Chapter 21 – Physical Examination (Kinn’s The Medical Assistant, 15th ed.)

A comprehensive set of 40 Q&A flashcards covering patient history, communication skills, documentation, examination preparation, body mechanics, examination methods, and legal/ethical considerations for Chapter 21 on Physical Examination.

What four items must be documented at every patient visit before the interview begins?

Chief complaint (CC), vital signs (VS), height & weight, and a pain score on a 1–10 scale.

Which section of the medical history records the reason the patient is seeking care?

The Chief Complaint (CC).

What does HPI stand for in a patient history?

History of Present Illness.

Name at least four elements included in the Past Medical History (PMH).

Usual childhood diseases, major illnesses, surgeries, allergies, accidents, immunizations (any four).

Which two additional histories accompany the PMH to give a complete picture?

Family history (FH) and Social history (SH).

Why must over-the-counter drugs and supplements be recorded in a medication history?

They can interact with prescribed medications and affect treatment decisions.

What is the key to creating a caring, therapeutic environment when working with diverse populations?

Empathy.

List three channels through which messages can be sent in health care communication.

Face-to-face, telephone, email, letter, video conferencing (any three).

Define the active-listening technique of restatement.

Paraphrasing the patient’s statements to confirm understanding.

How does reflection differ from restatement?

Reflection repeats the main idea and identifies the patient’s feelings.

What is the purpose of clarification during an interview?

To summarize or simplify the patient’s thoughts and resolve confusion.

Approximately what percentage of communication is nonverbal?

More than 90%.

Give two examples of nonverbal behaviors that convey interest during an interview.

Leaning toward the patient and maintaining eye contact (other examples: open posture, facing at eye level).

When are open-ended questions most useful?

To begin an interview, introduce a new topic, or gather detailed information.

Why would a medical assistant use closed-ended questions?

To confirm specific facts with brief answers.

What is the key principle when communicating across the life span?

Use an age-specific approach appropriate to the patient’s developmental level.

Name the three stages of a patient interview.

Initiation (introduction), Body, and Closing.

List two environmental preparations that support a successful patient interview.

Ensure privacy and prevent interruptions (other answers: comfortable surroundings, take judicious notes).

Provide two examples of therapeutic communication techniques besides open questions.

Silence, acknowledgment, restating, reflecting, summarizing, establishing guidelines (any two).

Identify two common interview barriers that should be avoided.

Giving advice, providing unwarranted reassurance, using medical jargon, asking leading questions, talking too much, or displaying defense mechanisms.

Differentiate between a symptom and a sign.

Symptom = subjective finding reported by the patient; Sign = objective finding observed or measured by provider/MA.

What does the acronym PERRLA document?

Pupils Equal, Round, React to Light, and Accommodation.

State two key rules for documentation in the medical record.

Date each entry (month/day/year) and record unusual complaints in detail (others: describe objective data, record pain quality & intensity, document complete medication history).

List three primary roles of the medical assistant in a physical examination.

Prepare the exam room, assist the patient, and assist the provider.

Name three Standard Precaution supplies that must be available in every exam room.

Disposable gloves, biohazard waste container, sharps container (others: sink with antibacterial soap, paper towels, impervious gowns, face guards).

Before assisting a patient, what administrative item must the MA verify?

Accuracy of insurance information (and ensure consent forms are signed).

Give two tasks performed while assisting the provider during an examination.

Hand equipment, adjust lighting, position drapes, collect & label specimens, perform follow-up diagnostics (any two).

Which instrument is used to inspect the inner structures of the eye?

Ophthalmoscope.

What patient position is preferred for vaginal speculum examinations and Pap smears?

Lithotomy position.

Describe the Sims position and its common use.

Patient lies on left side with right knee flexed; used for rectal exams or rectal medication administration.

Why should a medical assistant bend at the knees when lifting?

To maintain natural spinal curves and use leg muscles, preventing back injury.

When transferring a patient, support should be provided on which side?

The patient’s strong side.

List the six basic methods of physical examination.

Inspection, palpation, percussion, auscultation, mensuration, manipulation.

During percussion, what tool may be used to test reflexes?

Percussion (reflex) hammer.

Which three reflexes are commonly checked with the patient seated?

Biceps, patellar (knee jerk), and Achilles (ankle jerk).

What monthly self-examinations are recommended for early cancer detection?

Breast self-exam for women and testicular self-exam for men.

State two points to consider when providing patient coaching.

Determine what information the patient needs and how they will use it (others: ensure understanding, identify community resources, tailor teaching methods).

How should a paper medical record be placed to maintain HIPAA compliance?

Facing away from patient view, typically toward the door or in a secure location.

What should be done with an EHR when you leave the room?

Close the patient file and lock the computer to protect confidentiality.

Which three therapeutic tools verify congruence between verbal and nonverbal cues?

Restatement, reflection, and clarification.