Physical examination techniques Review

Stimulus

Any object or event that the body can sense, detected by sensory receptors.

Receptors

The specialized nerve endings found in sensory nerves responsible for responding to various stimuli.

Sclera

The tough outer layer of the eye that helps maintain its shape and provides protection.

Extraocular muscles

A group of six muscles that control the movements of the eyeball, allowing it to turn and orient in different directions.

Choroid

The layer of the eye located beneath the sclera that contains blood vessels and a pigment layer to absorb excess light and prevent reflections.

Retina

The innermost layer of the eye that contains photoreceptors and processes visual information, focusing an image onto its surface.

Iris

The colored part of the eye that is a muscle surrounding the pupil, regulating the amount of light that enters the eye.

Cornea

The transparent, curved front surface of the eye that helps focus light onto the retina.

Conjunctiva

The thin, transparent membrane that covers the inner surface of the eyelids and the outer surface of the eyeball, protecting and lubricating the eye.

Lacrimal glands

Glands located above the outer corner of each eye that produce tears to keep the eye surface moist and free from debris.

Aqueous humor

The clear, watery fluid located in the anterior chamber of the eye, helping to maintain intraocular pressure and providing nutrients to the eye tissues.

Vitreous humor

A gel-like substance filling the main cavity of the eye, providing structural support and keeping the retina in place.

Fovea centralis

The small pit in the retina that contains a high concentration of cones and is responsible for sharp central vision.

Rods

Photoreceptor cells in the retina that are sensitive to low light levels and enable vision in dim lighting, seeing in black and white.

Cones

Photoreceptor cells in the retina responsible for color vision and visual acuity, functioning best in bright light conditions.

Optic disc

The region at the back of the eye where the optic nerve leaves the retina, creating a natural blind spot.

Hyperopia

Also known as farsightedness, a condition where nearby objects appear blurry as the eye focuses images behind the retina.

Myopia

Also known as nearsightedness, a condition where distant objects appear blurry as images are focused in front of the retina; affects about 42% of the U.S. population.

Age-Related Macular Degeneration (AMD)

A progressive eye disease that causes loss of central vision due to damage to the macula; occurs in early, intermediate, and late stages.

Drusen

Yellow deposits of fat that form between the retinal pigment epithelium and Bruch's membrane; used in identifying the stages of Age-Related Macular Degeneration.

Amblyopia

Commonly known as lazy eye, a vision development disorder where one eye is weaker, commonly seen in children with uncorrected strabismus.

Arcus Senilis

A grayish or white arc surrounding the cornea, often associated with aging but may indicate high cholesterol in younger individuals.

Blepharitis

Inflammation of the eyelid margins characterized by redness, crusting, and itching; often related to seborrheic dermatitis or bacterial infection.

Cataract

A condition in which the lens of the eye becomes cloudy, leading to hazy vision; commonly occurs in older adults.

Conjunctivitis

Inflammation of the conjunctiva often caused by infection, allergies, or irritants, characterized by redness, irritation, and discharge.

Diabetic Retinopathy

A complication of diabetes characterized by damage to the blood vessels in the retina, often leading to blindness.

Glaucoma

A group of eye diseases that damage the optic nerve, often related to increased intraocular pressure, leading to vision loss.

Hordeolum

A localized infection of an oil gland in the eyelid, known as a stye, causing swelling, redness, and pain.

Iritis

Inflammation of the iris, leading to pain, light sensitivity, and sometimes blurred vision; requires prompt medical attention.

Presbyopia

The gradual loss of the eye's ability to focus on nearby objects, commonly associated with aging.

Ptosis

Drooping of the upper eyelid, which can affect one or both eyes and may be a sign of underlying health issues.

Pinna (auricle)

The visible part of the outer ear that collects sound waves and directs them into the ear canal.

Ossicles

The three small bones in the middle ear—the malleus (hammer), incus (anvil), and stapes (stirrup)—that transmit sound vibrations to the inner ear.

Eustachian tube

A passage connecting the middle ear to the throat, helping to equalize pressure in the ear.

Organ of Corti

The sensory organ within the cochlea that contains hair cells and is responsible for converting sound vibrations into neural signals.

Semicircular canals

Three structures in the inner ear that help maintain balance by detecting rotational movement.

Videonystagmography (VNG)

A specialized test used to assess balance and eye movements, often to diagnose vestibular disorders.

Ménière’s Disease

A disorder of the inner ear characterized by episodes of vertigo, hearing loss, and tinnitus.

Otitis Externa

An infection or inflammation of the outer ear canal, often caused by bacteria or fungi.

Otitis Media

An infection of the middle ear, often following a respiratory infection, characterized by ear pain and possible hearing loss.

Otosclerosis

A condition that affects the bones of the middle ear, leading to progressive hearing loss due to abnormal bone growth.

Presbycusis

Age-related hearing loss that typically affects ability to hear high-pitched sounds.

Epistaxis

The medical term for bleeding from the nose, which can occur due to various causes including trauma or dry air.

Rhinitis

Inflammation of the nasal mucosa resulting in symptoms such as sneezing, nasal congestion, and runny nose, often due to allergies.

Candidiasis

A fungal infection characterized by white patches in the mouth or throat, often caused by an overgrowth of the yeast Candida.

Mechanoreceptors

Sensory receptors that respond to mechanical pressure or distortion, critical for the sense of touch.

Thermoreceptors

Receptors that detect temperature changes, allowing the body to perceive sensations of heat and cold.

Complete Physical Examination

A comprehensive assessment performed by a healthcare provider to evaluate a patient's overall health status.

Inspection

A systematic examination method involving visual assessment of the body, including the skin and organs.

Palpation

A technique where hands are used to feel the body to assess the size, shape, texture, and tenderness of organs.

Percussion

An examination method that involves tapping the body to evaluate the underlying structures and their condition.

Auscultation

The technique of listening to body sounds, primarily using a stethoscope to assess heart, lung, and abdominal health.

Mensuration

The process of measuring body parts to gather data on growth, development, and health status.

Manipulation

Refers to the passive movement of a joint during a physical examination to evaluate range of motion.

HEENT

An acronym for a physical examination area focusing on the Head, Eyes, Ears, Nose, and Throat.

Muscle Strength test

An assessment where a patient performs movements against resistance to evaluate muscle strength.

Romberg balance test

A test used to evaluate balance and proprioception by having the patient stand with their eyes closed.

POMR

A method of clinical documentation that organizes patient information using a problem-oriented approach.

Provider Assessment

The healthcare provider's interpretation and evaluation of a patient's health status based on subjective and objective findings.

Medical Assistant's Role (During Exam)

Includes preparing the examination area, ensuring necessary equipment is ready, assisting the provider, and attending to patient comfort.

Provider Plan

A comprehensive strategy established by the healthcare provider after an examination, outlining the next steps in patient care.

HITECH Act

A 2009 law aimed at promoting the adoption of electronic health records and improving healthcare IT.

Medicare Promoting Interoperability (PI) Program

A program that emphasizes the necessity of interoperability and enhancing patient access to their own healthcare information.

Electronic Medical Record (EMR)

A digital version of a patient's paper chart, maintained and accessed within a single healthcare organization.

Electronic Health Record (EHR)

A digital record that includes a patient's medical history and can be shared across different healthcare systems.

HIMSS

The Health Information Management Systems Society, which focuses on improving healthcare quality through information technology.

Subjective Information

Data derived from the patient’s perspective or experience, including symptoms and patient history.

Objective Information

Data collected through clinical examination and diagnostic tests, providing measurable evidence of health status.

Progress Notes

Clinical notes that are organized chronologically, detailing patient interactions, interventions, and outcomes.

SOAP

An acronym in healthcare documentation standing for Subjective, Objective, Assessment, and Plan.

HPIP

A structured method of recording patient information using History, Physical, Impression, and Plan.

CHEDDAR

A system for organizing patient information encompassing Chief complaint, History, Examination, Details, Drugs/dosages, Assessment, and Return visit.

Handwritten Correction Procedure

The method of correcting a written document by striking through the error and writing the correction with a date and note indicating it is a correction.

The Five Steps in Filing

The structured approach to organizing files: 1. Inspecting, 2. Indexing, 3. Coding, 4. Sorting, 5. Storing.

OUTguides / OUTfolders

Folders used in filing systems to mark where a file was removed, helping to keep track of documents.

Numeric Filing Systems

Filing systems categorized into various types based on numbering methods, such as straight numeric and terminal-digit filing.

Balance Beam Scale

A precision scale used to measure a person's weight accurately by balancing weights on a beam.

Body Mass Index (BMI)

A calculation that relates a person's weight to their height, estimated by multiplying weight in pounds by 703 and dividing by height in inches squared.

Vital Signs

Measurements critical to assessing the basic body functions, including temperature, pulse, respiration rate, and blood pressure.

Hypothalamus

The brain region responsible for regulating body temperature and maintaining homeostasis.

Febrile

A condition indicating that a person's body temperature is higher than the normal range.

Afebrile

A state in which a person's body temperature is within the normal range.

Celsius to Fahrenheit Conversion

Conversion formula from Celsius to Fahrenheit: $[C imes \frac{9}{5}] + 32 = F$.

Fahrenheit to Celsius Conversion

Conversion formula from Fahrenheit to Celsius: $[F - 32] imes \frac{5}{9} = C$.

Rectal Temperature

A highly accurate method for measuring body temperature, typically reflecting a degree higher than oral measurements.

Axillary Temperature

The least accurate method for measuring temperature, done in the armpit, usually one degree lower than oral temperature.

Temporal Artery (TA) Temperature

An alternative, non-invasive method for measuring body temperature by scanning the forehead, correlating closely with rectal readings.

Pulse

The detectable rhythmic expansion of an artery, reflecting the heartbeat, felt at various pulse points and measured per minute.

Radial Pulse

The most common site to measure the pulse, found on the wrist.

Brachial Pulse

The pulse site located in the upper arm, commonly used in blood pressure assessments.

Carotid Pulse

The pulse felt in the neck, usually assessed during emergencies or resuscitation.

Apical Pulse

A heart rate measured directly over the heart using a stethoscope, particularly important in infants and patients with irregular heart rhythms.

Arrhythmia

An irregular heartbeat that can indicate various underlying cardiac issues.

Pulse Oximeter

A device that uses light to measure the amount of oxygen present in a person's blood, often clamped onto a fingertip.

Respiration

The total process of inhalation and exhalation, with normal adult rates ranging from 12 to 20 breaths per minute.

Dyspnea

Difficult or labored breathing, which may signal respiratory or cardiac distress.

Rales

Abnormal lung sounds often described as crackles, typically heard during inhalation when listening with a stethoscope.

Apnea

 A temporary cessation of breathing, can occur during sleep or in other situations.

Systole

The phase of the heartbeat when the heart muscle contracts and pumps blood out of the chambers.

Diastole

The phase of the heartbeat when the heart muscle relaxes and allows the chambers to refill with blood.