CHAPTER 5

CHAPTER 5THE PHYSICAL EXAMINATION

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

Introduction to the Physical Examination

1. Complete patient examination consists of:a. Health historyb. Physical examination (PE)c. Laboratory and diagnostic tests

2. Results used by physician to:a. Determine patient's state of healthb. Arrive at a diagnosis and prescribe treatmentc. Observe any change in patient's illness after

treatment has been instituted


Introduction to the Physical Examination, cont.

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

• Helps prevent serious health problemsb. Prerequisite for employmentc. Participation in sportsd. Attendance at summer campe. Admission to school


Definition 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 proceduresa. Often simply called the diagnosis (dx)


Definition of Terms, cont.

2. Clinical diagnosis: intermediate step in the determination of a final diagnosisa. Obtained through evaluation of health history

and PE (without laboratory and diagnostic tests)b. Outside laboratories provide space on

laboratory request: to specify clinical diagnosisc. Once physician has analyzed test results: final

diagnosis can usually be established



3. Differential diagnosis: two or more diseases may have similar symptomsa. Determines which disease is causing the

symptoms so that a final diagnosis can be madeb. 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



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



6. Acute illness: characterized by symptoms that have a rapid onseta. Usually severe and intenseb. Subside after a short time

• Example: influenza7. Chronic illness: characterized by symptoms

that persist for more than 3 monthsa. Patient shows little change over a long time

• Examples: diabetes, hypertension, emphysema


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 conditiona. 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


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


Preparation of the Examining Room, cont.

h. Remove dust/dirt from furniture & towel dispensersi. Change examining table paper after each patientj. Patient's privacy should be ensured

• Keep door closed during patient examinationk. Clean and prepare items the physician will be using

for examinations (equipment, instruments, supplies)l. Check equipment and instruments frequently for

proper working conditionm. Have equipment and supplies ready for examinationn. Know how to operate and care for equipment


Physical Exam Equipment and Supplies


Physical Exam Equipment and Supplies, cont.


Preparation 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 birthb. Take vital signsc. Measure height and weightd. Explain purpose of examination and answer

questionse. Apprehension can be reduced by:

• Address patient by name of choice• Have a friendly and supportive attitude• Speak clearly, distinctly, and slowly


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


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


Measuring Weight and Height1. Mensuration: process of measuring 2. Change in weight may be significant in:

a. Diagnosis of patient's conditionb. Prescribing treatment

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

progress


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 visit6. Adult height usually only measured:

a. First office visit b. Complete PE



7. Children weighed and measured at each office visit to:a. Observe pattern of growthb. Calculate and determine medication

dosage8. Height and weight are compared

against a standardized chart:a. Determines if patient falls within normal

limits



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


Balance the Scale

Balance the Scale



• 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



• Interpret calibration markings accurately– Lower calibration bar: divided into 50-

pound increments



– Upper calibration bar is divided into pounds and quarter pounds1) Longer calibration lines: indicate

pound increments2) Shorter calibration lines indicate

quarter-pound and half-pound increments


Measuring Weight



• 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 dosage2) 1 kg = 2.2 pounds3) To convert pounds to kg: Divide

the number of pounds by 2.2



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) Inches2) Feet and inches


Measuring Height



• Read the measurement correctly– Read the measurement at the junction of

the stationary calibration rod and the movable calibration rod



– If patient's height is less than the top value of the stationary calibration rod1) Read the measurement directly on the

stationary roda) 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


Measuring Height



• 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)


Positioning and Draping

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

examinedb. Sitting: Examination of the head, neck,

chest, upper extremities; measure vital signs


Sitting Position

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


Supine PositionSupine:

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

comfortable position for patients with:– Respiratory

problems– Back injury– Low back

pain


Prone Position

Prone: Examination of back; assess extension of hip joint


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


Lithotomy Position

Lithotomy: Vaginal, pelvic and rectal examinations


Sims Position

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


Knee-Chest Position

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


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


Positioning and Draping, cont. Position used depends on type of examination

being performeda. More than one position may be usedb. Explain position to patient and assist them into itc. 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


Positioning and Draping, cont.

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

exposed5. Gowns and drapes are made of paper

or cloth


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


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


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)


Percussion, cont.


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

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CHAPTER 5