chapter 21: physical exam

breathing patterns

• rapid respirations, sighing, shallow thoracic breathing

• indicated anxiety, boredom, pain

eye patterns

• no eye contact, side to side movement, looking down at the hands

• indicates anxiety, distrust, embarrassment

hands

• tapping fingers, cracking knuckles, continuous movement, sweaty palms

• indicates anxiety, worry, fear, pain

arm placement

• folded across chest, wrapped around abdomen 

• indicates anxiety, worry, fear, pain

leg placement

• tensions, crossed or tucked under, tapping foot, continuous movement

• indicates frustration, anger

open ended questions

• ask for general information or states the topics to be discussed, but only in general terms

• encourage the patients to respond comfortably

• ex: “what brings you to the doctor?” or “tell me more about that.”

closed-ended questions

• ask for specific information

• often answered with a yes or no. use when you need confirmation of specific facts

• ex: “do you have a headache?” or “have you ever broken a bone?”

open-ended questions and statements

encourage the patient to respond in more detail

direct or closed-ended questions

ask for a specific information; usual reply is yes or no

active listening 

nonverbally communicates your interest in the patient

silence

nonverbally communicated your acceptance of the patient and willingness to wait until the patient is ready to answer

establishing guidelines

informs the patient of what to expect during the interview

acknowledgment 

shows the importance of the patient’s role and respect for autonomy

restating

checks your interpretation of the patient’s message for validation

reflecting

shows the patient your acknowledgment of his or her feelings

summarizing 

helps the patient separate relevant from irrelevant material; provides clarity to the interview

interview barriers

• providing unwanted assurance

• giving advice

• using medical terminology

• leading questions

• talking too much

• defense mechanisms

denial

the patient completely rejects the information

suppression

the patient is consciously aware of the information or feeling but refuses to admit it

reaction formation

the patient expresses her feelings as the opposite of what she really feels

projection

the patient accuses someone else of having feelings that she has

rationalization

the patient comes up with various explanations to justify her response

undoing

the patient tries to reverse a negative feeling by doing something that indicates the opposite feeling

regression

the patient reverts to old, usually immature behavior to vent her feelings

sublimation

the patient redirects her negative feelings into a socially productive activity

guidelines for obtaining the health history of a child

• make sure the environment is safe and attractive

• do not keep children and their caregivers waiting any longer than necessary because children become anxious and distracted quickly

• do not offer a choice unless the child can truly make one

• praising the child during the examination reduces anxiety and boosts self-esteem

• permitting the child to manipulate the equipment may help relieve anxiety and create a feeling on inclusion during the examination

• regression and comfort measures

• listen to the parents’ concerns and response truthfully to questions

documentation guidelines

• do all the charting in black ink except for noting allergies in red ink; never use pencil

• write in clear legible manner

• do not leave any black spaces on the paper record and do not skip lines between documentation entries

• never scribble, erase, or use whiteout on an error

• if details are omitted, add information by documenting after the last entry

subjective information

date or information obtained from the patient, including the patient’s feelings, perceptions, and concerns; this information is obtained through interviews or written questions

objective information

date obtained through physical examination, laboratory and diagnostic testing, and by measurable information

gloves

gloves protect the healthcare worker and the patient from microorganisms. according to standard precautions, gloves mist be worn whenever the potential exists for contact with any body fluid, broken skin or wounds, or contaminated items

additional supplies

gauze, cotton balls, cotton-tipped applicators, disposable tissues, specimen containers, fecal occult blood test cards, Pap test supples for female patients, lubricating jelly for vaginal and rectal examinations, and laboratory request forms should be easily accessible during the examination

database

the record of the patient’s demographic information, history, physical examination, and initial laboratory findings. as new information is added, it becomes part of this database

chief complaint (cc)

the purpose of the patient’s visit. generally, this is documented in the patient’s own words

history of present illness (HPI)

the medical assistant should gather as much information about the health problem as possible and document in chronological order. documentation should include:

• location

• quality

• severity

• duration

• context

• timing

• modifying factors

• associated signs and symptoms

past history (PH) / past medical history (PMH)

a summary of the patient’s previous health. it includes dates and details about the patient:

• usual childhood diseases (UCD or UCHD)

• major illnesses

• surgeries

• allergies

• accidents

• immunization record

family history (FH)

details about the patient’s parents and siblings and their health; if they are deceased, the age and cause of death.

this information is important because certain diseases and disorders have familial or hereditary tendencies

social history (SH)

• whether the patient feels safe at home

• use of tobacco, alcohol, or recreational drugs

• sleeping and exercise habits

• typical diet

• education and occupation

system reviews (SR) / review of systems (ROS)

these questions provide a guide to the patient’s general health and help detect conditions other than those covered under the present illness

a system review is obtained through logical sequence of questions about the state of health of body systems, beginning with the head and proceeding downward

differential diagnosis

considered which one of the several diseases may be producing the patient’s symptoms

based on information gathered from the patient about symptoms, contributing family, personal, and social histories, and a complete physical examination

clinical diagnosis / working diagnosis

arrived after taking a detailed history and doing a comprehensive physical examination, but before any laboratory tests or x-rays, diagnostic testing is done.

collecting medical data

documentation should include the following:

• purpose of the patient’s visit, written as the chief complaint (cc)

• patient’s vital signs

• height and weight

• pain; documented using a scale of 1 to 10, with 1 being the least amount of pain and 10 being the greatest amount

laboratory and diagnostic tests help to:

• refine the patient’s diagnosis

• help the provider plan or revise treatment for the patient

• evaluate and maintain current drug therapy

• determine the patient’s progress

purpose of a physical examination

• determines the patient’s overall state of well being

• all major organ and body systems are checked 

• provider interprets the findings

• by the end, the provider has formed an initial diagnosis of the patient’s condition

roles of medical assistant before the exam

• ensures the patient feels comfortable 

• gather all necessary medical information

• duties include: preparing and maintaining the examination room and equipment, preparing the patient, and assisting the provider during the physical examination

preparing the examination room

• check the room at the beginning of each day and between patient’s

• ensure the room is stocked equipment and supplies and that all equipment is functioning properly

• regularly check expiration dates on all packages and supplies

• keep the room private

• clean and disinfect the area daily and between patients to prevent the spread of infection and to ensure patients comfort

• arrange drapes, gowns, and supplies before the patient enters the room so that they are ready to use

• prepare instruments and equipment needed for the examination

• ensure materials for standard precautions: gloves, a sink with soap, paper towels, biohazard waste containers, sharps containers, impervious gowns and face guards

assisting the patient

• make sure health record is complete

• verify the patient’s identity

• obtain specimens if the provider has preordered them or if this practice is part of the office policy

• measure and record the patient’s height, weight, BMI, and vital signs

• investigate reason for the visit and explain the examination procedure to the patient

• ask if patient needs to empty bladder before the examination

• explain clothing removal and gown instructions

• assist with examination positions as needed

• maintain the patient’s privacy and confidentiality

• help patient with dressing as needed after the examination

assisting the provider

fowler

• patient is sitting at 90° angle

• used for examinations and treatments of the head, neck, chest, and for patients who have difficulty breathing while lying down

semi-fowler

• head of the bed is at 45° angle

• used for postoperative examinations, patients with breathing disorders, patients suffering from head trauma or pain

supine / horizontal recumbent

• the patient lies flat with the face upward and the lower legs supported by the table extension

• used to examine the front of the body, including the heart, breasts and abdominal organs

dorsal recumbent

• patient lies flat with kneed flex

• relieves muscle tension in the abdomen and may be used for examination or inspection of the rectal, vaginal, and perineal areas

lithotomy

• patient legs are supported in stirrups

• used primarily for vaginal examinations that require the use of a speculum and for pap tests

sims / left lateral

• patient lies on their left side with top leg flex and left shoulder under body or under head

• used for rectal examinations, instillation of rectal medication, and for some perineal and pelvic examinations

prone

• patient is lying face down on the table

• used for examination of the back and for certain surgical procedures

knee-chest

• patient rests on the need and the chest with the head turned to one side. buttocks extend up into the air and the back should be straight

• used for proctologic examination and for sigmoid, rectal, and occasionally vaginal examinations

trendelenburg

• place patient’s head at the foot of the exam table. raise the legs up using the head of the exam table to support legs

• used in surgery, shock management procedures, or if patient has severe hypotension

ophthalmoscope

used to assess eyes

otoscope

used to asses the ears, nose, and mouth

tuning fork

used to assess hearing and bone vibration

tongue depressor

used to assist in oral examination

tape measure

used to measure infant length and head dimensions, would size, etc

stethoscope

used to auscultate and assess the heart, abdomen, etc

reflex hammer

used to assess neurologic reflexes