Define and turn in (chapter 5): Audiometer Auscultation Clinical diagnosis Inspection Ophthalmoscope...
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Transcript of Define and turn in (chapter 5): Audiometer Auscultation Clinical diagnosis Inspection Ophthalmoscope...
55Assisting with Physical Assisting with Physical ExaminationsExaminationsLesson 1:Lesson 1:Preparing the Exam Room and Preparing the Exam Room and Examination Methods – Part 1Examination Methods – Part 1
Lesson ObjectivesUpon completion of this lesson, students should be able to …
Define and spell the terms to learn for this chapter.
Recognize pieces of equipment commonly used during a physical examination.
Describe the examination methods used by physicians.
Discuss the steps to take in preparing a patient for a physical examination.
Medical Assistant’s Role in the Patient Physical ExamInterviewing the patientDocumenting patient informationPreparing the exam room prior to
the patient’s visitPositioning and draping the patientAssisting the physician during the
examCleaning the room after the visitInstrument care
Medical Assistant’s Role in the Patient Physical ExamsuppliessafetyObserving confidentiality
Cleaning the Examination Roomused gowns in the
laundry receptacle Discard used
examination table paper and drape
Dispose of pillow cover
Clean the exam table, and recover with new paper
Cleaning the Examination Room (cont)
new cover on pillow
Dispose of equipment
Clean and disinfect equipment
Disinfect all surfaces
Cleaning the Examination Room (cont)
Close all biohazard containers
remove if full
Ensure room is clean and odor free
Features of the Examination Room
Examination table PillowFootstoolSupply cupboardTrash canHazardous waste and
sharps containersRolling stoolChairMayo tray stand
Preparing the Examination RoomReady instruments and equipment
equipment is not within reach of the patient
exam lightproper body mechanics
Ensuring Patient Comfort and Privacythermostat around 71 to 73 degrees F
Provide blankets and sheetsExplain clearly about exam gownInform patients where to place clothes
Ensuring Patient Comfort and Privacy (cont)Leave the room when patients are undressing unless assistance is required
Knock and receive permission when reentering
Purpose of the Patient Historyassess general health status
Helps determine a diagnosis
Fill out Patient History form activityAccuracy countsSpelling countsNeatness counts
WorkBook Page17-19
Film ClipSaunders DVD
Assisting w/physical exams
Contents of the Medical HistoryChief complaint (cc)
Present illnessPast medical history
Family historySocial or personal history
Review of systems
The Chief Complaintpresenting problemconsists of one or two symptomsdocumented using the patient’s own words
The Chief Complaint (cont)Subjective symptoms
What the patient tells youNot directly observed
Objective symptomsSigns you can see, hear, feel, smell
Factual, measurable, observable
Do You Remember? Objective vs. Subjective1. Mr. Brown states that he has a toothache
2. Mrs. William’s urine appears to have blood in it.
3. Mrs. Smith’s respirations are very rapid
4. Mr. Lee states that he is nauseated after eating.
5. Mrs. Bender’s dressing is dry & intact.
Do You Remember? Objective vs. Subjective6. Mrs. Campbell complains of dizziness after each respiratory treatment
7. Mrs. Stark is jaundiced today.8. Mr. Runge has excessive bleeding every time he has a tooth extracted
9. Ms. Hime is perspiring, and her skin is cold & clammy.
10. Mr. Rue is experiencing some wheezing with each breath.
Steps to Interviewing a Patient and Preparing for an ExamId the patient, greet, and id yourself
Explain procedureProvide privacyAsk the patient to fill out form
Steps to Documenting a Chief Complaint Maintain eye contact and actively listen
Gather information What makes the problem better or worse? start? hurt? rate pain on a scale 0-10
Steps to Interviewing a Patient and Preparing for an Exam (cont)Review ask questionsAsk for the CCChart the CC
Steps to Interviewing a Patient and Preparing for an Exam (cont)observation skillsGather other information
PH, FH, and SHAllergies –
No allergiesNKDANKA
Steps to Interviewing a Patient and Preparing for an Exam (cont)Correct any errors drawing one
line through the error and date and initial them – Record the correct information
1/13/12 KG BP 180/96----------K. Gers MA
Steps to Interviewing a Patient and Preparing for an Exam (cont)Explain what procedures will follow
Place the patient history in the designated place
Obtaining the Past Medical History
all past diseases and medical problems
Dates of major illnesses
Hospitalizationssurgeries, current medications including OTC meds
The Family Medical HistoryHealth problems of blood relativescurrent health, major health
problems, and cause of death, as well as age at death
Family medical histories focus on diseases that may be inherited
Information Contained on the Personal HistoryLifestyle patterns Patient’s occupation
Marital statusSexual preferencesdiet choicesexerciseSleep habits
Inspection of Physical Examination
visually examining the exterior surface of the body
Palpation of Physical Examination
using the hands to feel the skin and accessible underlying organs
Percussion of Physical Examination
Use of the fingertips to tap the body to gain information about underlying body parts
Percussion Method of Physical Examination
Auscultation Method of Physical Examinationlisten to sounds that are found within the bodyA stethoscope is used to amplify body sounds
Mensuration Method of Physical Examination
Use of special tools to measure the body or specific parts
Weight scaleA tape measureA goniometerCalipers
Go to Lesson 2