CHAPTER 5 THE PHYSICAL EXAMINATION. Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 2 Introduction to the Physical Examination.

CHAPTER 5CHAPTER 5THE PHYSICAL EXAMINATION

Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 2

Introduction to the Physical Examination

Introduction to the Physical Examination

1. Complete patient examination consists of:a. Health history

b. Physical examination (PE)

c. Laboratory and diagnostic tests

2. Results used by physician to:a. Determine patient's state of health

b. Arrive at a diagnosis and prescribe treatment

c. Observe any change in patient's illness after treatment has been instituted

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Introduction to the Physical Examination, cont.

Introduction to the Physical Examination, cont.

3. Purpose of PEa. To detect early signs of illness

• Helps prevent serious health problems

b. Prerequisite for employment

c. Participation in sports

d. Attendance at summer camp

e. Admission to school

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Definition of TermsDefinition of Terms

1. Final diagnosis: scientific method of determining and identifying a patient's condition through evaluation of the health history, PE, laboratory tests, and diagnostic procedures

a. Often simply called the diagnosis (dx)

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Definition of Terms, cont. Definition of Terms, cont.

2. Clinical diagnosis: intermediate step in the determination of a final diagnosis

a. Obtained through evaluation of health history and PE (without laboratory and diagnostic tests)

b. Outside laboratories provide space on laboratory request: to specify clinical diagnosis

c. Once physician has analyzed test results: final diagnosis can usually be established

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Definition of Terms, cont. Definition of Terms, cont.

3. Differential diagnosis: two or more diseases may have similar symptoms

a. Determines which disease is causing the symptoms so that a final diagnosis can be made

b. Example: “Strep” throat and pharyngitis have similar symptoms• Differential diagnosis is made by strep test

4. Prognosis: probable course and outcome of a patient's condition and the patient's prospects for recovery

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Definition of Terms, cont. Definition of Terms, cont.

5. Risk factor: physical or behavioral condition that increases the probability that an individual will develop a particular condition

a. Includes:• Genetic factors• Habits• Environmental conditions

b. Does not mean the disease will develop• Only that chance is greater of developing it• Example: Smoking is a risk factor for lung cancer and

heart disease

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Definition of Terms, cont.Definition of Terms, cont.

6. Acute illness: characterized by symptoms that have a rapid onset

a. Usually severe and intense

b. Subside after a short time• Example: influenza

7. Chronic illness: characterized by symptoms that persist for more than 3 months

a. Patient shows little change over a long time• Examples: diabetes, hypertension, emphysema

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Definition of Terms, cont. Definition of Terms, cont.

8. Therapeutic procedure: a procedure performed to treat patient's condition with the goal of eliminating it or promoting as much recovery as possible

a. Example: administration of medications

9. Diagnostic procedure: performed to assist in the diagnosis of a patient's condition

a. Examples: electrocardiography, x-ray examination

10.Laboratory testing: the analysis and study of specimens obtained from patient to assist in diagnosis and treatment of disease

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Preparation of the Examining Room

Preparation of the Examining Room

Guidelines:a. Should be free from clutter and well litb. Check daily for ample supplies; restock as

neededc. Empty waste receptacles frequentlyd. Replace biohazard containers as necessarye. Room should be well ventilatedf. Maintain room temperatureg. Clean and disinfect daily:

• Examining tables• Countertops• Faucets

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Preparation of the Examining Room, cont.

Preparation of the Examining Room, cont.

h. Remove dust/dirt from furniture & towel dispensers

i. Change examining table paper after each patient

j. Patient's privacy should be ensured• Keep door closed during patient examination

k. Clean and prepare items the physician will be using for examinations (equipment, instruments, supplies)

l. Check equipment and instruments frequently for proper working condition

m. Have equipment and supplies ready for examination

n. Know how to operate and care for equipment

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Physical Exam Equipment and Supplies

Physical Exam Equipment and Supplies

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Physical Exam Equipment and Supplies, cont.

Physical Exam Equipment and Supplies, cont.

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Preparation of the PatientPreparation of the Patient

1. MA's responsibility: prepare the patient for PEa. After escorting patient to examining room

• Identify the patient by name and date of birth

b. Take vital signs

c. Measure height and weight

d. Explain purpose of examination and answer questions

e. Apprehension can be reduced by:• Address patient by name of choice• Have a friendly and supportive attitude• Speak clearly, distinctly, and slowly

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Preparation of the Patient, cont.

Preparation of the Patient, cont.

f. Ask patient if he needs to empty the bladder before examination• Makes examination easier for physician to perform and

more comfortable for patient • If urine specimen is needed: patient is asked to void

g. Instructions for disrobing should be specific• Clothing that should be removed• Where to place clothing

– Instructions for putting on gown and location of gown opening

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Preparation of the Patient, cont.

Preparation of the Patient, cont.

h. Disrobing facility should be comfortable and private

i. MA should have patient's medical record available for review by the physician• Use designated location for medical record

a. Shelf next to examining room door or chart holder • Follow HIPAA privacy rule to protect patient's health info

j. Help patient on/off the examining table for safety

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Measuring Weight and HeightMeasuring Weight and Height

1. Mensuration: process of measuring 2. Change in weight may be significant in:

a. Diagnosis of patient's condition

b. Prescribing treatment

3. Underweight/overweight patients on diet therapy program:a. Should have weight taken regularly to determine

progress

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

4. Prenatal patients weighed at each prenatal visit to:

a. Assess fetal development & mother's health

5. Adult weight is measured at each office visit

6. Adult height usually only measured:a. First office visit

b. Complete PE

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

7. Children weighed and measured at each office visit to:a. Observe pattern of growth

b. Calculate and determine medication dosage

8. Height and weight are compared against a standardized chart:a. Determines if patient falls within normal

limits

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

9. Guidelines for Measuring Ht/Wt:a. Weight: Using an upright balance scale

• Provide privacy for patient – Many patients are self-conscious about having

weight measured • Balance scale

– If scale not balanced: measurement will be inaccurate

– Scale is balanced when upper and lower weights are on zero and indicator point comes to a rest at center of balance area

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Balance the Scale Balance the Scale

Balance the Scale

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

• Assist the patient– Assist patient on and off the scale platform – Platform moves slightly: may cause patient to

become unsteady• Obtain an accurate weight

– Ask patient to remove shoes– Measure weight with patient in normal clothing– Ask patient to remove heavy outer clothing

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

• Interpret calibration markings accurately

– Lower calibration bar: divided into 50-pound increments

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

– Upper calibration bar is divided into pounds and quarter pounds

1) Longer calibration lines: indicate pound increments

2) Shorter calibration lines indicate quarter-pound and half-pound increments

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Measuring WeightMeasuring Weight

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

• Determine patient's weight correctly– Add the measurement on lower

scale to measurement on upper scale

– Round results to nearest quarter pound

– Occasionally weight may need to be converted to kilograms (metric unit)

1) May be required to determine medication dosage

2) 1 kg = 2.2 pounds

3) To convert pounds to kg: Divide the number of pounds by 2.2

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

Height: Using an upright balance scale

• Do not place patient on scale in a forward position– Measuring bar could fall

into patient's face when patient steps off scale

• Determine the calibration markings accurately– Calibration markings are

divided into either:

1) Inches

2) Feet and inches

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Measuring HeightMeasuring Height

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

• Read the measurement correctly

– Read the measurement at the junction of the stationary calibration rod and the movable calibration rod

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

– If patient's height is less than the top value of the stationary calibration rod

1) Read the measurement directly on the stationary rod

a) On most scales: highest calibration on stationary rod is 50 inches

b) Patients with a height of 50 inches or less will have their height read directly on stationary rod

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Measuring HeightMeasuring Height

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Measuring Weight and Height, cont.

Measuring Weight and Height, cont.

• Record the height measurement correctly.

– Record height measurement in feet and inches.

– If the scale is calibrated in inches:

1) Convert the reading to feet and inches: divide the number of inches by 12

2) Example: Height measurement of 60 inches is recorded as 5 feet (60 inches divided by 12 equals 5)

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Positioning and DrapingPositioning and Draping

1. Correct positioning of the patient facilitates the examinationa. Permits better access to part being

examined

b. Sitting: Examination of the head, neck, chest, upper extremities; measure vital signs

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Sitting PositionSitting Position

1. Examination of the head, neck, chest, upper extremities; measure vital signs

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Supine PositionSupine Position

Supine: Examination of head, chest, abdomen, extremities• Not a

comfortable position for patients with:– Respiratory

problems

– Back injury

– Low back pain

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Prone PositionProne Position

Prone: Examination of back; assess extension of hip joint

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Dorsal Recumbent Position Dorsal Recumbent Position

Dorsal recumbent: Vaginal and rectal examinations, insertion of urinary catheter, examine the head, neck, chest and extremities of patients who have difficulty maintaining supine position • Bending of legs is

more comfortable for some patients

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Lithotomy PositionLithotomy Position

Lithotomy: Vaginal, pelvic and rectal examinations

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Sims Position Sims Position

Sims: Used to examine the vagina and rectum, to measure rectal temperature, to perform a flexible sigmoidoscopy, an to administer an enema

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Knee-Chest Position Knee-Chest Position

Knee-chest: Examine the rectum, perform a proctoscopic examination

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Fowler’s Position Fowler’s Position

Fowler's: • Examine upper

body of patients with cardiovascular and respiratory problems – Easier for these

patients to breathe in this position

• Draw blood from patients likely to faint

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Positioning and Draping, cont. Positioning and Draping, cont.

Position used depends on type of examination being performeda. More than one position may be used

b. Explain position to patient and assist them into it

c. Take patient's endurance and degree of wellness into consideration• Weak or ill patient may not be able to assume a position

d. Do not keep patient in uncomfortable positions longer than necessary

e. Let the patient rest before getting off the examining table

f. Assist patient off table to prevent falls

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Positioning and Draping, cont. Positioning and Draping, cont.

4. Draping provides modesty, comfort, and warmtha. Only part being examined should be

exposed

5. Gowns and drapes are made of paper or cloth

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Inspection Inspection

Inspection: The process of observing a patient to detect the signs of disease• Observe patient for:

– Color

– Speech

– Deformities

– Skin condition

– Body contour and symmetry

– Orientation to the surroundings

– Body movements

– Anxiety level

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Palpation Palpation

b. Palpation: The process of feeling with the hands to detect the signs of disease • Helps verify data obtained from inspection• Patient's verbal and facial expressions are observed• Used to determine:

– Placement and size of organs– Presence of lumps– Pain– Swelling– Tenderness

• Examples of palpation

– Breast examination, measuring radial pulse

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Percussion Percussion

c. Percussion: The process of tapping body and listening to the sounds produced to detect the signs of disease• Used to determine:

– Size, density, location of organs• Example: examination of lungs and abdomen

1) Dense structures: produce a dull sound (liver)

2) Empty or air-filled structures: produce a hollow sound (lungs)

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Percussion, cont.Percussion, cont.

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Ausculatation Ausculatation

d. Auscultation: The process of listening with a stethoscope to the sounds produced within the body to detect the signs of disease• Used to:

– Listen to heart and lungs

– Measure blood pressure