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Medical Assisting HCT I

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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 Presentation

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Page 1: Medical Assisting

Medical AssistingHCT I

Page 2: Medical Assisting

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

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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

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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.

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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

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• 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

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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

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Assessment Techniques:

inspection

palpation

percussion

auscultation

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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

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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

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Centimeters Inches 0.3937 From To Multiply by

Formula. lbs / 2.2 = kilograms. kg x 2.2 = pounds ...

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