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39Assisting with

Examinations in the Basic Specialties


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Learning Outcomes39.1 Describe the medical specialties of internal medicine,

obstetrics and gynecology, and pediatrics.

39.2 Identify the types of examinations and diagnostic tests performed in internal medicine, obstetrics and gynecology, and pediatrics.

39.3 Discuss the role of the medical assistant in working in internal medicine, obstetrics and gynecology, and pediatrics.

39.4 Identify common diseases related to internal medicine, obstetrics and gynecology, and pediatrics.


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Learning Outcomes (cont.)

39.5 Describe typical treatments for diseases related to internal medicine, obstetrics and gynecology, and pediatrics.

39.6 Identify common signs of domestic violence, elder abuse, and child abuse.

39.7 Carry out the procedure for assisting with gynecological examinations and procedures.

39.8 Carry out the procedure for meeting the needs of a pregnant patient during an examination.


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Introduction• Specialties

– Specialist – physician with additional training, residencies, and certification

– Types of examinations and diagnostic tests– Common diseases and disorders

• Medical assistant– Assist with specialty examinations – Observe for signs of domestic violence and child

abuse


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The Medical Assistant’s Role in Specialty Examinations

• Medical practice act – Defines the exact

duties of physicians and other health-care personnel

• Medical assistants – May perform

clinical procedures only under the supervision of the physician

State laws vary. You will need to know the scope of practice for medical assistants in the state where you

work.


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The Medical Assistant’s Role in Specialty Examinations (cont.)

• Providing emotional support

• Providing patient education– Effective communication– Provide educational

materials – Verify understanding


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Apply Your Knowledge

What defines the procedures health-care personnel can perform, and how do you determine what you are able to do as a medical assistant?

ANSWER: In addition to education, training, and certification, the state’s medical practice act defines what duties and procedures health-care personnel can perform. As a medical assistant, you have to know your scope of practice for the state where you work.


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Internal Medicine• Diagnosis and treatment of

disorders and diseases of the body’s internal organs

• Internist – Often first to see patient– Uses medication and/or

treatment modalities– Refers to a specialist


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Assisting with the Physical Examination

• Usually the same as a general physical examination

• Medical assistant responsibilities– Gathering information

• Detect substance abuse, domestic violence, or elder abuse

– Preparing patient for the examination


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Detecting Substance Abuse

• Signs vary and depend on – Type of drug– Patient’s response to the drug

• Report suspicion of substance abuse to the physician

• Know state requirements for reporting


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Detecting Substance Abuse (cont.)

• Signs of abuse– Alcohol – depressed pulse rate, respiration,

and blood pressure– Cocaine – excitation, increased pulse rate

and blood pressure– Hallucinogens – hallucination, poor

perception of time and distance, severe panic, violent and bizarre behavior


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Detecting Substance Abuse (cont.)

– Inhalants – muscle weakness, hearing loss, changes in heart rate, nausea, and dizziness

– Marijuana – reddening of the eyes, increased heart rate, heightened appetite, muscular weakness

– Narcotics – drowsiness, depressed respiration, constricted pupils, nausea, vomiting, constipation

– Sedatives – nausea, slurred speech, drunken behavior with no odor of alcohol


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Detecting Domestic Violence• Signs of domestic violence – bring to doctor’s

attention– Injuries that the patient tries to hide or excuse– Unusual bruising– Signs in a patient’s tone of voice or choice of words– Self blame

• Reporting suspected domestic violence is mandatory in some states

• Keep a list of services available for a victim of abuse


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Detecting Elder Abuse Difficult to detect –

no uniform definition Can be mistaken for

falls or chronic illnesses

Categories Domestic Institutional Self

– Types • Physical, sexual,

psychological• Neglect• Abandonment• Exploitation

• Occurs in all racial, socioeconomic, and religious groups


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Detecting Elder Abuse (cont.)

• Most victims are older women with chronic illness or disabilities

• Risk factors– History of alcoholism, drug abuse, or violence in the

family– History of mental illness in the abuser or victim– Isolation of the victim from family members and

friends other than the abuser– Recent stressful events affecting the abuser or victim


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Detecting Elder Abuse (cont.)

• Observe interactions between patient and caregiver

• Take careful history

• Report suspicions of abuse to physician

• Signs of neglect– Foul odor from the

patient’s body– Poor skin color– Inappropriate clothing

for the season– Soiled clothing– Extreme concern

about money


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Diagnostic Testing• Radiologic testing

– X-rays– CT scans– MRI scans– Ultrasound – Nuclear imaging

• Medical assistant– Set up

appointments– Explain procedures

and preps to patient


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Diseases and Disorders

• Diseases of aging– Constipation-

diarrhea cycle– Hyperlipidemia– Osteoporosis– Alzheimer’s

disease

• Infectious diseases– Lyme disease– Pneumonia– Rabies – Staph and strep

infections


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Diseases and Disorders (cont.)

• STDs– Acquired through

sexual contact with an infected person

– Patient education • Prevention • Treatment

– Common types of STDs

• Candidiasis• Chlamydia• Genital herpes• Genital warts• Gonorrhea• Trichomoniasis


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Condition DescriptionAnemia Deficiency of iron or vitamins; results from blood loss

Arthritis Chronic inflammatory disease of tissues of joints

Gout Metabolic disease caused by the overproduction or retention of uric acid

Hypertension Blood pressure greater than 140/90; usually asymptomatic

Peptic ulcer Lesion of mucous membrane of the esophagus, stomach, or duodenum


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What are the types of elder abuse, and what is the medical assistant’s role in identification of elder abuse?

ANSWER: Elder can be abused physically, sexually, or psychologically. Neglect, abandonment, and exploitation are also forms of elder abuse. The medical assistant should take a careful history, observe interactions between caregiver and patient, observe for signs of abuse, and report suspicions to the physician.


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Obstetrics and Gynecology• Specialization of the female reproductive

system– Obstetrician – focuses on caring for women

during pregnancy and childbirth

– Gynecologist – focuses on conditions of the female reproductive system


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Gynecologic Physical Examination• Purpose

– Overview of a woman’s health – Opportunity for cancer-screening exams and tests

• Female assistant should be present during the exam – Assist a male doctor – Provide legal protection

• Your role is similar to that of the general physical examination


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Gynecologic Physical Examination (cont.)

• Physician’s interview– Evaluation of total

health– Review of factors that

may indicate cancer or STDs

• Breast exam– Check for abnormal

lumps– Patient education

• Annual mammograms starting at 40 years old

• Breast exam by physician annually

• Monthly breast self-examination


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Gynecologic Physical Examination (cont.)

• Pelvic examination– External genitalia, cervix, vaginal wall, internal

reproductive organs, and rectum

– Speculum – expands the vaginal opening

– Medical assistant’s role • Assist the patient into position

• Assist the doctor


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Life Cycle Changes• Menstruation

– Normal cycle of preparation for conception

– Menarche – • Onset of

menstruation• 10–15 years of age

– Prompted by hormonal changes

• Menopause– Cessation of

menstrual cycle– Stages

• Premenopause• Perimenopause

– Hormonal changes or surgical removal of uterus and ovaries


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Diagnostic Tests and Procedures• Pregnancy test –

detect presence of HCG – Blood– First voided urine

• Tests for STDs– Cultures and blood

tests– Examining lesions– Patient’s history


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Diagnostic Tests and Procedures (cont.)

• Radiologic tests– X-rays

• Avoid if pregnant• Hysterosalpingography • Mammograms

– Ultrasounds– CT scan– MRI

• Fetal screening – Alpha fetoprotein

• Abnormal levels can indicate neural tube defect

– Ultrasound


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• Amniocentesis– To determine if there

is a genetic or metabolic problem with the fetus

• Biopsy – Surgical removal of

tissue– Diagnose cancers

• Colposcopy – Examination of vagina

and cervix– To identify abnormal

cells• D and C

– Dilation of the cervix and scraping the uterine lining


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• Fine-needle aspiration– Remove a sample of

tissue from a cyst, lump, or tumor

• Pap smear– Used to determine

presence of abnormal or precancerous cells

• Hysterectomy– Removal of the uterus– Hysterosalpingectomy

• Removal of uterus and fallopian tubes

– Hysterosalpingo-oophorectomy

• Removal of uterus, fallopian tubes, and ovaries


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Pregnancy• Stages

– First trimester – conception to 12 weeks– Second trimester – 12 weeks to sixth month– Third trimester – sixth month until birth

• Nägele’s rule – estimate of delivery date – Subtract 3 months from first day of last period

and add 7 days plus one year


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Pregnancy (cont.)

• Physician monitors for– Placenta previa– Abrupt placenta– Gestational diabetes

• Assisting with prenatal care– Patient education– Assist with routine visit

• Interview patient• Documentation • Specimen testing• Patient and physician

assistance


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Pregnancy (cont.)

• Labor – stages – First – regular

contractions and cervical dilation

– Second – complete cervical dilation and entrance of head into vagina

– Third – expulsion of the placenta

• Delivery – Baby’s nose and

mouth suctioned– Umbilical cord

clamped, tied, and cut

– Vaginal vs. cesarean section

– Apgar testing of newborn


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Pregnancy (cont.)

• Breast-feeding– Human milk – preferred form of nutrition

• Colostrum – rich in antibodies that provide passive natural immunity to baby

– Economical and convenient– Provide education– Refer mother to community resources


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Contraception

Method DescriptionBirth control pill Daily oral contraceptive; inhibits ovulation

Birth control patch Inhibits ovulation; replaced weekly for 3 weeks, no patch 4th week

Injection Synthetic hormone administered every 3 months; inhibits ovulation

Condom Worn on penis or inserted into vagina; barrier to sperm

Diaphragm Barrier device fits over patient’s cervix; used with spermicide


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Contraception (cont.)

Method DescriptionSpermicidal foam, cream, jelly, vaginal suppositories

Contain chemicals that kill sperm; inserted into vagina

Vaginal contraceptive ring

Inserted for 3 weeks; removed for 1 week

Cervical cap Similar to diaphragm; covers smaller area of cervix

IUD Small piece of plastic or metal inserted into uterus; inhibits fertilization or implantation


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Contraception (cont.)

Method Description

Sterilization Surgical procedure; males – vasectomy; female – fallopian tubes cut or blocked

Periodic abstinence Rhythm method; refraining from intercourse when woman is fertile

Withdrawal Withdrawing the penis before ejaculation

Postcoital pills Prevent implantation


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Obstetrics and Gynecology (cont.)

• Contraception information– Planned

Parenthood Federation

– National Library of Medicine

– FDA

• Infertility– Inability to conceive– Patient education

• Tests• Treatments


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Diseases and Disorders

Condition DescriptionCancer Common occurrence in cervix, endometrium

(uterus), ovaries; cells divide uncontrollably,eventually forming tumor or other growth ofabnormal tissue

Ectopic pregnancy

Fertilized egg unable to move out of fallopian tube into uterus for implantation

Endometriosis Endometrial tissue present outside uterus, usuallyin pelvic area; not life-threatening but may causesterility


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Condition DescriptionFibroids, orleiomyomas

Common, benign, smooth tumors of muscle cells(not fibrous tissue) grouped in uterus

Fibrocysticbreast disease

Benign, fluid-filled cysts or nodules in breast

Menstrual disturbances

Amenorrhea, dysmenorrhea, menorrhagia, or metrorrhagia

Ovarian cysts Sacs of fluid or semisolid material; usually benign


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Condition DescriptionPelvic inflammatory disease (PID)

Acute or chronic infection of the reproductive tract; causes include STDs or other organism

Pelvic support problems

Abnormal weakening of vaginal tissue, unusual increase in abdominal pressure, congenital weakening

Polyps Red, soft, and fragile growths, with slender stem attachment on mucous membranes of cervix or endometrium


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Condition DescriptionPremenstrual dysphoric disorder (PMDD)

Severe premenstrual syndrome affecting 5% of women; symptoms have disrupting effect on patient’s life

Premenstrual syndrome (PMS)

Symptoms include swelling, bloating, weightgain, breast tenderness, headaches, and moodshifts 1 week to 10 days before menstruation


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Condition DescriptionSexual dysfunction disorders

Interruption or lack of sexual response cycle(excitement, plateau, orgasm, and resolution);

Vaginitis Inflammation of vagina caused by bacteria,viruses, yeasts, or chemicals in sprays, douches, or tampons


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ANSWER: Tests will probably include:Ultrasound to determine fetal size, position, and number of fetusesAmniocentesis to determine if there are possible genetic or metabolic disorders of the fetus.Alpha fetoprotein to determine if there is a possible neural tube defect.

1. A 38-year-old pregnant patient may be carrying twins. What diagnostic tests may be performed and why?


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ANSWER: Nägele’s rule says count back three months [1-December, 2-November, 3-October], then add seven days plus 1 year, [23 + 7 = 30]. Her estimated date of delivery would be October 30th.

2. A patient has just found out she is pregnant. Her last period started on January 23rd. Using Nägele’s rule, what day would be her estimated date of delivery?


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Pediatrics• Specialization in

the health care of children– Monitoring

development– Diagnosing and

treating illnesses– Pediatrician

• Medical assistant responsibilities– Parent or caregiver

education– Immunization

schedule– Detection of child

abuse


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Assisting with the Pediatric Physical Examination

• Ask about eating habits, sleep patterns, daily activities, immunization schedules, and toilet training

• Adolescents– STDs, drugs, and alcohol– Awkward and self-conscious

• Relieve fear– Explain procedures– Allow child to examine

instruments

• Speak in terms appropriate to age level


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Assisting with the Pediatric Physical Examination (cont.)

• Examining the well child– Infants need seven well-baby

examinations during their first year at these intervals

• 2 weeks 6 months• 1 month 9 months• 2 months 1 year• 4 months


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• Examining the well child (cont.)– Children in the second year of life should

have checkups at 15 and 18 months– Annually after 2 years old

• Prepare for exam as you would for an adult

• Follow Universal Precautions


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Detecting Child Abuse• Watch for problems

in relationship between child and parent/caregiver

• Observe for unexplained injuries

• Signs of abuse – Dirty diaper– Neglected appearance– Hunger– Extreme sadness or

fear– Inability to

communicate– Bruises or burns– Lesions on child’s

genitalia


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Detecting Child Abuse (cont.)

• Risk factors for abuse– Stress– Single parenthood– Inadequate knowledge of developmental

expectations– Lack of family support/family hostility– Financial problems– Mental health problems


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Detecting Child Abuse (cont.)

• Physician will examine for:– Internal injuries, tenderness when palpated or

auscultated – Malnutrition, tooth discoloration, unhealthy

gums– Lack of cognitive ability, dulled neurological

responses

• You are legally responsible for reporting suspected child abuse or neglect


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• Examining for growth abnormalities– Compare the child’s physical, intellectual, and

social signs to national averages– Growth stages

• One and Two – first and second years• Three – ages 3 to 5 years• Four – age 6 years to puberty• Five – adolescence


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• General eye exam– Pediatrician examines

interior of the eye– Visual acuity testing

• General ear exam– Children more

susceptible to ear infections

• Diagnostic testing – Most are same as for

adults– Rapid test for

presence of streptococcal bacteria

– Throat cultures– Urine specimens– Blood specimens


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• Immunizations– Store vaccines properly– Administer vaccines correctly– Maintain careful immunization

records– Educate parents– Follow recommended schedule

for follow-up appointments


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Diseases and Disorders• Frequently seen in pediatric office

– Common childhood diseases (Table 39-2)– Upper respiratory infections

• Do not make assumptions regarding diagnosis or treatment

• Do not recommend aspirin for fever in children


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Condition DescriptionAIDS Most transmitted from mother to infant; decreased

chance of infected infant if mother is being treatedJuvenile rheumatoid arthritis

Autoimmune disease of the joints; occurs in children 16 years or younger

ADHD All conditions identified as hyperactivity, hyperkinesis, and attention deficit

Learning disabilities

Conditions that interfere with learning, including dyslexia, dysgraphia, and dyscalculia


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Condition DescriptionCerebral palsy

Birth-related disorder of nerves and muscles; caused by brain damage occurring before, during, or after birth

Congenital heart disease

Cardiovascular malformations in the fetus before birth; causes include genetic mutations, maternal infections, maternal alcoholism, or maternal insulin-dependent diabetes

Down syndrome

Genetic disorder due to one extra chromosome in all cells formed during fetal development; characteristic facial features


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Condition Description

Hepatitis B Infection of liver; virus can be transmitted from the mother before or during birth; immunization available

RSV Major cause of lower respiratory infections; highly contagious; difficult to treat; antibiotics only treat any secondary infections

SIDS Unexplained sudden death of an infant during sleep; usually occurs before 6 months old; “Back to Sleep”


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Condition Description

Spina bifida Defect of spinal development occurring during the first trimester of pregnancy; spinal cord not fully protected because tissues fail to close around it

Viral gastroenteritis

Inflammation of stomach and intestines; can cause dehydration and electrolyte imbalance due to fluid loss


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Patient and Caregiver Education• Answer questions

appropriately

• American Academy of Pediatrics– Brochures and

booklets


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ANSWER: The medical assistant should be sure that vaccines are stored properly, administer vaccines correctly (if within scope of practice), maintain careful immunization records, educate parents, follow recommended immunization schedule for follow-up appointments.

What are the responsibilities of the medical assistant relating to immunizations?

Super!


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In Summary 39.1 Internal medicine practitioners diagnose and treat

diseases and disorders of the internal organs. An obstetrician/ gynecologist (OB/GYN) specializes in the female reproductive system, cares for pregnant women and delivers babies. A pediatrician specializes in the health care of children.

39.2 Examples of exams and diagnostic tests performed in internal medicine, obstetrics and gynecology and pediatrics include the basic physical exam, the gynecological exam, the cervical biopsy, and the well child exam.


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In Summary (cont.)

39.3 As a medical assistant in basic specialties, you might perform or assist with testing such as urine, blood tests, and bacterial cultures. You might educate patients on diseases of aging, infectious diseases, and STDs.

39.4 Some common diseases related to internal medicine include hypertension, coronary artery disease, and diabetes mellitus. Childhood diseases include chickenpox, influenza, measles, mumps, rubella, scarlet fever, and tetanus. Examples of diseases related to obstetrics and gynecology include cancer, endometriosis, and fibrocystic breast disease. Other diseases are outlined in Tables 39-1, 39-3, and 39-5.


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In Summary (cont.)

39.5 Typical treatments for diseases related to internal medicine, obstetrics and gynecology, and pediatrics include such things such as local or oral medication, including antibiotics, stress reduction, diet restrictions, and surgery. Treatments are outlined in more detail in Tables 39-1, 39-3, and 39-5.

39.6 Some common signs of domestic violence, elder abuse, and child abuse include unusual bruising or injuries that the patient tries to hide or excuse, foul odor, poor skin color, soiled clothing, and malnutrition. Recognizing the signs of these three problems is essential to your role as a medical assistant.


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In Summary (cont.)

39.7 During a gynecological exam or procedure, you will need to ensure patient comfort and safety as well as assist the physician with patient positioning, draping, equipment, and specimens obtained.

39.8 A pregnant woman will need to have her concerns and questions answered. During late pregnancy, she may not be able to move into certain positions and will require assistance.


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End of Chapter 39

If pregnancy were a book they

would cut the last two

chapters.

~ Nora Ephron

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