NH

MAST 1090: Chapter 36 - Specialty Examinations Notes

I. N. E. A. R. S. Examinations

Instrumentation

  • Otoscope: Used to check ears, features a small light, and a magnification screen. Essential for visualizing the external auditory canal and tympanic membrane (eardrum) to detect infections, foreign bodies, or cerumen buildup. Instrument with a light and magnifying lens to view ear canal and eardrum.

  • Ophthalmoscope: Used to look inside the eye at blood vessels and internal structures. Allows for the examination of the fundus, retina, and optic nerve to identify conditions such as glaucoma, diabetic retinopathy, or hypertension-related changes. Also used to examine the back of the eye (retina, blood vessels).

Medical Assistant (MA) Responsibilities

  • Hand instruments to the provider, ensuring they are clean and in working order. This includes confirming proper assembly and functionality before handing them over.

  • Most instruments are wall-mounted and charge there; some are counter-top models with batteries (check/change periodically). Regular checks prevent unexpected power loss during patient examinations.

  • Periodically check light bulbs and batteries. Maintain a supply of spare bulbs and batteries for immediate replacement.

  • Clean instruments after each patient, wiping down with alcohol. For non-critical items, a disinfectant wipe or alcohol swab is sufficient, ensuring patient safety and instrument longevity.

  • Ensure equipment is charged, bulbs work, disposable parts (ear speculums) are used properly.

  • Provide patient education or reassurance. Empathetic communication helps reduce patient anxiety and improves compliance with instructions.

  • Explain procedures. Clearly detailing what will happen helps patients prepare and cooperate.

  • Document results of conversations, procedures performed, or provider's actions. Accurate and timely documentation is crucial for patient care continuity and legal records, including documenting findings.

Ear Exams

  • Ear Speculums: Disposable plastic speculums twist onto the otoscope and are discarded after use. Non-disposable ones must be sanitized between patients using appropriate disinfection protocols, often high-level disinfection or sterilization depending on hospital policy.

  • Surgical Asepsis: Instruments used in sterile procedures must follow strict aseptic techniques. While ear exams are typically clean rather than sterile procedures, any breach of skin would require sterile technique.

  • Cerumen (Ear Wax) Buildup: Accumulation of ear wax (cerumen) can impair hearing and cause pain, often due to patients pushing wax deeper when cleaning. Cerumen naturally migrates out of the ear canal, but improper cleaning methods can disrupt this self-cleaning mechanism.

  • Ear Irrigation (Lavage):

    • May be required to remove excess ear wax if determined by the provider. This is typically considered when cerumen obstructs the view of the eardrum or causes symptoms like hearing loss or fullness, especially when cerumen blocks hearing.

    • The MA usually performs ear irrigation/lavage.

    • Methods of Irrigation:

      • Elephant or Rhino Ear Wash System: Suitable for children and adults. These systems provide a controlled stream of water at a comfortable pressure.

      • Water Pick

      • Electronic Ear Irrigators

      • Old-fashioned Method (Bulb/Metal/Plastic Syringe):

        • Involves a large syringe, attaching a butterfly needle (with the actual needle part cut off and disposed of in biohazard). The plastic tubing of the butterfly acts as a soft, directional nozzle, preventing direct trauma to the ear canal.

        • Water is drawn into the syringe, the butterfly is attached, and water is pushed through while holding the butterfly. Warm water (body temperature) is used to prevent caloric stimulation which can cause severe dizziness.

        • A metal basin is used under the patient's ear to catch the water. The basin should be positioned snugly against the neck and shoulder to minimize spills.

    • Post-Irrigation Dizziness: Patients may feel dizzy due to their equilibrium being temporarily off after significant ear wax removal. Ensure they are stable before leaving. This vestibular upset is often temporary; instruct patients to sit for a few minutes and ambulate cautiously. Check stability after. Tools include bulb syringe, irrigator, or special ear wash systems.

  • Auditory Acuity: Function of the Ear: To perceive sound. More specifically, the ear converts sound waves into electrical signals that the brain interprets, enabling hearing and maintaining balance. Tested with audiometer. Patient raises hand or presses button when they hear tones. Test records hearing thresholds.

    • Causes of Impairment: Can be as simple as impacted cerumen (which resolves with irrigation) or more complex nerve problems. *Other causes include otitis media (middle ear infection), otosclerosis, damage to the eardrum, or age-related sensorineural hearing loss (presbycusis).

    • Common Behaviors Indicating Hearing Loss: Asking for repetition, speaking loudly, not responding when not facing speaker, lip-reading, turning one ear toward speaker, social withdrawal or depression.

      • Frequently asking for repetition during conversations.

      • Talking in an inappropriately loud voice.

      • Not responding when spoken to if out of sight range.

      • Not pronouncing words well.

      • Responding only when spoken to very loudly.

      • Increasing the volume of TV, radio, or phone calls excessively.

      • Difficulty following conversations in noisy environments.

  • Symptoms Requiring Immediate Provider Attention: Bring patients to the provider for:

    • Ringing in their ears (tinnitus). Tinnitus can be a symptom of various underlying conditions, from Meniere's disease to noise-induced hearing loss.

    • Decreased hearing in one or both ears (potentially due to impacted cerumen or infection). Sudden hearing loss can be a medical emergency requiring prompt evaluation.

    • Infection of the ear.

    • Bleeding or discharge from the ears. Any discharge, especially purulent or bloody, warrants immediate investigation as it could indicate perforation of the eardrum or severe infection.

    • Any unusual noises or feelings inside their ears.

  • Tympanometry: Test measuring middle ear pressure, used to diagnose infections, common in children.

  • Tuning Fork Tests: Rinne test (air vs. bone conduction), Weber test (lateralization of sound). Used to detect nerve vs. conduction hearing loss.

Patient Education (Ears)

  • Avoid Inserting Objects: Advise patients not to put anything smaller than their elbow in their ear (e.g., cotton swabs), as it pushes wax deeper. Also, objects can scratch the delicate ear canal skin or even perforate the eardrum, leading to infection or hearing loss. Never put cotton swabs in ear (pushes wax deeper).

  • Purpose of Ear Wax: Provides protection and moisture. It traps dust and foreign particles and has antibacterial and antifungal properties, preventing infections.

  • Professional Wax Removal: If wax builds up, patients should see a provider for professional removal. Home remedies or forceful cleaning can exacerbate the problem or cause injury.

  • Ear Drops/Medications: Only use ear drops or other ear medications when advised by a provider. Over-the-counter drops may not be suitable for all conditions and can sometimes worsen issues or mask serious problems. Some drops are contraindicated if the eardrum is perforated. Only use prescribed ear drops.

  • Hearing Loss Prevention: Discuss the dangers of loud noises (radios, TVs, noisy workplaces) and the importance of wearing ear protection. Prolonged exposure to sounds over 85 decibels can cause permanent damage to the hair cells in the cochlea. Wear ear protection in noisy environments.

  • Regular Hearing Tests: Urge patients to have routine hearing tests. Early detection of hearing loss can prevent further deterioration and allow for timely intervention, such as hearing aids. Get regular hearing checks.

  • Compensating Behaviors for Hearing Loss:

    • Reading lips.

    • Turning their unaffected ear towards the sound source or leaning in.

    • Relying on visual cues and body language during conversations.

    • Report ringing, drainage, or pain.

II. Eye Examinations

  • Ophthalmoscope: Views retina, optic nerve, and blood vessels for disease or injury.

  • Eye Irrigation: Performed for chemical exposure, infection, or foreign body. Flush from inner to outer canthus to avoid recontamination. Patient positioned with affected eye down.

  • Visual Acuity Tests:

    • Snellen Chart: Measures distance vision (20/20 = normal vision). Patient stands 20 feet away.

    • Jaeger Chart: Measures near vision using a small handheld card (14–16 inches away).

    • Ishihara Plates: Screens for color blindness by distinguishing colored numbers/patterns.

  • Patient Education: Wear protective eyewear, sunglasses, avoid rubbing eyes, flush with water for 20 minutes after foreign body or chemical exposure, routine eye exams (glaucoma, cataracts).

  • Eye Medication Installation: Patient looks at a fixed spot on ceiling to reduce blinking while drops are placed in conjunctival sac.

III. Respiratory Examinations

  • Spirometry (Pulmonary Function Test): Measures lung volume and airflow. Patient takes deep breath and exhales forcefully into mouthpiece. Disposable mouthpiece used for infection control.

    • Preparation: No heavy meal, no smoking 4–6 hrs before test, avoid meds unless told otherwise.

    • Interpretation: Normal = 80% or higher of expected lung function. Below 80% = abnormal.

  • Peak Flow Testing: Measures speed of exhalation (peak expiratory flow). Used for asthma monitoring and medication effectiveness. Daily readings help detect changes before symptoms worsen.

  • Pulse Oximetry: Non-invasive device clipped to finger (or toe/ear/nose) to measure oxygen saturation in blood. Normal: 95% or higher. Nail polish, cold hands, or poor circulation may affect readings.

IV. Proctologic Examinations

  • Anoscopy: Instrument to view anal canal and rectum. Used to diagnose hemorrhoids, fissures, infections.

  • Proctoscope: Longer scope that allows biopsies or removal of small growths.

  • Sigmoidoscopy: Flexible scope to view sigmoid colon for polyps, tumors, cancer, or bleeding.

  • MA Role: Prepare instruments (autoclave or cold sterilization), explain procedures, provide prep instructions (light meal, no dairy, bowel prep with laxatives/enemas). Document thoroughly.

V. Neurological Examinations

  • Focuses on brain, spinal cord, and nerves. Examples: diabetic foot exams, reflex tests, sensory tests.

  • Monofilament Test: Small nylon filament pressed on foot to test sensation (used for diabetes).

  • Tuning Fork: Checks vibration sense in extremities, used in both neurological and hearing exams.

  • MA Role: Assist provider, document findings, provide wound care and dressing changes for neuropathic ulcers.

VI. Supplemental Notes

  • Speech Technology:

    • Text-to-Speech (TTS): Converts written text to spoken words (e.g., audiobooks).

    • Speech-to-Text: Converts spoken words to text (e.g., voice typing, Siri, Alexa).

    • Voice Recognition: Identifies specific speaker’s voice for transcription accuracy.

  • Imaging Tests:

    • PET Scan: Shows brain activity and metabolism.

    • IVP (Intravenous Pyelogram): Evaluates kidneys, ureters, bladder with contrast dye.

    • CT/CAT Scan: Detailed cross-sectional x-ray images of body structures.

    • MRI: Uses magnetic fields and radio waves to visualize soft tissues and brain.

  • Disorders:

    • Kyphosis: Hunchback curve in thoracic spine.

    • Lordosis: Inward lumbar spine curve (swayback).

    • Paget’s Disease: Bones thicken but weaken due to abnormal bone remodeling.

    • Rickets: Soft, weak bones due to vitamin D deficiency (mostly in children).

    • Cleft Palate: Congenital gap in roof of mouth; requires surgery for feeding/speech.

    • Iron-Deficiency Anemia: Low iron prevents hemoglobin production; causes fatigue, pallor.

    • Sickle Cell Anemia: Hereditary disorder where red cells are sickle-shaped, causing pain and poor oxygen transport.

  • Medical Specialties:

    • Obstetrics: Pregnancy, childbirth.

    • Gynecology: Female reproductive health.

    • Geriatrics: Elderly care.

    • Bariatrics: Obesity and weight management (BMI > 30 = obese).

  • Casts & Care:

    • LAC: Long Arm Cast (fingers to underarm).

    • SAC: Short Arm Cast (wrist and forearm only).

    • Air Casts: Lightweight, fiberglass or plastic.

    • Patient Education: Report odors, numbness, tingling, inability to move fingers/toes, or burning sensation under cast.

  • Screening Tests:

    • Mono Test: Detects Epstein-Barr virus (mononucleosis).

    • Strep Test: Detects Streptococcus bacteria (strep throat).

    • Sputum Culture: Identifies bacteria in lungs/airways (e.g., pneumonia