Introduction to Physical Exams
O: Objective
signs that can be seen or measured.
visual acuity charts
snellen chart used to test far vision, Jaeger chart used to test near vision, and Ishihara plates used to test color vision
percussion
tapping on a surface to determine the difference in the density of the underlying structure
Which of the following would be most appropriate for an examination of the rectum?
Sim's
In relation to medical records, what does the acronym SOAP stand for?
Subjective, Objective, Assessment, Plan
prenatal exam
given to a woman during pregnancy
Subjective examples:
headache, back pain, nausea, and fatigue
otoscope
instrument for examining the ear
sphygmomanometer
instrument to measure blood pressure
stethoscope
instrument used for listening to internal body sounds
tonometer
instrument used to measure eye pressure
manipulation
moving a joint to determine range of motion and flexion
A: Assessment
physical evaluation of signs and symptoms
documentation
- MA do most documentation of a physical exam appointment in the pt's medical record
knee chest position
- examine the anus and rectum - MA should provide support as needed - should not be placed in this position till Dr arrives
prone position
- examine the back, feet, or spine
dorsal recumbent position
- examine the head, chest, or abdomen - used on pt's older, arthritis, or back pain - used for vaginal/rectal exams, or insertion of urinary catheters
fowlers position
- examine the head, neck,and upper body - commonly used for pts with respiratory difficulties
Why is appropriate draping so important during physical exams?
Draping helps to preserve a patient's dignity.
EENT exam
Eye, ear, nose and throat examination
In which direction does the patient lay while in the supine position?
Face-up
A drape is not needed if a patient is being examined in the sitting position.
False
Why is it important for the medical assistant to remain in the room with the physician and patient during a physical exam?
For legal protection
Which instrument is used to measure range of motion?
Goniometer
What is a tuning fork?
Instrument used to test hearing
Which two tools would be most helpful when examining the throat?
Laryngeal mirror and tongue depressor
auscultation
Listening with a stethoscope
What is the name of the position in which a patient lays face-up with the feet elevated in stirrups?
Lithotomy
Why is the knee-chest position considered risky?
Patients may easily lose their balance in this position.
Why might microscope slides be needed for a gynecological exam?
To collect cells for a Pap test
tuning fork
Used to test hearing
Which of the following is used to open the vagina during a gynecological exam?
Vaginal speculum
CPE
complete physical exam
prenatal exam purpose
examination of the mother and the fetus
S: Subjective
finding symptoms. Are complains made by the pt that can not be seen or measured by another person
GYN exam
gynecological exam
Plan Examples:
may order a throat culture, prescribe penicillin, and request to see the pt for a follow-up appointment in 5 days
tape measure
measure the circumference of body parts, such as the head
SOAP notes
notes to record progress notes from an exam
inspection
observing a pt's general condition, including speech, skin condition, color posture, gait, awareness, sensitivity, anxiety, and grooming
Assessment examples:
pt complains of a sore throat and fever, and the throat shows signs of swelling and infection, the physician may suspect strep throat.
Objective examples:
rashes, bleeding, and swelling. Vital signs and body measurements
CPE purpose
review of the entire body and all body system
well-child visit
routine examination of a pediatric pt
EENT exam purpose
screenings for vision and hearing problems
P: Plan
the poposed course of action.
mensuration
the process of measuring a patient
cervical brush, spatula, and ayer blade
used to collect cells from the vaginal walls and cervix
What piece of equipment is needed for the proctologic position?
Proctologic exam table
sitting position
- first and last position during an exam - used to obtain pt's vital signs and gather medical history. - examine pt's head and neck, listening for heart and lung sounds - testing reflexes
equipment
- MA must prepare an exam room, and anticipate the equipment that the Dr will need
proctologic position
- examine of the anus and rectum - created to eliminate the need for the uncomfortable and potentially dangerous knee chest position.
sims position
- examine the rectum/vagina - used to administer enemas/taking a rectal temp
CPE known also
- general physical exam - physical exam - history and physical - physical
Role of MA:
- help physician and pt - prepare exam room - gather equipment, and make sure they work - prepare pt - gather pt specimens and complete UA and Blood tests - handing equipment to Dr - record findings dictated by the Dr - help pt down from exam table - answer any further questions - clean up room - complete any remaining medical record papers
draping purposes:
- preserve a pt's dignity - keep pt warm and comfortable
supine position
- recumbent position - examine the front of the body, including head, chest, abdomen, arms and legs
Tredelenburg position
- used for pelvic exam or surgery - used to increase blood circulation to the heart and brain
lithotomy position
- used for rectal and pelvic examinations
nasal speculum
An instrument used to examine the inside of the nose
Which of the following is a role of a medical assistant during a physical exam?
Assist the physician as needed
Which examination technique involves listening to internal body sounds with a stethoscope?
Auscultation
Which of the following is an examination of the entire body and all body systems?
CPE
What is the name of the position in which a patient lays face-up with knees bent and feet flat on the table?
Dorsal recumbent
Which of the following is most likely to occur while a patient is in the sitting position?
Evaluating the patient's reflexes
In which position is the head of the bed elevated?
Fowler's
ophthalmoscope
Instrument used to examine the eyes
Why should the physician be consulted before placing an elderly patient into the prone position?
Limited range of motion in their necks can make it uncomfortable.
When Gina brings her 3-month-old daughter to the pediatrician for a well-baby check-up, the medical assistant measures the baby's height, weight, and head circumference. What type of examination technique is this?
Mensuration
Which of the following is a lighted tool used to examine the ears?
Otoscope
Which examination technique involves touching the patient with fingers or hands?
Palpation
What technique is Dr. Crosby using when she taps a patient's flesh and listens for sounds from the underlying organs?
Percussion
Which of the following is an example of a subjective finding?
The patient complains of dizziness and nausea.
Which of the following is an example of an objective finding?
The patient has a fever of 102° F.
What is the purpose of a percussion hammer?
To test reflexes
Which tool would be most helpful when testing vision?
Visual acuity chart
lubricant
a fluid used to reduce friction
physical exam
an examination by the physician of all or part of a pt's body
GYN exam purpose
an examination of the female reproductive organs
Goniometer
an instrument for measuring angles
laryngeal mirror
an instrument used to examine the throat and larynx
vaginal speculum
an instrument used to open the vagina to examine it and the cervix
The Trendelenburg position increases circulation to the ____.
brain and heart
specimen cup
contains specimen samples
tongue blade/depressor
flat stick to old down tongue when examining the throat
palpation
to examine by touch. Determining temp, size, and shape of organs, and the presence of abnormal structures
percussion hammer
used to test reflexes.