#7 NHA CCMA: Abnormal Signs/Symptoms and Pathophysiology

What are the medical assistant's (MA’s) responsibilities when preparing a patient for a provider exam?

To obtain, document, and report abnormal signs and symptoms, including vital signs, anthropometric measurements, and the chief complaint.

When does the MA usually gather abnormal signs and symptoms?

During the patient interview and intake process, before the provider’s exam.

Why are vital signs important at every visit?

They provide a baseline and help identify potential disease or disorders.

What should an MA do if a vital sign is abnormal?

• Report the abnormal value to the provider.

• Document the value clearly.

• Provide context if external factors (e.g., hot coffee) may have affected it.

• Recheck the value later if needed.

What are examples of external factors that can influence vital signs?

• Hot drinks before a temperature reading

• Recent activity before a pulse or blood pressure reading

• Stress or anxiety during the visit

Where should abnormal signs and symptoms be documented?

In the medical record, as part of the patient intake notes.

When should the provider be alerted about abnormal results?

Immediately, before they see the patient.

What should you do if the abnormal sign is clearly caused by a temporary or explainable factor?

Report it with an explanation, and reassess later if needed.

Do pediatric vital sign ranges differ from adults?

Yes, they vary widely by age.

What should MAs working in pediatrics always have available?

A validated reference guide for pediatric vital sign ranges.

What is the key purpose of identifying, documenting, and reporting abnormal signs and symptoms?

To detect possible illnesses early and ensure the provider can act on abnormal findings promptly.

Are medical assistants expected to memorize all diseases and disorders?

No. MAs should be familiar with common conditions, and experience will build deeper knowledge.

How are diseases in this section organized?

By body system—this section focuses on the integumentary system.

What are common signs and symptoms of cellulitis?

Skin that is swollen, red, hot to the touch, often painful.

What causes cellulitis?

A bacterial infection (usually Streptococcus or Staphylococcus) that enters through cuts or abrasions.

How is cellulitis diagnosed?

Through physical exam, wound culture, and blood tests.

What is the treatment for cellulitis?

• Resting the area

• Debridement (removing dead tissue, if needed)

• Antibiotics

What are symptoms of dermatitis?

Red, itchy rash, possibly with blisters or oily scales.

What causes dermatitis?

An allergic reaction to a specific allergen causing inflammation.

How is dermatitis diagnosed?

Physical examination

What is the treatment for dermatitis?

• Moisturizers

• Steroid creams

What are signs of eczema?

Red, itchy skin, often inflamed and dry.

What causes eczema?

Likely hereditary and environmental factors.

How is eczema diagnosed?

Physical exam

What is the treatment for eczema?

• Mild, fragrance-free soaps

• Moisturizers

• Steroid creams

• Antihistamines

What are signs of basal cell skin cancer?

A waxy bump or sore that does not heal and continues to grow.

What causes basal cell carcinoma?

DNA damage to basal skin cells from UVB exposure (sun or tanning beds).

How is basal cell carcinoma diagnosed?

• Physical exam

• Biopsy

What are treatments for basal cell carcinoma?

• Surgical excision

• Cryotherapy (liquid nitrogen)

• Curettage (scraping)

What are the signs of melanoma?

A mole with the ABCDE characteristics:

• Asymmetry: irregular shape

• Border: rough or irregular

• Color: not uniform

• Diameter: larger than ¼ inch

• Evolving (not listed, but commonly included)

What causes melanoma?

Excessive exposure to UVB rays (sunlight or tanning beds)

How is melanoma diagnosed?

Physical exam and biopsy

What is the treatment for melanoma?

• Surgery

• Radiation therapy

Why is early diagnosis important for melanoma?

It is crucial for survival and effective treatment.

What are signs and symptoms of a sprain?

• Painful swelling

• Bruising of a joint

• Decreased mobility

What causes a sprain?

A joint is pushed outside its normal range, damaging ligaments.

How is a sprain diagnosed?

Physical exam and imaging (like X-rays or MRIs)

What is the treatment for a sprain?

The RICE method:

• Rest

• Ice

• Compression

• Elevation

What are symptoms of osteoporosis?

• Often no symptoms

• In severe cases: fractures and back pain

What causes osteoporosis?

• Poor calcium intake

• Malnutrition

• Lack of exercise

• Hormonal imbalance

• Aging

How is osteoporosis diagnosed?

By measuring bone mineral density with a DEXA scan

What is the treatment for osteoporosis?

• Medications to slow bone loss

• Fall prevention

• Calcium & Vitamin D supplements

What are symptoms of osteoarthritis?

• Joint pain during movement

• Stiffness after inactivity

• Lack of flexibility

What causes osteoarthritis?

• Degeneration of articular cartilage

• Changes in synovial membrane

How is osteoarthritis diagnosed?

• Medical history

• Physical exam

• Imaging tests

What are the treatment options for osteoarthritis?

• Exercise & physical therapy

• Steroid injections

• Joint replacement surgery (if severe)

What are symptoms of rheumatoid arthritis?

• Pain and decreased mobility in small joints (e.g., fingers)

• Progresses to larger joints (e.g., knees, hips)

What causes rheumatoid arthritis?

Autoimmune disorder affecting connective tissues, especially joints
(Also considered an immune/lymphatic system disorder)

How is rheumatoid arthritis diagnosed?

Physical exam, blood tests, and imaging

What are the symptoms of gout?

Red, hot, swollen joint (usually the big toe)

What causes gout?

Excess uric acid in the joint forms needle-like crystals

How is gout diagnosed?

Joint aspiration to examine crystals under a microscope

What is the treatment for gout?

• Anti-inflammatory medications

• Dietary changes to reduce uric acid levels

What are the symptoms of muscular dystrophy?

• Chronic, progressive muscle weakness

• Leads to paralysis of muscle groups over time

What causes muscular dystrophy?

• Genetic mutation, often inherited or spontaneous

• Affects muscle-protecting proteins

What are the symptoms of myopathy?

• Muscle weakness, cramps, stiffness, spasms, or tetany

What causes myopathy?

Various causes:

• Trauma

• Infections (viral)

• Systemic disease

How is myopathy diagnosed?

• History, physical exam, muscle enzyme tests

• Electromyography, muscle biopsy, genetic testing

What is the treatment for myopathy?

• Based on cause

• May include physical therapy, medications, supportive bracing, surgery, and massage

What is myalgia?

General muscle pain

What causes myalgia?

• Often due to:

  • Overuse or overstretching

  • Injury

  • Viral infection

How is myalgia diagnosed?

Based on symptoms and medical history

What are the symptoms of RSD?

• Pain

• Tingling

• Numbness

• Swelling

• Redness

• Loss of flexibility

• Muscle weakness

What causes RSD?

Repetitive motions and strain from:

• Forceful exertions

• Vibrations

• Mechanical compression

• Sustained awkward positions

• Repetitive tasks

How is RSD diagnosed?

Physical exam, patient history, and imaging

What is the treatment for RSD?

• Symptom-targeted treatments:

  • Massage

  • Heat or cold therapy

  • Medications for pain or muscle relaxation

• Severe cases may require surgery

What are the symptoms of shin splints?

Pain and swelling in the lower leg

What causes shin splints?

Repeated stress on the tibia and surrounding connective tissue

How are shin splints diagnosed?

Physical exam and patient history

What is the treatment for shin splints?

• RICE (Rest, Ice, Compression, Elevation)

• Anti-inflammatory medications

• Rest and massage

• Surgery if condition is severe

What are the symptoms of anemia?

• Fatigue

• Dizziness

• Cold extremities

• Headache

• Irregular heartbeat

What causes anemia?What causes anemia?

• Blood loss

• Dysfunction in hemoglobin production

• Excessive destruction of red blood cells

How is anemia diagnosed?

Blood test

How is anemia treated?

• Depends on the cause

• Blood transfusion (if due to blood loss)

• Iron or vitamin K supplementation (for deficiency)

What are the symptoms of atherosclerosis?

• Chest pain

• TIAs (mini-strokes)

• Peripheral artery disease

• Kidney dysfunction

What causes atherosclerosis?

• Fatty deposits hardening the arteries

• Risk factors: High blood pressure, high cholesterol, smoking, diabetes

How is atherosclerosis diagnosed?

• Physical exam, blood tests,

• Doppler ultrasound, EKG,

• Stress test, angiogram, CT or MRI

What is the treatment for atherosclerosis?

• Lifestyle changes, medications (cholesterol meds, beta blockers, ACE inhibitors)

• Angioplasty, stents, endarterectomy, bypass surgery

What are the symptoms of CHF?

• Fatigue

• Peripheral edema

• Shortness of breath

What causes CHF?

Heart’s decreased pumping ability due to:

• Coronary artery disease

• High blood pressure

• Cardiomyopathy

• Valve disease or heart defects

How is CHF diagnosed?

• Medical history, physical exam, blood tests

• EKG, echocardiogram, chest x-ray

What is the treatment for CHF?

• Varies by type/severity

• Weight loss, blood pressure control,

• ACE inhibitors, beta blockers

What are the symptoms of hemophilia?

• Excessive bleeding

• Frequent bruising

What causes hemophilia?

Genetic defect causing absence of blood clotting factors

How is hemophilia diagnosed?

Family history, physical exam, blood tests

What is the treatment for hemophilia?

Replacement therapy (infusing clotting factors into a vein)

What are the symptoms of hypertension?

• Often asymptomatic

• May include:

  • High blood pressure

  • Headaches

  • Irregular heart rhythms

  • Vision changes

  • Chest pain

What causes hypertension?

• Genetics

• Smoking

• Obesity

• Stress

• Excess salt intake

How is hypertension diagnosed?

Consistently high BP over 2–3 visits in 1–4 weeks

What is the treatment for hypertension?

• Medications

• Weight management

• Healthy diet

• Stress reduction

What are the symptoms of a myocardial infarction?

• Acute chest pain

• Nausea, vomiting

• Heartburn

• Profuse sweating

What causes a myocardial infarction?

• Ischemia (lack of oxygen) to heart muscle

• Typically caused by atherosclerosis of a coronary artery

How is a myocardial infarction diagnosed?

• EKG

• Blood tests

How is a myocardial infarction treated?

• Fibrinolytic agents (clot busters)

• Diagnostic angiogram

• Stenting

• Bypass surgery (if severe)

What are the symptoms of acute renal failure?

• Decreased urine output

• Fluid retention

• Fatigue

• Shortness of breath

• Confusion, nausea

What causes acute renal failure?

• Direct damage to kidneys

• Sudden loss of filtering ability, causing toxic buildup

How is acute renal failure diagnosed?

• Urine output observation

• Blood tests, urinalysis, imaging

How is acute renal failure treated?

• Correcting underlying cause

• Medications

• Hemodialysis (if severe)

What are the symptoms of chronic renal failure?

• Early stages: Often no symptoms

• Later stages:

  • High blood pressure

  • General fatigue

  • Feeling unwell

What causes chronic renal failure?

• Progressive kidney damage

• Often caused by:

  • Diabetes

  • High blood pressure

  • Glomerulonephritis