or in the first 3 days after a menstrual period. The test should not be conducted when blood is visible in the stool or urine, such as from bleeding from hemorrhoids or a urinary tract infection. These conditions would result in false-positive test results. Store the slides with the flaps in a closed position at room temperature, and protect them from heat, sunlight, and fluorescent light. The slides must also be stored away from volatile chemicals such as ammonia, bleach, and other household cleaners. Improper storage can result in deterioration of the active reagents on the slides, leading to inaccurate test results.

Quality Control

Quality control methods must be employed with the guaiac slide test to ensure reliable and valid results. It is important to properly store the box containing the guaiac slides and developing solution. Adverse storage conditions can result in deterioration of the developing solution and the active reagents impregnated on the filter paper of the slides, leading to inaccurate test results. The box must be stored at a room temperature between 59° F (15° C) and 86° F (30° C). The contents of the box must be protected from heat, sunlight, and strong fluorescent light. In addition, the box should not be stored in close proximity to volatile chemicals such as ammonia, bleach, bromine, iodine, and disinfectant cleaners. If stored properly, the slides and developer will remain effective until the expiration date that is stamped on the side of the box, each slide itself, and the container of developing solution.

A quality control procedure must be performed after the patient’s test has been developed, read, and interpreted. This ensures that the test results are accurate and valid. The Hemoccult slide test contains an on-slide performance monitor that consists of positive and negative monitor areas. This monitor is located on the developing side of the filter paper under the back flap of the cardboard slide. The positive monitor area contains a control chemical that has been impregnated into the filter paper during the manufacturing process.

The medical assistant should apply 1 drop of the developing solution between the positive and negative performance monitor areas on each of the three slides. The results must be read within 10 seconds after application of the developer. If the slides and developer are functioning properly, the positive area turns blue, whereas the negative area shows no color change. Failure of the expected control results to occur indicates an error, and the test results are not considered valid; possible causes include the use of outdated slides or developing solution; an error in technique; and subjection of the slides to heat, sunlight, strong fluorescent light, or volatile chemicals. Procedure 28-1 outlines the medical assistant’s responsibilities related to fecal occult blood testing using the Hemoccult guaiac slide test. Procedure 28-2 describes the development of a Hemoccult slide test.

Procedure 28-1 Fecal Occult Blood Testing

Guaiac Slide Test

Outcome

Instruct a patient in specimen collection for a Hemoccult guaiac slide test.

Equipment/Supplies

• Hemoccult slide testing kit

1. Procedural Step. Obtain a Hemoccult testing kit. Check the expiration date on the slides.

Principle. Outdated slides can lead to inaccurate test results.

2. Procedural Step. Greet the patient and introduce yourself. Identify the patient and explain the purpose of the test. Tell the patient that the test should not be conducted during a menstrual period or when hemorrhoids are bleeding or a urinary tract infection is present.

Principle. Bleeding from other (identifiable) sources causes a false-positive test result.

3. Procedural Step. Instruct the patient in proper preparation for the test. See the box Highlight on Colorectal Cancer for the specific guidelines the patient should follow. Tell the patient to begin the diet modifications 3 days before collecting the first stool specimen. Encourage the patient to adhere to the diet modifications.

Principle. The diet modifications may discourage patient compliance. The medical assistant should reinforce the importance of adhering to the diet requirements. Improper patient preparation can lead to inaccurate test results.

4. Procedural Step. Provide the patient with the Hemoccult testing kit. The kit consists of three identical cardboard slides attached to one another; each slide contains two squares, labeled “A” and “B.” Three wooden applicator sticks and written instructions also are included in the testing kit.

Principle. Three slides are provided so that three stool specimens can be collected. The two squares in each slide (A and B) contain filter paper impregnated with guaiac, a chemical necessary for detection of blood in the stool.

5. Procedural Step. Instruct the patient on completion of the information required on the front flap of each card. This includes the patient’s name, address, phone number, and age and the date of the specimen collection. A ballpoint pen should be used to write this information.

6. Procedural Step. Provide instructions on proper care and storage of the slides. Make it clear that the slides must be stored (with the flaps in a closed position) at room temperature and protected from heat, sunlight, strong fluorescent light, and volatile chemicals.

Principle. Adverse storage conditions can result in deterioration of the active reagents impregnated on the filter paper, leading to inaccurate test results.

7. Procedural Step. Instruct the patient on initiation of the test by telling him or her to begin the diet modifications and then to collect a stool specimen from the first bowel movement after the 3-day preparatory period.

8. Procedural Step. Instruct the patient on proper collection of the stool specimen:

a. Fill in the sample collection date on the front flap of the first cardboard slide.

b. Use a clean, dry container to collect the stool sample. The sample must be collected before it comes in contact with toilet bowl water. Allow the stool to fall into the collection container.

c. Use one of the wooden applicators to obtain a specimen from one part of the stool sample.

d. Open the front flap of the first cardboard slide (located on the left in the series of three).

e. Spread a very thin smear of the specimen over the filter paper in the square labeled “A.”

f. Using the same wooden applicator, obtain another specimen from a different area of the stool.

g. Spread a thin smear of the specimen over the filter paper in the square labeled “B.”

h. Close the front flap of the cardboard slide.

i. Discard the wooden applicator in a waste container. Do not flush it down the toilet.

j. Place the slides in a regular paper envelope to air-dry overnight.

Principle. Two squares are included in each slide to allow specimen collection from different parts of the stool because occult blood is not always uniformly distributed throughout the stool. Thick specimens prevent adequate light penetration through the filter paper, making it difficult to interpret the test results.

9. Procedural Step. Instruct the patient to continue the testing period on 3 different days until all three specimens have been obtained as follows.

a. Repeat Procedural Step 8 after the second bowel movement the next day. If you do not have a bowel movement on the next day, then collect the specimen on the following day. The specimens should be collected on 3 different days. Use the cardboard slide located in the middle of the series of three.

b. Repeat Procedural Step 8 after the third bowel movement, using the cardboard slide located to the right in the series of three.

c. Allow the completed slides to air-dry overnight in the paper envelope.

10. Procedural Step. Instruct the patient to place the cardboard slides in the envelope lined with foil, seal carefully, and return them as soon as possible to the medical office. Emphasize to the patient that only the foil-lined envelope can be used to mail the slides; a standard envelope cannot be used. Inform the patient that the slides must be returned no later than 14 days after the first specimen is collected.

Principle. Standard paper envelopes are not approved by U.S. postal regulations for mailing fecal occult blood testing slides. Slides should not be developed after 14 days, as the test results may not be accurate.

11. Procedural Step. Give the patient an opportunity to ask questions; ensure that the patient understands the instructions for patient preparation and collection of the stool specimen and for storage of the slides.

Principle. Improper patient preparation and poor collection technique can lead to inaccurate test results.

12. Procedural Step. Record in the patient’s chart. Include the date and documentation that the Hemoccult test and instructions were given to the patient.

Note: The ColoScreen and Seracult guaiac slide tests use a procedure similar to that of the Hemoccult test.

Procedure 28-2 Developing the Hemoccult Slide Test

Outcome

Develop a Hemoccult slide test.

Equipment/Supplies

• Disposable gloves

• Prepared cardboard slides

• Hemoccult developing solution

• Waste container

1. Procedural Step. Assemble the equipment. Check the expiration date on the developing solution bottle. The developing solution contains hydrogen peroxide and must be stored away from heat and light. It must be tightly capped when not in use.

Principle. Outdated solution should not be used because it can lead to inaccurate test results. The solution should be stored properly because it is flammable and evaporates easily.

2. Procedural Step. Sanitize your hands and apply gloves. Open the back flap of the cardboard slides. Apply 2 drops of the developing solution to the guaiac test paper underlying the back of each smear.

Principle. The developing solution is absorbed through the filter paper and into the stool specimen. This solution could irritate the skin and eyes; if contact occurs, immediately rinse the area with water.

3. Procedural Step. Read the results within 60 seconds. Fecal blood loss greater than 5 mL per day results in a positive reaction, which is indicated by any trace of blue on or at the edge of the fecal smear. If no detectable color change occurs, the result is considered negative.

Principle. In the presence of hydrogen peroxide, the heme compound in hemoglobin oxidizes guaiac, causing it to turn blue within 60 seconds after the developer is added. The reading time is important because the color reaction may fade after 2 to 4 minutes.

4. Procedural Step. Perform the quality control procedure as follows:

a. Apply 1 drop of developing solution between the positive and negative control performance indicators on each of the three slides.

b. Read the results within 10 seconds.

c. The positive area should turn blue and the negative area should show no color change. Failure of the expected control results to occur indicates an error and that the test results are invalid.

Principle. The quality control procedure must be performed after developing, reading, and interpreting the slides. Quality control procedures ensure the accuracy and reliability of the test results.

5. Procedural Step. Properly dispose of the Hemoccult slides in a regular waste container.

Principle. Fecal material is not considered regulated medical waste and can be discarded in a regular waste container.

6. Procedural Step. Remove gloves and sanitize your hands. Chart the results. Include the date and time, the brand name of the test (Hemoccult), and the test results for each slide (recorded as positive or negative).

What Would You Do? What Would You Not Do?

Case Study 1

Beatrice Bernard is 52 years old and has come to the office for a physical examination. The physician wants Mrs. Bernard to perform a Hemoccult test. After being told the purpose of the test and how to prepare for it, Mrs. Bernard expresses some concerns. She does not like the idea of what she has to do to perform the test because it does not seem sanitary to her. She also thinks it will be a lot of work to prepare for the test. She has red meat for dinner at least four times a week, and she does not understand why she has to eliminate it from her meals. She says she takes a baby aspirin every day for “heart health” and would prefer not to stop taking it. Mrs. Bernard says that she has always taken very good care of herself, and she has never had problems with her colon. She also says no history of colon cancer has been reported in her family. Mrs. Bernard is too embarrassed to talk about this topic with the physician. She says she may just throw the test away when she gets home.

Highlight on Colorectal Cancer

Incidence

Colorectal cancer is used to describe both cancer of the colon and cancer of the rectum. Based on what area is affected, these cancers are often referred to separately as colon cancer (see illustration below) and rectal cancer. Colorectal cancer is the third leading cause of cancer-related deaths in the United States for both men and women. According to the American Cancer Society, every year approximately 150,000 people are diagnosed with colorectal cancer, and approximately 50,000 people die every year from this disease. As the U.S. population of baby boomers ages, these numbers may increase.

Risk factors

The following factors increase the risk of developing colorectal cancer:

• Age. The risk of colorectal cancer increases significantly after 50 years of age and reaches a peak from ages 60 to 75 years. More than 90% of individuals diagnosed with colorectal cancer are older than 50 years of age.

• Colorectal polyps. A colorectal polyp is a grapelike growth that protrudes from the inner lining (mucosa) of the colon or rectum (see Figure 28-7). Individuals with large polyps or numerous polyps are particularly at risk for colorectal cancer. Most cases of colorectal cancer arise from adenomatous polyps that gradually become malignant over many years. Colorectal polyps are fairly common in individuals older than 50 years of age. Approximately 1 in 20 colorectal polyps can become cancerous if not removed.