Chapter 20; Assisting with the Physical Examination

Hernia

protrusion of an organ through the muscle wall of the cavity that normally surrounds it

Range of Motion (ROM)

range in degrees of angle through which a joint can be extended or flexed

Babinski Reflex

reflex (dorsiflexion of the great toe and extension and fanning of the other toes upon stroking the sole of the foot) exhibited normally by infants; this reflex is abnormal in children and adults

Manipulation

skillful use of the hands in diagnostic procedures

Papanicolaou (PAP) Test or Smear

smear of tissue cells examined for abnormalities including cancer, especially of the cervix; named for George N. Papanicolaou, a physician, anatomist, and cytologist

Percussion

striking with the hands to evaluate the size, borders, consistency, and presence of fluid or air

Palpation

technique in which the examiner feels the texture, size, consistency, and location of parts of the body with the hands

Tympanic Membrane

thin, semitransparent membrane in the middle ear that transmits sound vibrations; the eardrum

Inspection

visual examination

Nasal Septum

wall or partition dividing the nostrils

Sclera

white fibrous tissue that covers the eye

Cerumen

yellowish or brownish wax-like secretions in the external ear canal; earwax

Sigmoidoscope

A longer instrument used to visualize the rectum and the sigmoid colon is the sigmoidoscope. This instrument consists of a tube with an obturator, fiberoptic light handle, and magnifying lens. It may be rigid and made of stainless steel, or it may be flexible. The advantages of the flexible sigmoidoscope include a smaller diameter, greater depth during the examination, better visualization of the intestinal mucosa, and less discomfort for the patient.

Penlight or Flashlight

A penlight or flashlight provides additional light to a specific area during the examination. The penlight is the shape and size of a ballpoint pen and is easily carried in the examiner's pocket. A common flashlight may be used if a penlight is not available. The penlight is often used to examine the eyes, nose, and throat.

What is the function of the rectovaginal and bimanual pelvic examinations?

A rectovaginal examination is necessary to palpate the posterior uterus and vaginal wall and the bimanual pelvic exam is performed to palpate the internal reproductive organs for size, contour, consistency, and any masses.

Abdomen

After the breasts are examined, the drape is lowered to expose the abdomen to the public area. The patient's chest is draped or gowned to just below the breasts. The abdomen is inspected for contour, symmetry, and pulsations from the aorta, a large artery that extends from the heart down the center of the thoracic and abdominal cavities. The examiner uses the stethoscope to auscultate the bowel sounds. Percussion may be used to determine the outlines of the abdominal organs, and palpation is used to assess any organ enlargement, masses, pain, or tenderness. The lower abdomen and groin are palpated to assess enlargement of inguinal lymph nodes and detect any hernia. A hernia is protrusion of an organ, such as the intestines, through a weakened muscle wall. The femoral arteries, which pass through each groin, may also be palpated and auscultated.

Postexamination Duties

After the physical examination, you should perform any follow-up treatments and procedures as necessary or as ordered by the physician. Always offer the patient help returning to a sitting position after the examination. Ask the patient to dress, and leave the room unless the patient needs your assistance. Tell the patient what to do after getting dressed. In many offices, the patient gets dressed and remains in the examination room until the medical assistant gives further instructions; in other offices, patient are told to go to the front desk to schedule future appointments or receive further instructions or prescriptions. In either situation, you are responsible for reinforcing any instructions given by the physician and providing appropriate patient education. Unless the patient was advised to wait in the examination room for instructions after dressing, escort the patient to the front desk for scheduling future appointments and addressing billing issues while maintaining confidentiality. Check the medical record to be sure that all data have been accurately documented before releasing the record to the billing department. Clean all reusable equipment, and properly dispose of any disposable supplies or equipment used during the examination. Cover the examination people with clean paper, and prepare the room for the next patient.

Why is there variation in the types of instruments and supplies used in each medical office?

Although there are some basic instruments and supplies found in most medical offices, the exact equipment used from one office to the next may vary according to the preference and specialty of the physician.

Audiometer

An audiometer is used to measure a patient's hearing. An audiometer is a machine used for evaluating hearing acuity. It typically consists of an embedded hardware unit connected to a pair of headphones and a test subject feedback button, sometimes controlled by a standard PC. Such systems can also be used with bone vibrators, to test conductive hearing mechanisms.

Head Light and Mirror

An ear, nose, and throat specialist may wear a headlight or head mirror during the examination of the structures. This instrument consists of a light or mirror attached to a headband that fits over the examiners head. A headlight provides direct light on the area being examined, the mirror reflects light from the examination light into the area.

Auscultation

Auscultation is listening to the sounds of the body. This examination method uses a stethoscope or ear placed directly on the patient's body. Areas of the body that can be auscultated include the heart, lungs, abdomen, and blood vessels. In the abdominal examination, auscultation is performed before palpation and percussion, which can affect normal bowel sounds.

Assisting the Physician

During the physical examination, you may assist the physician by handing him or her instruments or supplies and directing light appropriately. Depending on the examination and the physical condition of the patient, you may also assist the patient into an appropriate position and adjust the drape to expose only the body area being examined. Be supportive and offer reassurance to the patient during examination. Always assess the patient's facial expressions and level of anxiety by noting verbal and nonverbal behavior during the examination.

Inspection

Inspection is looking at areas of the body to observe physical features. The examiner inspects the patient's general appearance, including movements, skin and membrane color, contour, and symmetry or asymmetry, which is equality or inequality in size and shape. Inspection is done both with the naked eye and with instruments, using either room lighting or a special light source. In some cases, inspection includes use of the sense of smell to note any unusual orders of the breath or foul orders from infected wounds or lesions.

Basic Instruments and Supplies

Instruments used during the physical examination enable the examiner to see, hear, or feel areas of the body being assessed. In most cases, it is the physician who uses these instruments, but you must be familiar with instruments and supplies. These instruments should be kept in a special trait or drawer in a convenient location and each examination room. The exact equipment used varies among medical offices according two physicians' preferences and the specialty.

Lubricant

Lubricant is a water-soluble gel used to reduce fiction and provide easy insertion of an instrument in the physical examination. After cells are obtained for a Pap smear, lubricant may also be used for a bimanual examination. This examination allows the examiner to palpate internal structures of the pelvic cavity with one hand on the abdomen and with two fingers of the other gloved hand inserted into the vagina. Lubricant may also be used for rectal examinations.

Responsibilities of the Medical Assistant -- Room Preparation

Medical Assistants are usually responsible for preparing the examination rooms, equipment, and supplies in the clinical area. Examination rooms should be clean, well lighted, well ventilated, and at a comfortable temperature for the patient. The examination table is decontaminated with an appropriate disinfectant between patients, and the paper on the table is removed and replaced with clean paper. At the beginning of each day, you are responsible for checking each examination room for adequate supplies and equipment, including the working condition of equipment. Batteries in otoscopes, ophthalmoscopes, and laryngoscopes are to be checked daily and replaced as needed.

Why are monthly breast self-examinations important for women aged 20 to 40 years?

Monthly breast self-examinations should be performed monthly to allow the patient to detect and report any abnormalities in breast tissue between visits to the physician.

Patient Preparation

Once the examination room is ready, you will call the patient back by name from the waiting room and escort him or her to the treatment room. It is important that you develop rapport with your patients and practice good interpersonal skills. This helps put your patient at ease and increases their confidence in you and the physician. Your goal is to create a positive, supportive, caring, and friendly atmosphere. Treat each patient as an individual, and speak clearly with a confident tone of voice as you explain any procedures. Before the physician sees the patient, it may be your responsibility to obtain and record the patient's history, Chief complaint, and vital signs. If a urine specimen is needed, explain how to obtain the specimen, direct the patient to the bathroom, and explain what to do with the specimen. Once in the examination room, give the patient instructions for disrobing and putting on the examination gown. Depending on the type of examination to be performed, the patient may wear the gown with the opening in the front or in the back. Leave the room while the patient undresses unless the patient needs help. Then ask the patient to sit on the examination table, helping if needed, and covering the legs with a drape. Place the chart outside the examination room door and notify the physician that the patient is ready.

Palpation

Palpation is touching or moving body areas with the fingers or hands. The examiner palpates the body to determine pulse characteristics and the presence of growth, swelling, tenderness, or pain. Organs can be palpated to assess there size, shape, and location. Skin temperature, moisture, texture, and elasticity may also be assessed by palpation. Palpation performed with both hands is called bimanual palpation; if the fingers are used, it is called a digital examination. Manipulation is the passive movement of the joints to determine the extent of movement or range of motion (ROM).

Percussion

Percussion is tapping or striking the body with the hand or an instrument to produce sounds. Direct percussion is performed by striking the body with a finger. Indirect percussion is done by placing a finger on the area and then striking this finger with a finger of the other hand while listening to the sounds and feeling the vibrations. This allows the examiner to determine the position, size, and density of air or fluid within a body cavity or organ.

Which of the examination techniques requires the use of the hands and fingers to feel organs or structures?

The examination technique that requires the use of hands or fingers is palpation.

Reflexes

The examiner uses the percussion hammer to test the patient's reflexes by striking the biceps, triceps, patellar, Achilles, and plantar tendons. The patient is usually sitting when these reflexes are checked but may move to supine for checking the plantar reflexes.

General Health Guidelines and Checkups

Physicians very as to how often they recommend a complete physical examination. For patient's age 20 to 40 years, physical examinations are scheduled about every 1 to 3 years. Annual examinations are typically performed on patients over age 40 unless a medical condition requires more frequent visits. For women, the American Cancer Society recommends the first Pap smear when sexual activity occurs, but no later than 21 years of age. This test should be done annually for conventional testing or every 2 years if the practitioner uses a liquid-based Pap test. A breast examination by a physician is recommended every 3 years for women aged 20 to 40 to detect lumps and thickening that could be malignancies, but breast self-examinations should be performed monthly to allow the patient to detect and report any abnormalities in breast tissue between visits to the physician. As with most cancers, early detection of breast cancer is the key to survival. A baseline mammogram is recommended for those aged 35 and yearly after 40. If the patient is at risk for developing breast cancer, the physician may recommend mammograms earlier and more often. The American Cancer Society also recommends that male patients have the prostate-specific antigen (PSA) blood test and digital rectal examination (DRE) yearly beginning at age 50 to detect early signs of prostate cancer. Men who are high risk for developing prostate cancer should have these tests started at age 45. Risk factors include African-American men and those with close family members who were diagnosed with prostate cancer before the age of 65. Again, early detection is important for early treatment, which saves lives. All patients should have a baseline electrocardiogram (ECG) at age 40 and follow-up ECGs as necessary. In addition, a rectal examination and fecal occult blood test are recommended annually beginning at age 40. At age 50, a proctoscopic examination (colonoscopy) is recommended, and if the results are negative, this exam should be performed every 3 to 5 years thereafter.

Examination Light and Gooseneck Lamp

Some offices are equipped with an adjustable overhead examination light for better visualization during the examination. The gooseneck lamp is a floor lamp with a movable stand that bends at the neck for use when the overhead light is not adequate. You have the responsibility to make sure all examination lights are in proper working order and to direct the light toward the area of the body as indicated by the physician.

The Body's Warning Signals

Teach your patients the CAUTION acronym to recognize these early warning signs of cancer: C -- Change in bowel or bladder habits A -- A sore or wound that does not heal U -- Unusual bleeding or discharge T -- Thickening, lumps, or changes in the shape of the breasts or testicles I -- Indigestion or difficulty swallowing O -- Obvious changes in a wart or mole N -- Nagging cough or hoarseness of the voice Frequent, severe headaches and persistent abdominal pain are other signals that should never be ignored. Instruct your patients to never overlook the following signs in their children: • Continual crying for no obvious reason • Unexplained nausea and vomiting • General failure to thrive • Spontaneous bleeding or bleeding that does not stop in the normal amount of time • Bumps, lumps, masses, or swelling anywhere on the body

Immunizations for Adults

The Centers for Disease Control and Prevention recommends the following immunizations for all adults: • Tetanus booster every 10 years, or sooner if the patient has an open wound. • Measles, mumps, rubella (MMR) one or two doses between 19 and 49 years for patients who do not have documentation of having the vaccine or for those who have never had the disease. • The Varicella vaccine (chickenpox) should be given in two doses between the ages of 19 and 49 years for patients who do not have documentation of having the vaccine or for those who have never had the disease. • One injection of pneumococcal vaccine should be given at age 65 years. • After age 50, an annual influenza vaccine should be given. • Some doctor also recommend a series of three Hepatitis B injections for any adult patient who has not received this immunization.

Anoscope

The anoscope is a short stainless steel or plastic Speculum that is inserted into the rectum to inspect the anal canal. An obturator with a rounded tip extends beyond the anoscope to allow the instrument to be easily inserted into the rectum. After the anoscope is inserted, the obturator is removed for visualization of the internal lining of the rectum.

What are the uses of the anoscope, proctoscope, and sigmoidoscope? What is the function of an obturator?

The anoscope is the shortest and is used to inspect the anal canal. The proctoscope is longer than the anoscope and is used to visualize the rectum and the anus. The sigmoidoscope is the longest of the three and is used to inspect the rectum and sigmoid colon. An obturator is a smooth, rounded, removable inner portion of a hollow tube, that allows for easier insertion.

Chest

The anterior chest is examined with the gown removed to the waist. The physician observes the general appearance and symmetry of the chest and breast area, the respiratory rate and pattern, and any obvious masses or swelling. Palpation includes the axillary lymph nodes and the area over the heart. Underlying structures may also be percussed. Using a stethoscope, the examiner auscultates the lungs for abnormal sounds, at which time the patient may be asked to take deep breaths. The heart sounds and apical pulse are also assessed. Inspection and palpation of the posterior chest include the muscles of the back and spine. This is followed by percussion of the back to assess lung fields. With a stethoscope, the examiner listens to posterior lung sounds, again with the patient asked to take deep breaths.

Audioscope

The audioscope is used to screen patients for hearing loss. Although it looks like an otoscope, the audioscope's handle has a variety of indicators and selection buttons that can be used to adjust its tones. The examiner places the tip of the audioscope in the patient's ear and asks the patient to respond to each of the tones that is produced. The results are recorded in the patient's medical record.

Breasts

The breasts may be palpated for both male and female patients. The supine position is preferred for palpation of the breasts because the breast tissue flattens out, making any abnormalities easier to feel. The tissue subject to breast examination includes not only the breasts and nipples, but the tissue extending up to the clavicle, under the axillary, and down to the bottom of the rib cage.

What are your four basic responsibilities in the performance of the physical examination?

The clinical medical assistant is responsible for preparing the examination room, preparing the patient, assisting the physician, and cleaning the examination room and equipment.

Nose and Sinuses

The external nose is palpated for abnormalities and inspected using a nasal speculum and light. The position of the nasal septum is noted for any deviation to the right or left. Each nostril is inspected for color of the mucosa, discharge, lesions, obstructions, polyps, swelling, or tenderness. The sender of smell may be assessed by having the patient close their eyes and identify a common substance such as alcohol, lemon, strawberry, or peppermint. The paranasal sinuses are also inspected and palpated. With the technique of transillumination to visualize the sinuses, the room is darkened and a penlight or flashlight is placed against the upper cheek or periorbital ridge.

Female Genitalia and Rectum

The female genitalia and rectum are usually examined with the patient in the Lithotomy position and with one corner of the drape extended over the genitalia and the other corner covering the patient's chest. A gooseneck lamp is adjusted to direct light on the vaginal area, and the external genitalia are inspected for lesions, edema, cysts, discharge, and hair distribution. With clean gloves, the examiner inserts the vaginal speculum and inspects the condition of the vaginal mucosa and cervix. A Pap smear sample from the cervix is obtained, and the speculum is removed. At this time, the examiner performs a bimanual examination to palpate the internal reproductive organs for size, contour, consistency, and any masses. Two fingers of the gloved dominant hand are inserted into the vagina while the gloved nondominant hand is placed on the lower abdomen to compress the internal organs. Sometimes a rectovaginal examination is necessary to palpate the posterior uterus and vaginal wall. The examiner places a gloved index finger in the vagina and the middle finger of the same hand in the rectum at the same time. The rectum is usually inspected and palpated for lesions, hemorrhoids, and sphincter tone. A stool specimen may be obtained from the gloved finger to test for occult blood.

Vaginal Speculum

The general physical examination of female patients may include a pelvic examination and Papanicolaou (Pap) smear. This is a simple test in which cells obtained from the cervix or vagina are examined microscopically for abnormalities including cancer. To obtain the cells for a pap smear, or to visually examine internal female reproductive structures, the vaginal speculum is inserted into the vagina to expand the opening. This instrument is made of stainless steel or disposable plastic. To obtain vaginal or cervical cells, the physician may use the Ayre spatula or cervical scraper. This scraper is about 6 inches long and is made of plastic or wood. One tip has an irregular shape that is placed in the cervical opening and rotated to collect the specimen, the other end is rounded and may be use to collect cells from the vaginal cul-de-sac. A histobrush may be used to obtain cells for a Pap smear; it is made of nylon or plastic with soft bristles at one end. The collected cells are transferred to either a glass slide or a liquid preservative and sent to a laboratory for analysis.

Posture, Gait, Coordination, Balance, and Strength

The general posture of the patient and the spine may be inspected with the patient standing. The patient may be asked to walk and perform other movements so that gait and coordination can be observed. A balance test may be done by having the patient stand with the feet together and the eyes closed. Range of motion and strength of arms and legs are assessed.

Examination of the Rectum and Colon

The instruments used for examination of the rectum and colon vary in length as appropriate for the structure to be examined. During all rectal examinations, you need a suction machine, cotton-tipped applicators, glass microscope slides, specimen containers, and Laboratory request slips available. Tissue or stool specimens obtained during any rectal procedure must be properly preserved and protected for transport to the laboratory for analysis.

Laryngeal Mirror and Laryngoscope

The laryngeal mirror is a stainless steel instrument with a long, slender handle and a small, round mirror. It is used to examine areas of the patient's throat and larynx that may not be directly visible. The laryngoscope handle is similar to the battery handle of a portable otoscope or ophthalmoscope, but the head allows attachment of curved or straight laryngoscope stainless steel blades and a small light source. The examiner places the blade in the patient's throat to visualize the larynx or vocal cords, which cannot be seen by simply looking down the patient's throat.

Legs

The legs are inspected and the peripheral pulse sites palpated with the patient supine. The patient stands, with assistance if needed, and the peripheral pulse sites may be palpated again and the legs observed for varicose veins.

Percussion Hammer

The percussion hammer is used to test neurologic reflexes. Also called a reflex hammer, this instrument has a stainless steel handle and a hard rubber head. The head is used to test reflexes by striking the tendons of the ankle, knee, wrist, and elbow. The tip of the handle may be use two stroke the sole of the foot to assess the Babinski reflex (a reflex noted by extension of the great toe and abduction of the other toes). Some hammers have a brush and needle in the handle specifically used to test sensory perception.

Male Genitalia and Rectum

The male genitalia are inspected to note symmetry, lesions, swelling, masses, and hair distribution. The scrotal contents may be visualized using transillumination in a darkened room. In addition, the scrotum is palpated for testicular size, contour, and consistency. The male patient is then asked to stand and bear down as if having a bowel movement while the examiner places a gloved index finger upward along the side of the scrotum in the inguinal ring to assess for a hernia. The physician asks the patient either to bend over the examination table or to assume the Sims position to inspect the anus for lesions and hemorrhoids. The examiner inserts a gloved and lubricated finger into the rectum to palpate the rectal sphincter muscle and prostate gland for size, consistency, and any masses. An occult blood (hidden blood) stool test may be obtained on any stool obtained from the gloved finger.

Nasal Speculum

The nasal speculum with a stainless steel instrument that is inserted into the nostril to assist in the visual inspection of the lining of the nose, nasal membranes, and septum. The tip of the instrument is inserted into the nose, and the handles are squeezed, opening the end and allowing for visualization. Nasal specula are also available in a disposable form.

Ophthalmoscope

The ophthalmoscope is used to examine the interior structures of the eyes. Like the otoscope, it may have a stainless steel handle that contains batteries or may be mounted on the wall. The head of the ophthalmoscope also has a light source, magnifying lens, and opening through which to view the eye. Portable units me have a common base handle with various otoscope or ophthalmoscope tips that can be attached for different examinations.

Otoscope

The otoscope permits visualization of the ear canal and tympanic membrane. The tympanic membrane, or eardrum, is a thin, oval membrane between the outer and middle ear that transmits sound vibrations to the inner ear. The otoscope has a stainless steel handle at one end and a head with a light, a magnifying lens, and a cone-shaped hollow speculum at the other end. A portable otoscope has batteries in the handle to operate the light in the head; other otoscopes are parts of a unit attached to a wall and plugged into an electrical outlet. In both types, the hollow speculum is covered with a disposable speculum cover before it is placed in the ear canal. An otoscope with a specialized nasal speculum tip may be used to examine the nose.

Head and Neck

The patient's skull, scalp, hair, and face are inspected and palpated for size, shape, and symmetry. The examiner looks for nodules, masses, and local trauma. The patient may be asked to roll the head in all directions to assess range of motion and to check for any limitations of movement. The trachea and lymph nodes on the anterior neck are palpated for size and symmetry. The thyroid gland, also on the anterior neck, is palpated for size and symmetry. The patient may be asked to swallow to facilitate palpating this gland. The carotid arteries are palpated and auscultated on both sides of the neck to check for bruit (abnormal sound) caused by abnormal blockage.

Physical Examination Format

The physical examination of the patient begins with the patient seated on the examining table with a drape sheet over the lap and covering the legs. The physician usually progresses through the examination in an orderly, methodical sequence. The patient's general appearance, behavior, speech, posture, nutritional status, hair distribution, and skin are observed throughout the examination.

Mouth and Throat

The physician inspects the mucous membranes of the mouth, gums, teeth, tongue, tonsils, and throat using clean gloves, a light source, and a tongue blade or tongue depressor. A laryngeal mirror may also be used. The examiner assesses general dental hygiene and salivary gland function and looks for any abnormalities in the oral cavity, including color, ulcerations, and nodules.

Proctoscope

The proctoscope is another type of Speculum that is used to visualize the rectum and the anus. It is longer than the anoscope and allows the examiner to inspect more areas of the rectum. While it also consists of an obturator that is removed after the instrument is inserted, a fiberoptic light handle and magnifying lens are attached. The tubular part of the scope is marked in centimeters so that the depth of abnormalities in the anal canal can be noted.

Assisting with the Physical Examination

The purpose of the complete physical examination is to assess the patient's general state of health and detect signs and symptoms of disease. New patients usually receive a complete physical examination, which gives the physician baseline information about the patient. This baseline information is valuable for future comparison and can aid the physician in diagnosis (identifying a disease or condition). Routine examinations are performed thereafter at regular intervals to help maintain the patient's health and prevent disease. When a patient comes into the office, the physician can make a clinical diagnosis based only on the patient's symptoms. At other times, symptoms are vague and could be caused by one of several diseases. In this situation, a differential diagnosis is made by comparing symptoms of several diseases.

Stethoscope

The stethoscope is used for listening to body sounds. The bell or diaphragm is at one end and is placed on the patient's body. This end is connected to two ear pieces by flexible rubber or vinyl tubing. The two ear pieces have plastic or rubber tips that must be adjusted and directed outward before being placed in the examiner's ears. The stethoscope is used to listen to the sounds of the heart, lungs, and intestines. It is also used for taking blood pressure.

Why is the patient Supine for palpation of the breasts?

The supine position is preferred for palpation of the breasts because the breast tissue flattens out, making any abnormalities easier to feel.

Which instruments are used to test the ears and hearing?

The tuning fork and audioscope are used to test hearing. The otoscope is used to assess the internal structures of the ear.

Tuning Fork

The tuning fork is used to test hearing. It is a stainless steel instrument with a handle at one end and two prongs at the other end. The examiner strikes the prongs against his or her hand, which causes them to vibrate and produce a humming sound. While vibrating, the handle is placed against a bony area of the skull near one of the ears, and the patient is asked to describe what, if anything, is heard in that ear. Depending on the results of the hearing test, the physician may order additional auditory tests.

What is the tympanic membrane, and how does infection affect its appearance?

The tympanic membrane is a thin, semitransparent membrane in the middle ear that transmits sound vibrations; when infected may be discolored and fluid behind the eardrum may cause the membrane to bulge.

What would be the advantage of checking the working condition of the equipment at the beginning of each work day?

The working condition of equipment that may be use during patient examinations should be checked at the beginning of each work day to increase efficiency and improved patient care.

Eyes and Ears

Usually you perform the visual acuity test before the physician's examination. The physician also inspects the sclera, or fibrous tissue covering the eye, for normal color. The pupils are inspected with a light to see if they are equal in size, round, and normally reactive to light and accommodations (adjustment). Normal pupil reaction is recorded as PERRLA, which means that pupils are equal, round, and reactive to light and accommodations. Eye movement is assessed by asking the patient to follow the examiner's fingers. Normal movement may be documented as "EOM intact," which means extraocular (outside the eye) movement intact. Peripheral vision, or side vision while looking straight ahead, may also be assessed. Using the ophthalmoscope, the physician visualizes the interior of the eye and evaluates the condition of the retina and any pathology of the interlobular blood vessels. The ears are inspected and palpated for size, symmetry, lesions, and nodules. The otoscope is used to examine the interior of the ear canal, including any cerumen, or ear wax. The tympanic membrane is checked for color and intact or broken condition. Normally the tympanic membrane is pearly gray and concave. However, infection may cause discoloration, and fluids behind the eardrum may cause the membrane to bulge outward. Auditory acuity is tested with the tuning fork or the audioscope.

Examination Techniques

While performing the physical examination, the physician uses four basic techniques to gather information. These include inspection, palpation, percussion, and auscultation.

Clinical Diagnosis

a diagnosis based only on the patient's clinical symptoms

Differential Diagnosis

a diagnosis made by comparing the patient symptoms to two or more diseases that have similar symptoms

PERRLA

abbreviation used in documentation to denote pupils equal, round, reactive to light, and accommodation if all findings are normal; refers to the size and shape of the pupils, their reaction to light, and their ability to adjust to distance

Bruit

abnormal sound or murmur in the blood vessels during auscultation

Auscultation

active listening for sounds within the body, usually with a stethoscope, such as to evaluate the heart, lungs, intestines, or fetal heart tones

Lubricant

agent that reduces friction

Applicator

device for applying local treatments and tests

Symmetry

equality in size or shape or position of parts on opposite sides of the body

Occult

hidden or concealed from observation

Diagnosis

identification of a disease or condition by evaluating physical signs and symptoms, health history, and laboratory tests; a disease or condition identified in a person

Asymmetry

lack or absence of symmetry; inequality of size or shape on opposite sides of the body

Gait

manner or style of walking

Baseline

original or initial measure with which other measurements will be compared

Extraocular

outside the eye, as in extraocular eye movement

Transillumination

passage of lights through body tissues for the purpose of examination

Peripheral

pertaining to or situated away from the center

Rectovaginal

pertaining to the rectum and vagina

Inguinal

pertaining to the regions of the groin

Bimanual

pertaining to the use of both hands; an examination performed with both hands

Patient Examination Positions

• Erect or Standing Position The patient stands erect facing forward with arms at the side. • Sitting Position The patient sits erect at the end of the examination table with the feet supported on a footrest or stool. • Supine Position (Horizontal Recumbent Position) Typically used to examine the anterior portion of the body, the patient lies on the back with arms at the side. A pillow may be placed under the head for comfort. • Dorsal Recumbent Position The patient is supine with the legs separated, knees bent, and feet flat on the table. • Lithotomy Position The patient is supine with the legs separated, knees bent, and feet in stirrups. The stirrups should be level with each other and about one foot out from the edge of the table. The patient's feet are moved into or out of the stirrups at the same time to prevent back strain. • Sims Position The patient lies on the left side with the left arm and shoulder behind the body, right leg and arm sharply flexed on the table, and left knee slightly flexed. • Prone Position Typically used to examine the spine and back, the patient lies on the abdomen with the head supported and turned to one side. The arms may be under the head or by the sides, whichever is more comfortable. • Knee-Chest Position The patient kneels on the table with the arms and chest on the table, hips in the air, and back straight. • Fowler's Position The patient is half-sitting with the head of the examination table elevated 80° to 90°. • Semi-Fowler's Position The patient is in a half-sitting position with the head of the examination table elevated 30° to 45° and the knees slightly bent. • Trendelenburg Position The patient lies on the back with arms straight at either side, and the head of the bed is lowered with the head lower than the hips; the legs are elevated at approximately 45°