CHAPTER 5

1. CHAPTER 5 THE PHYSICAL EXAMINATION

2. Introduction to the Physical Examination Complete patient examination consists of: Health history Physical examination (PE) Laboratory and diagnostic tests Results used by physician to: Determine patient's state of health Arrive at a diagnosis and prescribe treatment Observe any change in patient's illness after treatment has been instituted

3. Introduction to the Physical Examination, cont. • Purpose of PE • To detect early signs of illness • Helps prevent serious health problems • Prerequisite for employment • Participation in sports • Attendance at summer camp • Admission to school

4. Definition of Terms • Final diagnosis: scientific method of determining and identifying a patient's condition through evaluation of the health history, PE, laboratory tests, and diagnostic procedures • Often simply called the diagnosis (dx)

5. Definition of Terms, cont. • Clinical diagnosis:intermediate step in the determination of a final diagnosis • Obtained through evaluation of health history and PE (without laboratory and diagnostic tests) • Outside laboratories provide space on laboratory request: to specify clinical diagnosis • Once physician has analyzed test results: final diagnosis can usually be established

6. Definition of Terms, cont. • Differential diagnosis:two or more diseases may have similar symptoms • Determines which disease is causing the symptoms so that a final diagnosis can be made • Example: “Strep” throat and pharyngitis have similar symptoms • Differential diagnosis is made by strep test • Prognosis:probable course and outcome of a patient's condition and the patient's prospects for recovery

7. Definition of Terms, cont. • Risk factor:physical or behavioral condition that increases the probability that an individual will develop a particular condition • Includes: • Genetic factors • Habits • Environmental conditions b. Does not mean the disease will develop • Only that chance is greater of developing it • Example: Smoking is a risk factor for lung cancer and heart disease

8. Definition of Terms, cont. • Acute illness:characterized by symptoms that have a rapid onset • Usually severe and intense • Subside after a short time • Example: influenza • Chronic illness:characterized by symptoms that persist for more than 3 months • Patient shows little change over a long time • Examples: diabetes, hypertension, emphysema

9. Definition of Terms, cont. 8. Therapeutic procedure:a procedure performed to treat patient's condition with the goal of eliminating it or promoting as much recovery as possible • Example: administration of medications • Diagnostic procedure:performed to assist in the diagnosis of a patient's condition • Examples: electrocardiography, x-ray examination • Laboratory testing:the analysis and study of specimens obtained from patient to assist in diagnosis and treatment of disease

10. Preparation of the Examining Room Guidelines: • Should be free from clutter and well lit • Check daily for ample supplies; restock as needed • Empty waste receptacles frequently • Replace biohazard containers as necessary • Room should be well ventilated • Maintain room temperature • Clean and disinfect daily: • Examining tables • Countertops • Faucets

11. Preparation of the Examining Room, cont. • Remove dust/dirt from furniture & towel dispensers • Change examining table paper after each patient • Patient's privacy should be ensured • Keep door closed during patient examination • Clean and prepare items the physician will be using for examinations (equipment, instruments, supplies) • Check equipment and instruments frequently for proper working condition • Have equipment and supplies ready for examination • Know how to operate and care for equipment

12. Physical Exam Equipment and Supplies

13. Physical Exam Equipment and Supplies, cont.

14. Preparation of the Patient • MA's responsibility: prepare the patient for PE • After escorting patient to examining room • Identify the patient by name and date of birth • Take vital signs • Measure height and weight • Explain purpose of examination and answer questions • Apprehension can be reduced by: • Address patient by name of choice • Have a friendly and supportive attitude • Speak clearly, distinctly, and slowly

15. Preparation of the Patient, cont. • Ask patient if he needs to empty the bladder before examination • Makes examination easier for physician to perform and more comfortable for patient • If urine specimen is needed: patient is asked to void • Instructions for disrobing should be specific • Clothing that should be removed • Where to place clothing • Instructions for putting on gown and location of gown opening

16. Preparation of the Patient, cont. • Disrobing facility should be comfortable and private • MA should have patient's medical record available for review by the physician • Use designated location for medical record a. Shelf next to examining room door or chart holder • Follow HIPAA privacy rule to protect patient's health info • Help patient on/off the examining table for safety

17. Measuring Weight and Height • Mensuration: process of measuring • Change in weight may be significant in: • Diagnosis of patient's condition • Prescribing treatment • Underweight/overweight patients on diet therapy program: • Should have weight taken regularly to determine progress

18. Measuring Weight and Height, cont. 4. Prenatal patients weighed at each prenatal visit to: • Assess fetal development & mother's health • Adult weight is measured at each office visit 6. Adult height usually only measured: • First office visit • Complete PE

19. Measuring Weight and Height, cont. • Children weighed and measured at each office visit to: • Observe pattern of growth • Calculate and determine medication dosage • Height and weight are compared against a standardized chart: • Determines if patient falls within normal limits

20. Measuring Weight and Height, cont. • Guidelines for Measuring Ht/Wt: • Weight: Using an upright balance scale • Provide privacy for patient • Many patients are self-conscious about having weight measured • Balance scale • If scale not balanced: measurement will be inaccurate • Scale is balanced when upper and lower weights are on zero and indicator point comes to a rest at center of balance area

21. Balance the Scale

22. Measuring Weight and Height, cont. • Assist the patient • Assist patient on and off the scale platform • Platform moves slightly: may cause patient to become unsteady • Obtain an accurate weight • Ask patient to remove shoes • Measure weight with patient in normal clothing • Ask patient to remove heavy outer clothing

23. Measuring Weight and Height, cont. Interpret calibration markings accurately Lower calibration bar: divided into 50-pound increments

24. Measuring Weight and Height, cont. • Upper calibration bar is divided into pounds and quarter pounds • Longer calibration lines: indicate pound increments • Shorter calibration lines indicate quarter-pound and half-pound increments

25. Measuring Weight

26. Measuring Weight and Height, cont. • Determine patient's weight correctly • Add the measurement on lower scale to measurement on upper scale • Round results to nearest quarter pound • Occasionally weight may need to be converted to kilograms (metric unit) • May be required to determine medication dosage • 1 kg = 2.2 pounds • To convert pounds to kg: Divide the number of pounds by 2.2

27. Measuring Weight and Height, cont. Height: Using an upright balance scale • Do not place patient on scale in a forward position • Measuring bar could fall into patient's face when patient steps off scale • Determine the calibration markings accurately • Calibration markings are divided into either: • Inches • Feet and inches

28. Measuring Height

29. Measuring Weight and Height, cont. • Read the measurement correctly • Read the measurement at the junction of the stationary calibration rod and the movable calibration rod

30. Measuring Weight and Height, cont. • If patient's height is less than the top value of the stationary calibration rod • Read the measurement directly on the stationary rod • On most scales: highest calibration on stationary rod is 50 inches • Patients with a height of 50 inches or less will have their height read directly on stationary rod

31. Measuring Height

32. Measuring Weight and Height, cont. • Record the height measurement correctly. • Record height measurement in feet and inches. • If the scale is calibrated in inches: • Convert the reading to feet and inches: divide the number of inches by 12 • Example: Height measurement of 60 inches is recorded as 5 feet (60 inches divided by 12 equals 5)

33. Positioning and Draping • Correct positioning of the patient facilitates the examination • Permits better access to part being examined • Sitting: Examination of the head, neck, chest, upper extremities; measure vital signs

34. Sitting Position • Examination of the head, neck, chest, upper extremities; measure vital signs

35. Supine Position Supine:Examination of head, chest, abdomen, extremities • Not a comfortable position for patients with: • Respiratory problems • Back injury • Low back pain

36. Prone Position Prone:Examination of back; assess extension of hip joint

37. Dorsal Recumbent Position Dorsal recumbent:Vaginal and rectal examinations, insertion of urinary catheter, examine the head, neck, chest and extremities of patients who have difficulty maintaining supine position • Bending of legs is more comfortable for some patients

38. Lithotomy Position Lithotomy: Vaginal, pelvic and rectal examinations

39. Sims Position Sims: Used to examine the vagina and rectum, to measure rectal temperature, to perform a flexible sigmoidoscopy, an to administer an enema

40. Knee-Chest Position Knee-chest: Examine the rectum, perform a proctoscopic examination

41. Fowler’s Position Fowler's: • Examine upper body of patients with cardiovascular and respiratory problems • Easier for these patients to breathe in this position • Draw blood from patients likely to faint

42. Positioning and Draping, cont. Position used depends on type of examination being performed • More than one position may be used • Explain position to patient and assist them into it • Take patient's endurance and degree of wellness into consideration • Weak or ill patient may not be able to assume a position • Do not keep patient in uncomfortable positions longer than necessary • Let the patient rest before getting off the examining table • Assist patient off table to prevent falls

43. Positioning and Draping, cont. • Draping provides modesty, comfort, and warmth • Only part being examined should be exposed • Gowns and drapes are made of paper or cloth

44. Inspection Inspection:The process of observing a patient to detect the signs of disease • Observe patient for: • Color • Speech • Deformities • Skin condition • Body contour and symmetry • Orientation to the surroundings • Body movements • Anxiety level

45. Palpation • Palpation:The process of feeling with the hands to detect the signs of disease • Helps verify data obtained from inspection • Patient's verbal and facial expressions are observed • Used to determine: • Placement and size of organs • Presence of lumps • Pain • Swelling • Tenderness • Examples of palpation • Breast examination, measuring radial pulse

46. Percussion • Percussion:The process of tapping body and listening to the sounds produced to detect the signs of disease • Used to determine: • Size, density, location of organs • Example: examination of lungs and abdomen • Dense structures: produce a dull sound (liver) • Empty or air-filled structures: produce a hollow sound (lungs)

47. Percussion, cont.

48. Ausculatation • Auscultation:The process of listening with a stethoscope to the sounds produced within the body to detect the signs of disease • Used to: • Listen to heart and lungs • Measure blood pressure