medical assisting
DESCRIPTION
Medical Assisting. HCT I. Physical Exam. A complete PE consists of 3 parts: ·health history· physical exam of each body system· lab and diagnostic tests The MA assists the physician in all 3 aspects. *. Physical Exam Terms. acute illness- Rapid onset (cold, flu, sinus infection ) - PowerPoint PPT PresentationTRANSCRIPT
Medical AssistingHCT I
Physical Exam
* A complete PE consists of 3 parts:·health history·
physical exam of each body system·
lab and diagnostic tests
The MA assists the physician in all 3 aspects
Physical Exam Terms acute illness- Rapid onset (cold, flu, sinus infection)
chronic illness- gradual onset, A disease or illness lasting more than 3 months
therapeutic procedure- Done to treat the condition, eliminate or correct the cause. (promotes recovery)
diagnostic procedure- Test done to find the cause of an illness.
lab testing- analysis of the tests to determine a specific causative agent
clinical diagnosis- Initial diagnosis based on the patient's signs and symptoms
differential diagnosis - use labs and diagnostic tests to rule out a similar injury or illness.
final diagnosis (the diagnosis)
prognosis - outcome or course of a disease
risk factor - physical behaviors that increase the risk of a disease.
Preparation of Exam Roomroom should be well lit, free from clutterrestock supplies dailykeep trash cans empty; replace full biohazard containersroom should be well-ventilated use air fresheners to eliminate odorskeep room comfortable temp for pt.clean & disinfect exam table, counters and faucets qdchange exam paper after each pt.prepare equipment, instruments & supplies; arrange in order for physician to useknowledgeable on operation/use of equipment
• PREPARATION OF THE PATIENT.• Escort pt to exam room• ID patient by name and birth
date• Obtain VS, Ht & Wt
(mensuration)and chart results in medical record
• explain procedures in a friendly manner·ask patient to void (if a urine spec is needed this is the time!)• Instructions on disrobing• maintain pt privacy• provide physician w/ pt's medical record (HIPPA)• assist pt w/positioning on exam table
Positioning & Draping: provides visualization of body part being examined; draping provides modesty, comfort & warmth
Sitting position - drape over pt thighs and knees
Fowler's - semi = 45; full = 90
Supine (horizontal recumbent) - remember to pull out table extension; drape length-wise
Prone - place in supine then assist them to roll onto stomach, hands at side or folded above head
dorsal recumbent - have pt. bend knees & place each foot @ edge of table; drape diagonally
Lithotomy - have pt. slide bottom to edge and rotate thighs out ward, feet in stirrup; diagonal drape
Sim's - Right leg flexed sharply over slightly flexed left
Knee-chest - Place supine, roll towards you into prone, have them bend arms @ elbow and elevate buttocks keeping back straight; diagonal drape
Assessment Techniques:
inspection
palpation
percussion
auscultation
Assisting the physician:
• assisting with position changes& draping
• handing instruments and supplies
• reassure patient to decrease apprehension
• review treatment plan, patient education, and instructions for a return visit –chart this in the medical record
• escort patient to reception area
Height and Weight• Measurements are a procedure common for different types of office
visits / physical exams.• Special Points:
• Conversions – kg to pounds, pounds to kg
• Height vs. length, feet and inches.
• Types of scales
• Head Circumference
• Abdominal Girth
• Chest Circumference
Centimeters Inches 0.3937 From To Multiply by
Formula. lbs / 2.2 = kilograms. kg x 2.2 = pounds ...