Medical Assisting
Physical Examination
#2
In this section we will learn...
1. The principles of physical examination
2. The methods of patient examination
3. The most common instruments of examination
4. The patient positions used for examination and
procedures
5. Obtaining medical history
6. Parts of the medical record
7. Charting
Physical Examination (P/E)
Purpose of a P/E is to determine over-all
well-being of the pt. All major systems are
checked & Dr’s findings are interpreted.
When Assisting Physician w/ P/E
■ Always ensure the
physician’s
preferred
instruments are set
up for easy access
& sequence for use.
Preparing the Room
The room is usually set-up with equipment &
supplies before the pt is brought back from
the waiting room.
Room is cleaned & table paper changed after
each pt
Review of Systems (ROS)
Physician’s overall assessment of major body
functions by evaluation of each body system
Methods of Examination
■ Inspection- what is seen by the eye or notable
(color, visible injuries, posture, odor)
■ Palpation- what is felt (temp, masses, rigidity,
moisture)
■ Percussion- tapping or striking to elicit sound,
vibration or response
More……
■ Mensuration- measuring (ht, wt, wound size)
■ Auscultation- listening to body sounds, usually w/
stethoscope (heart, lungs, bowels)
■ Manipulation-
forceful passive
movement of a joint
to determine range
of motion (flexion &
extension)
Instruments…….
■ Nasal Speculum- inspection of nose
■ Ophthalmoscope- inspects inner structure of
eye
■ Otoscope- inspection of ear, (external auditory
canal & tympanic membrane)
■ Tongue Depressor-
(tongue blade) holds
tongue for throat or
oral exams
■ Tuning Fork- checks
auditory acuity & bone
vibration
■ Reflex/Percussion Hammer- tests
neurological reflexes of knee & elbow when
tendons are struck
■ Stethoscope- listening device to auscultate
areas of body, especially heart, lungs &
intestines.
■ Vaginal Speculum-
opens vaginal walls for
exams or pap smears
■ Tape Measure- soft
flexible types used for
infant head or wound
measurement
■ Gloves- protect pt & worker from infection or
illness. Wash hands before & after use. Come
in sterile & non-sterile (clean)
■ Gowns & Drapes- used to ensure pt privacy
during exams
Positions
Purpose: Allows Dr to examine selected areas
efficiently
■ Supine/Horizontal Recumbent- flat on back,
used for physical exams
■ Prone- lying on stomach, face down used for
back/spinal exams & surgeries
■ Dorsal Recumbent- on
back w/ knees up, used
for rectal & vaginal exams
that do not require
speculum use, back or
abd pain, elderly or
physically challenged pts
■ Dorsal Lithotomy- on
back, knees up in stirrups,
used w/ speculum for
vaginal exams or pap
More positions……..
■ Sitting Position- pt sitting on side of exam table, used
for head, neck & chest exams
■ Semi-fowlers- lying down, w/ head up 45 degrees,
legs flat, used for post surgical exams, breathing
difficulties, head trauma, pain
■ Fowlers- (high
fowlers) head up 90
degrees, used for
breathing or
cardiovascular issues
■ Sims- (lateral) left
side, right knee slightly
flexed, for rectal
exams, meds or rectal
temps
A little more……….
■ Knee-Chest- pt on knees, head down on table, used
for proctologic, sigmoid, & rectal exams (wait until Dr
in room)
■ Trendelenberg- pt in supine w/ feet raised above
level of head 30 degrees, used for shock, decreased
B/P, not routinely used in ambulatory care
Medical History
The medical hx is the basis of all tx rendered by
the physician. Purpose:
■ Helps guide pt’s tx/shows progress
■ Makes it easier to recall previous tx
■ Keeps statistical info
■ A good precise record provides support in
malpractice suits
Steps in Obtaining Hx
1. Prepare room
2. Identify yourself
3. Confirms pts identity
4. Put pt at ease
5. Explain purpose & imp. of gathering info
6. Attempt to build rapport before questioning
(especially sensitive topics as drugs, ETOH
or sexuality)
Tips in Questioning
1. Always avoid interjecting opinion or judgment
2. Do not interrupt unless pt is off course
3. Clarify as needed
4. Keep conversation on track
5. Watch your & the pts body language & non-
verbal communication
6. Answer pt questions
1. If a pt refuses to answer a
question, make an attempt to
return to the question later
2. If a pt comes in for a singular
complaint but wants to discuss
many problems, advise them they
may need to reschedule for
another appointment w/ more
time
Parts of the Medical Record
1. Chief complaint (cc)
2. Personal data/demographics
3. Present illnesses
4. Past history
5. Medications/allergies
6. Other physicians seen
7. Family hx
8. Social/occupational hx
9. Diagnosis (*signed by Dr.)
Chief Complaint (CC)
Is the specific reason the pt is being seen,
usually contained in the 1st part of the medical
hx. Usually obtained by the MA.
Characteristics:
Location, radiation, quality, severity, associated
sx, aggravating factors, alleviating factors,
setting & timing.
Past History
1. Includesallergies, immunizations,
childhood diseases, surgeries &
hospitalization
Treatment Success
1. A pts idea of successful treatment usually
means they are able to manage their
disease
Signs & Symptoms (S/Sx)
1. Objective Symptoms (also called signs)-
information that can be observed by
someone other than the pt, such as pallor,
diaphoresis, & SOB.
1. Subjective Symptoms- changes in the body
as sensed by the pt but not observable,
such as vertigo, nausea, & pain.
Rules of Charting
1. Black Ink
2. Sign w/ 1st initial last name then title
3. Do not leave empty spaces
4. Use only standard abbreviations
5. Never erase, use white out, or cross out
6. Never chart for anyone else
7. Never future date, or post date entries
8. If an error is made, draw a single line thru &
initial entry
Charting
Always remember the importance of charting each
skill that is performed in the medical office w/
complete details.
A medical record may be your only defense in a
deposition or trial.
In the world of charting, if it is not charted, it is not
done!
The 6 “C's” of Charting
1. Client words
2. Clarity
3. Completeness
4. Conciseness
5. Chronological order
6. Confidentiality
Electronic Medical Record
(EMR)
A new record is initiated when the pt makes
their first apt
When pt arrives for apt, record the visit, note
the reason for the visit, record past hx (use
active listening)
i
Medical Records
Adults: kept for 7 yrs.
Minors: until 18, +7 yrs.
Reasons for retrieval:
1. Note response to tx
2. Provide past med hx
3. Legal Subpeona
The end!
