define and turn in (chapter 5): audiometer auscultation clinical diagnosis inspection ophthalmoscope...

55Assisting with Physical Assisting with Physical ExaminationsExaminationsLesson 1:Lesson 1:Preparing the Exam Room and Preparing the Exam Room and Examination Methods – Part 1Examination Methods – Part 1

Lesson ObjectivesUpon completion of this lesson, students should be able to …

Define and spell the terms to learn for this chapter.

Recognize pieces of equipment commonly used during a physical examination.

Describe the examination methods used by physicians.

Discuss the steps to take in preparing a patient for a physical examination.

Medical Assistant’s Role in the Patient Physical ExamInterviewing the patientDocumenting patient informationPreparing the exam room prior to

the patient’s visitPositioning and draping the patientAssisting the physician during the

examCleaning the room after the visitInstrument care

Medical Assistant’s Role in the Patient Physical ExamsuppliessafetyObserving confidentiality

Cleaning the Examination Roomused gowns in the

laundry receptacle Discard used

examination table paper and drape

Dispose of pillow cover

Clean the exam table, and recover with new paper

Cleaning the Examination Room (cont)

new cover on pillow

Dispose of equipment

Clean and disinfect equipment

Disinfect all surfaces

Cleaning the Examination Room (cont)

Close all biohazard containers

remove if full

Ensure room is clean and odor free

Features of the Examination Room

Examination table PillowFootstoolSupply cupboardTrash canHazardous waste and

sharps containersRolling stoolChairMayo tray stand

Preparing the Examination RoomReady instruments and equipment

equipment is not within reach of the patient

exam lightproper body mechanics

Ensuring Patient Comfort and Privacythermostat around 71 to 73 degrees F

Provide blankets and sheetsExplain clearly about exam gownInform patients where to place clothes

Ensuring Patient Comfort and Privacy (cont)Leave the room when patients are undressing unless assistance is required

Knock and receive permission when reentering

Purpose of the Patient Historyassess general health status

Helps determine a diagnosis

Fill out Patient History form activityAccuracy countsSpelling countsNeatness counts

WorkBook Page17-19

Film ClipSaunders DVD

Assisting w/physical exams

Contents of the Medical HistoryChief complaint (cc)

Present illnessPast medical history

Family historySocial or personal history

Review of systems

The Chief Complaintpresenting problemconsists of one or two symptomsdocumented using the patient’s own words

The Chief Complaint (cont)Subjective symptoms

What the patient tells youNot directly observed

Objective symptomsSigns you can see, hear, feel, smell

Factual, measurable, observable

Do You Remember? Objective vs. Subjective1. Mr. Brown states that he has a toothache

2. Mrs. William’s urine appears to have blood in it.

3. Mrs. Smith’s respirations are very rapid

4. Mr. Lee states that he is nauseated after eating.

5. Mrs. Bender’s dressing is dry & intact.

Do You Remember? Objective vs. Subjective6. Mrs. Campbell complains of dizziness after each respiratory treatment

7. Mrs. Stark is jaundiced today.8. Mr. Runge has excessive bleeding every time he has a tooth extracted

9. Ms. Hime is perspiring, and her skin is cold & clammy.

10. Mr. Rue is experiencing some wheezing with each breath.

Steps to Interviewing a Patient and Preparing for an ExamId the patient, greet, and id yourself

Explain procedureProvide privacyAsk the patient to fill out form

Steps to Documenting a Chief Complaint Maintain eye contact and actively listen

Gather information What makes the problem better or worse? start? hurt? rate pain on a scale 0-10

Steps to Interviewing a Patient and Preparing for an Exam (cont)Review ask questionsAsk for the CCChart the CC

Steps to Interviewing a Patient and Preparing for an Exam (cont)observation skillsGather other information

PH, FH, and SHAllergies –

No allergiesNKDANKA

Steps to Interviewing a Patient and Preparing for an Exam (cont)Correct any errors drawing one

line through the error and date and initial them – Record the correct information

1/13/12 KG BP 180/96----------K. Gers MA

Steps to Interviewing a Patient and Preparing for an Exam (cont)Explain what procedures will follow

Place the patient history in the designated place

Obtaining the Past Medical History

all past diseases and medical problems

Dates of major illnesses

Hospitalizationssurgeries, current medications including OTC meds

The Family Medical HistoryHealth problems of blood relativescurrent health, major health

problems, and cause of death, as well as age at death

Family medical histories focus on diseases that may be inherited

Information Contained on the Personal HistoryLifestyle patterns Patient’s occupation

Marital statusSexual preferencesdiet choicesexerciseSleep habits

Inspection of Physical Examination

visually examining the exterior surface of the body

Palpation of Physical Examination

using the hands to feel the skin and accessible underlying organs

Percussion of Physical Examination

Use of the fingertips to tap the body to gain information about underlying body parts

Percussion Method of Physical Examination

Auscultation Method of Physical Examinationlisten to sounds that are found within the bodyA stethoscope is used to amplify body sounds

Mensuration Method of Physical Examination

Use of special tools to measure the body or specific parts

Weight scaleA tape measureA goniometerCalipers

Go to Lesson 2