Assisting with Physical Examinations

Medical Assistant's Role in Patient Physical Exam

  • Preparing the exam room before the patient's visit.
  • Interviewing the patient.
  • Documenting information in the patient record.
  • Positioning and draping the patient.
  • Assisting the physician during the exam.
  • Cleaning the room after the visit.
  • Instrument care.

Preparing the Examination Room

  • Ready instruments and equipment for the physician.
  • Ensure equipment is not within reach of the patient.
  • Position exam light to provide correct illumination for the physician.
  • Ensure exam light is positioned so it does not tip over.
  • Use proper body mechanics when assisting with patient care.

Procedure 33-1: Cleaning the Examination Room

  • Objective: Clean an examination room to instructor specifications.
  • Equipment and Supplies: Disinfectant, paper towels, disposable gloves, examination table, pillow, pillow cover, disposable gown, examination table paper.
  • Method:
    1. Perform hand hygiene and don a pair of disposable gloves.
    2. Roll the soiled disposable gown into a ball and dispose of it in the appropriate waste container.
    3. Roll the soiled examination table paper into a ball and dispose of it in the appropriate waste container.
    4. Remove the soiled pillow cover and dispose of it in the appropriate waste container.
    5. Remove any other soiled items or equipment from the examination room, discarding them in the appropriate waste containers.
    6. Clean the examination table, countertops, and cabinet surfaces with disinfectant and paper towels.
    7. Dispose of the soiled paper towels in the appropriate waste container.
    8. Remove the soiled gloves and dispose of them in the appropriate waste container.
    9. Perform hand hygiene.
    10. Put clean paper on the examination table.
    11. Put a new pillow covering over the pillow.
    12. Perform a second check, making sure the examination room is clean and free of clutter and odor.

Examination Room Features

  • Size and layout varies based on office or facility.
  • Other variables include the number of examination rooms and types of equipment.
  • Standard examination room includes:
    • Examination table (with stirrups where pelvic exams are performed).
    • Pillow.
    • Footstool.
    • Supply cupboard.
    • Trash can.
    • Hazardous waste and sharps containers.
    • Rolling stool.
    • Chair.
    • Writing surface.
    • Sink.

Examination Room Safety

  • Rooms must conform to ADA standards:
    • Width of doorways and hallways.
    • Placement of door handles.
    • Grab bars.
    • Handrails.
    • Spatial accommodations for patients in wheelchairs.
    • Floor surfaces.
    • For more information, visit www.ada.gov.
  • Unsafe situations:
    • Clutter in the hallway or examination room.
    • Spill on the floor.
    • Improperly stored equipment.
    • Unsecured electrical cords or cables.
  • Check furniture routinely for proper maintenance.
    • If repairs cannot be made immediately, document in the maintenance log book.

Patient Comfort

  • Keep thermostat around 71 to 73 degrees F.
  • Provide blankets and sheets as needed to keep patients warm.
  • Ensure examination room is well-ventilated to decrease odors.
    • Properly dispose of any items causing an offensive odor.
    • Double-bag items soaked in urine, feces, blood, or infectious waste and store in dirty utility room.
    • Use room deodorizer and air freshener.

Patient Privacy

  • Always knock before entering exam room.
  • Announce yourself, ask permission to enter, and enter when the patient gives consent.
  • Inform patient where to store personal items.
  • Properly drape patients to protect their modesty and sense of well-being.

Review of Patient Communication and Documentation

  • Enter all communications with the patient in the patient's medical record.
  • Complete and accurate documentation is vital to the treatment and care of the patient.
  • Patient interview takes place when the patient enters the exam room and the MA identifies the reason for the office visit.
  • The goal is to obtain information about the patient's condition and establish rapport.
  • Effective Communication:
    • Review the patient's medical record before meeting the patient; plan the interview.
    • Greet the patient by last name.
    • Maintain a professional demeanor.
    • Ask permission to interview the patient.
    • Make the patient feel at ease.
    • Be aware of verbal and nonverbal cues.
    • Avoid making judgmental responses.
    • Avoid providing medical assurances.
    • Summarize important points, giving the patient a chance to correct anything you may have misunderstood.
    • Document the interview in the patient's medical record according to facility policy.
  • Correct Documentation:
    • Record the date and time of every entry.
    • Use accepted medical terminology and abbreviations.
    • Use correct spelling and grammar.
    • Sign every entry (digital or electronic).
    • Stick to the facts when documenting.
    • Document the proper sequence of events.
    • Document appropriate information.
    • Be concise.
    • When documenting in paper records:
      • Write legibly.
      • Use permanent black ink.
      • Correct errors only by drawing a single line through the error and initialing it; then record the corrected entry.

The Six C’s of Charting

  1. Client’s (or patient’s) own words must be used and placed within quotation marks.
  2. Clarity must be achieved when recording information, using proper spelling, medical terminology, and abbreviations.
  3. Completeness is essential for all information recorded in the medical record.
  4. Conciseness of the entry helps ensure that only relevant information is included and helps in efficiency for those who are reading the medical chart.
  5. Chronological order of information is imperative to ensure a proper patient account.
  6. Confidentiality of patient information is mandatory in every aspect of patient care.

Patient Health History

  • Health history form varies according to office preference and specialty.
  • Forms may be filled out online before appointment, or the office can mail them beforehand.
  • Forms may also be filled out in the office.
  • Assist frail, disabled, or illiterate patients to fill out forms.
  • Depending on the facility, the MA or physician may obtain patient history.
  • History gathered during the patient's visit:
    • Chief complaint.
    • Present illness.
    • Past medical history.
    • Family medical history.
    • Social history.

Chief Complaint

  • Referred to as presenting problem.
  • Patient's reason for making the visit.
  • Usually consists of one or two signs the patient is concerned about.
  • Stated in the patient’s own words.
    • Signs are objective, observable by others (e.g., weight gain, fever, or rash).
    • Symptoms are subjective, something the patient experiences (e.g., dizziness, pain, anxiety).
  • Ask what-when-where questions.
  • Some offices use the abbreviation CC; others prefer C/O to record the chief complaint.
  • Do not use diagnostic terms when recording the chief complaint.
  • Pain is often the chief complaint.
    • Document using the patient's own words.
    • Recognize nonverbal cues (grimacing or moaning).
    • Recognize common terms used to describe pain.
  • Common Terms to Describe Pain:
    • Stabbing and sharp.
    • Cutting or tearing.
    • Burning, stinging.
    • Dull or throbbing.
    • Intermittent, continuous.
    • Aching, gnawing, nagging.
    • Unbearable or excruciating.

Procedure 33-2: Documenting a Chief Complaint During a Patient Interview

  • Objective: Document the chief complaint using correct charting format and abbreviations while interviewing a patient.
  • Equipment and Supplies: Patient’s medical record; patient health history form or progress notes form; black or blue pen.
  • Method:
    1. Perform hand hygiene.
    2. Gather supplies, including accessing the patient’s electronic medical record, patient health history form, or progress notes form.
    3. Briefly review the patient’s medical history form before greeting the patient.
    4. Greet and identify the patient. Introduce yourself and escort the patient into the examination room.
    5. Ask open-ended questions—those that cannot be answered just “yes” or “no”—to gather information about why the patient is being seen today. Maintain eye contact and actively listen to patient responses.
    6. Gather information about the present illness by asking questions:
      • What makes the problem better or worse?
      • When did it start? When does it occur?
      • Where does it hurt?
      • If pain is present, ask the patient to rate the pain on a scale of 0 to 10, with 10 being the greatest.
    7. Document the “CC” (chief complaint) and the “PI” (present illness) correctly within the medical record.
      • Document the CC and PI in the patient’s own words whenever possible.
    8. Before leaving the room, make sure that the patient is comfortable and ask if there are any questions.
    9. Thank the patient and explain that the physician will come in shortly to perform the examination.
  • Charting Example:
    • Patient Name: LaShawn Morris
    • Patient DOB: 1/09/1982
    • MR Number: 14829
    • Date: 03/03/YY
    • Time: 11:00 a.m.
    • Chart Note:
      • CC: “Pounding headache and Tylenol isn’t helping and I’ve been throwing up for three days.”
      • PI: N& V 3 × days. Started after she returned home from a business trip overseas. T :101∘^{\circ} F 2 × days, she states “my body aches all over.”
    • Staff Member: A. Martinez, CMA

Assessment of Pain

  • Use a numerical pain measurement scale.
  • For children and patients with communication barriers, picture scales with happy and sad faces are available.

Categories of Pain

  • Acute pain:
    • Begins suddenly and may be associated with trauma or surgery.
  • Chronic pain:
    • Long-term and interferes with the function of life.
  • Record patient's description and length of pain.
    • Visceral pain is not well localized and may be described as a dull ache or cramp.
    • Radiating: spreads out from a particular area.
    • Referred: felt at a site away from the injured or diseased body part.
    • Intractable: overwhelming, difficult to relieve, and all-consuming.
    • Phantom: sensation felt in a missing body part after it has been removed.

Present Illness

  • Provides a more complete, expansive description of the patient's chief complaint.
  • Must include the onset, duration, and intensity of each symptom.
  • Document each symptom as to its relationship to the chief complaint.

Procedure 33-3: Interviewing a New Patient to Obtain Information on Medical History and Preparing for a Physical Examination

  • Objective: Obtain pertinent patient information for a medical history that will assist the physician in establishing a diagnosis and treatment of the present illness (PI). Include CC, past history, social history, and family history.
  • Equipment and Supplies: Completed medical history form and other new patient documents; clipboard; pens (black and red); gown; drape.
  • Method:
    1. Perform hand hygiene.
    2. Identify the patient, greet the patient warmly, and introduce yourself.
    3. Escort the patient to a private examination room, and explain that you will be preparing the patient to be seen by the physician.
    4. Review the medical history form with the patient. Be sure that all the sections have been appropriately filled out.
      • Ask for additional information to complete any missing information.
    5. Speak in a clear voice and avoid using medical terminology when communicating with the patient.
    6. Ask why the patient is visiting the medical office today. Using the patient’s own words, as appropriate, record this information as the chief complaint (CC).
    7. Ask about the patient’s present illness (PI) to provide more information about the patient’s chief complaint.
      • Ask the patient open-ended questions.
      • Observe the patient for any nonverbal signs during the interview.
    8. Gather additional information regarding the patient’s social and family histories. Information should include education level; occupation; marital status; any disabilities; and use of alcohol, tobacco, and any recreational drugs with the frequency and amount of each, if applicable.
    9. Inquire about the patient’s allergies and the outcome of the allergy, such as hives, a rash, or difficulty breathing. Record allergy information, using red ink if documenting in a paper medical record.
      • If the patient states she does not have any allergies, record “NKA” (no known allergies), according to the office policy and as appropriate for the method of charting.
    10. Include any other information or observations you feel are relevant to the patient’s chief complaint or present illness.
      • This may include the illness of other family members at home or the recent loss of a loved one.
    11. Record all information using correct electronic medical record charting guidelines, according to office protocols.
    12. Inform the patient if a gown must be worn and which items of clothing will need to be removed. Provide the patient with a gown and drape the patient for modesty.
      • Inform the patient of where clothes may be stored.
    13. Ask if the patient has any questions before leaving the examination room and inform the patient that the physician will be in shortly to perform the examination.
    14. Thank the patient and leave the examination room, closing the door behind you to ensure privacy.
    15. Complete proper documentation within the patient’s EMR and review it for accuracy before saving the information.
    16. Inform the physician the patient is ready to be seen.

Past Medical/Surgical History

  • Includes all diseases and medical problems and surgical procedures the patient has experienced in the past.
  • Complete past medical history includes:
    • Childhood diseases.
    • Major illnesses.
    • Injuries.
    • Hospitalization.
    • Surgeries.
    • Allergies.
    • Immunizations.
    • Current and past medications (prescription and OTC complementary treatments).
    • Last examination.
    • Herbal supplements.
  • Challenging aspects of the patient history, particularly due to polypharmacy.
  • Patients may not realize that their dosage has changed according to the dispensing label.
  • Patients should be reminded to report on non-oral medications (inhalers, eye drops, patches); over-the-counter (OTC).

Family Medical History

  • Health problems of the patient's blood relatives.
  • May sometimes be limited to immediate family members only.
  • Information obtained details current health status, major health problems, cause of death, and age at death.
  • Focus on diseases that may be inherited.

Social History

  • Lifestyle patterns that could affect health status of the patient (smoking, drinking, use of recreational drugs).
  • Patient's occupation, marital status, and sexual preferences are also noted.
  • Dietary choices, frequency of exercise, sleep habits, and other health habits are also included.
  • Lesbian, gay, bisexual, and transgender (LGBT) patients and their specific health care needs cannot be identified.
  • Gender identity differs from their sex at birth or biological sex.
  • Sexual orientation and gender identity information as part of the patient’s medical history.
  • Gender identity differs from their sex at birth or biological sex.
  • Relevance of being asked about their sex listed at birth or their sexual orientation.
  • Gender identity, most electronic health records systems allow the capture.

Review of Systems

  • The final stage of the patient medical history is the review of systems (ROS).
  • Identify any symptoms or signs reported by the patient.
  • ROS may be comprehensive and include questioning of all organ systems.
  • ROS is used as a guide for the health care provider.
Table 33-1: Review of Systems
  • General: Weight loss, fatigue, difficulty sleeping, chronic pain, fevers, chills, sweating.
  • Head: Headaches, sinus pain, masses, alopecia (unusual hair loss), dizziness, injury, or trauma.
  • Eyes: Blurred or double vision, discharge, burning, tearing, photophobia (sensitivity to light), redness, jaundice (yellowing of skin and sclera).
  • Ears: Tinnitus or ringing in the ears, hearing loss, discharge, ear infections, pain.
  • Nose: Allergies, obstruction, sense of smell, pain, discharge.
  • Mouth: Dental work, dentures, gums, loss of taste, tooth pain, salivation (producing saliva), dryness of mouth, ulcers, or sores.
  • Neck: Hoarseness, difficulty swallowing, laryngitis (loss of voice), redness, speech defect, masses, pain, tenderness, swelling, enlarged nodes.
  • Respiratory: Dyspnea (shortness of breath), cough, asthma, wheezing, allergies, hemoptysis (coughing up blood), chest pain, orthopnea (difficulty breathing while lying down), snoring.
  • Cardiovascular (CV): Chest pain, peripheral edema (swelling of feet or ankles), cyanosis, fainting, dizziness, heart murmurs, palpitations, fainting.
  • Gastrointestinal (GI): Nausea, vomiting, anorexia (loss of appetite), indigestion, diarrhea, constipation, hemorrhoids, presence of blood in stool, incontinence.
  • Genitourinary (GU): History of urinary tract infection, frequency, hesitation, oliguria (reduced urine), hematuria (blood in urine), dysuria (difficult or painful urination), renal colic (kidney pain), stones, discharge, nocturia (urination during the night).
  • Female Reproductive: Menstrual history, obstetric history, leukorrhea (white discharge), itching, pain, discharge, date of last Pap test, breast self-exam history, sexual habits, menopause symptoms, last mammogram (breast exam).
  • Male Reproductive: Prostate problems, testicular self-exam, discharge, sexual habits, frequency of urination, decreased stream, nocturia, impotence.
  • Endocrine: Growth and development, goiter, excessive thirst, intolerance to temperature change, hormone therapy, diabetes symptoms, irregular menses, symptoms of thyroid disorders.
  • Skin: Rash, urticaria (hives), texture, moles, infection, redness, jaundice, cyanosis, allergies, dry/oily, acne, bruising.
  • Musculoskeletal (MS): Joint pain, swelling, weakness, stiffness, numbness, muscle pain, fractures, discoloration, edema.
  • Neurological: Fainting, loss of consciousness, headaches, tremor, nervousness, paralysis, pain, memory loss coordination.
  • Psychiatric: Mental health history, emotional stability, depression, stress.

Physical Examination

  • Common ROS sequence:
    • Skin
    • Hair
    • Nails
    • Head
    • Neck
    • Eyes
    • Ears
    • Nose
    • Mouth
    • Throat
    • Arms
    • Heart
    • Chest
    • Lungs
    • Breasts
    • Abdomen
    • Genitalia
    • Rectum
    • Legs
    • Feet
    • Neurological system

Adult Examination

  • Performed by the physician at each visit, regardless of type of appointment.
  • The purpose is to assess the body, determine diagnosis, and measure the effectiveness of the current plan of care of previously diagnosed issues.
  • May also include laboratory and diagnostic tests.
  • Patients often have a routine yearly wellness visit.
  • The physician must have up-to-date medical records to compare the current physical exam to previous exams.
  • The physician will look for weight changes, blood pressure variances, or other conditions requiring more frequent evaluations by the health care provider.
  • The physician analyzes information gained from the physical exam and combines it with past medical history, laboratory findings, and other medical information to determine a diagnosis.
  • Only the physician may diagnose a condition.
  • The MA’s role is to assist the physician in obtaining correct, current data.
  • Clinical (working) diagnosis—preliminary, presumptive diagnosis.
  • Differential diagnosis:
    • Process of determining which, of multiple possibilities, is the cause of the problem.
  • The physician rules out (R/O) diagnoses in an attempt to determine the most correct one.
  • Prognosis is made after diagnosis; consists of predicting the course of the condition and determining recovery rate.
  • The physician monitors the patient’s progress and adjusts treatment as needed.

Examination Methods Used By The Health Care Provider

  • Inspection:
    • Visual examination of the exterior surface of the body.
    • General state of health, demeanor, grooming, and social interactions are observed.
    • Some interior portions of the body, including the throat, eyes, ears, vaginal wall, cervix, and rectum, may be inspected using special instruments.
    • Notes are made of any unusual color, size, shape, position, or symmetry of the areas being inspected.
  • Palpation:
    • Performed by using the hands to feel the skin and accessible underlying organs.
    • Other areas examined by palpation include the axilla (armpits), neck, and chest.
    • Used to determine any unusual tenderness, size, shape, and texture.
    • Oftentimes, abnormalities and masses in the abdomen can be discovered through palpation.
  • Percussion:
    • Refers to the use of the fingertips to tap the body lightly but sharply to gain information about the position and size of the underlying body parts.
    • To do this, two fingers of one hand are placed on the patient's skin and then struck with the index and middle finger of the other hand.
    • The physician uses fingers to percuss the chest wall and abdomen by gentle thumping or tapping, which produces a standard sound or vibrations.
    • An alteration of this sound or vibration aids in determining the presence of fluid or pus in a cavity.
  • Auscultation:
    • Listening to sounds that are found within the body.
    • Sounds made by the heart, lungs, stomach, and bowel are assessed for strength, presence or absence, and rhythm.
    • The physician differentiates normal body sounds from abnormal ones.
    • A stethoscope is usually used to amplify body sounds; however, auscultation can also be performed by placing the ear directly over the body surface.
  • Mensuration:
    • Use of special tools to measure the body or specific parts, such as a scale, tape measure, and calipers.
    • Scales are used to measure adult and pediatric weight.
    • A tape measure is used to determine an infant's head and chest circumference and the abdomen, the diameter of a limb, the length of a limb, or the length and width of a wound.
    • Calipers are used to determine the amount of body fat.
    • A goniometer is used to measure the range of motion of a joint.
  • Manipulation:
    • Passively assessing the range of motion of a joint.
    • When performing this examination method, the physician may palpate the joint for abnormalities and warmth.