Clinical Diagnosis
Diagnosis based on the signs and symptoms of a disease
Sign
Objective information that can be detected by a person other than affected person.
Examples of Signs
Bloody nose, blood in the stool
Symptom
Subjective information supplied by the patient
Examples of Symptoms
Anxiety, back pain, abdominal pain, and fatigue
Why are diagnostic tests done?
To confirm a clinical diagnosis or to rule out other possible disorders and are necessary when a patient has symptoms that may indicate more than one condition. Formulate a treatment plan or appropriate drug therapy.
Differential Diagnosis
Determining the correct diagnosis when two or more diagnosis is possible
Prognosis
A forecast of the probable course and outcome of the disorder and the prospects of recovery
Responsibilities before the exam?
Ensuring all instruments/supplies are readily available to the practitioner. Patients are physically and emotionally comfortable during exam; by helping with positioning and keeping them aware of what is going on. Observe the patient for signs of distress
Aseptic Handwashing
Before and after each patient contact
Before and after each procedure
Wear gloves if come in contact with
Blood - Nonintact skin
Body fluids - Moist surfaces
Also when handling specimens
Respiratory hygiene/cough etiquette
Covering mouth and nose when coughing
Using tissues and how to dispose
Hand Hygiene
Wearing surgical mask
Wear Mask
Prevent exposure to an infectious disease transmitted by airborne droplets
Isolation Precautions
Personal protective equipment
Biohazardous Waste Container
Discard all disposable equipment and supplies appropriately
Following Each Patients Exam
Clean and disinfect the exam room
Sanitize, disinfect, and sterilize equipment appropriately
Emotional Preperation
Explain what is going to happen during the exam. Use simple, direct language that patients can understand
Physical Preperation
Offer the bathroom
Ask the patient to disrobe and put on an exam gown or cover with a drape
Be aware of modesty and comfort
Body Mechanics
To protect yourself from injury when helping to position a patient
Rules for good Body Mechanics
Lifting with you strongest muscles, including legs and arms
Keep feet apart
Bend from hip and knees
Positioning and Draping
Assist the patient to appropriate position
Make as comfortable as possible
Cover with appropriate drape
Keep patient warm
Maintain privacy/modesty
Sitting
Patient sits on the edge of the table without back support
Exams: Head, Neck, Chest, Heart, Back, and Arms
Evaluates: Patients ability to fully expand the lungs. Checks upper body parts for symmetry.
Drape: Placed across patients lap or across lap and che
Supine (Recumbent)
Patient lies flat on the back with hands to the side or on abdomen. Most relaxed position.
Exams: Head, Neck, Chest, Heart, Abdomen, Arms, and Legs
Drape: from neck or underarms down to the feet
Not comfortable for patients with short of breath or pregnan
Dorsal Recumbent
Patient lies face up, with back supporting all weight. Same are supine, but patient knees are drawn up and feet are flat on table.
Exams: Head, Neck, Chest, Heart
Drape: from neck or underarms down to feet
Not comfortable for patient with leg disabilities
Lithotomy
Exam for female genitalia. Lies on back with knees bent and feet in stirrups. Then slide forward to position buttocks at edge of table.
Drape: large, covers from breast to ankles. Placing the drape one point or corner between the legs will make exam easie
Fowlers
Patient lies back on exam table which head is elevated at 45-degree angle.
Exam: Head, Neck, and Chest
Drape: from neck and underarms down to the feet
Best for patient who experience shortness of breath or lower back injury
Prone
Lying flat on table facedown, patient head is turned to one side, arms are placed at sides or bent at the elbow
Drape: upper back to the feet
Exam: Back, Feet, or Musculoskeletal system
Not comfortable for women who are pregnant, patient who are obese, wi
Sims
Patient lies on left side, leg is slightly bent, left arm is placed behind the back so patients weight is resting primarily on the chest.
Right arm is bent and raised toward the chest, right arm is bent toward the head for support,
Drape: Upper back to th
Knee Chest or Knee Elbow
Patient lies facedown, supporting the body with knees and chest. Thighs should be at a 90-degree angle to table and slightly separated. Head is turned to one side and arms are placed to the side above the head.
Knee Chest Exam: anal and perineal areas and
Proctologic
Alternative to Sims or knee chest position
Patient is bent at the hips at 90 degree angle. Assumes position by standing next to exam table and bending at the waist until chest rests on the table.
Drape: fenestrated drape
Symmetry
Degree to which one side is the same as the other
Fenestrated Drape
Special opening provides access to the area to be examined
Culture
Pattern of assumptions, beliefs, and practices that shapes the way people think or act
Patient from Different Cultures
Avoid stereotyping an individual or group on basis of patients behavior.
Avoid making judgments on basis of your experience with patients or with your own family and friends.
Patients
-may not know what to expect
-may be more modest than others and requir
Patient with Physical Disabilites
May require extra assistance
-help them disrobe
-move from mobility device
-assume certain positions on or off table
Inspection
Visual exam of patients entire body and overall appearance.
Physician: assesses posture, mannerisms, and hygiene
Parts of the body for size, shape, color, position, symmetry, and presence of abnormalities like rashes or growths.
Ausculation
Process of listening to body sounds.
Physicians: detect flow of blood through an artery and perform auscultation extensively in the general exam to assess sounds from the heart, lungs, and abdominal organs.
Use stethoscope
Palpation
Touch
Physician: assess characteristics such as texture, temperature, shape, and the presence of vibrations or movements
Superficially (on skin surface)
Extra pressure when assessing characteristics of underlying tissues and organs
Perform using the finge
Percussion
Tapping or striking the body to hear sounds or feel vibrations.
Physicians: determine the location, size, or density of a body structure or organ under the skin.
Strike body directly with 1 or 2 fingers
Indirect percussion by placing one finger of one han
Mensuration
Measuring
Done to monitor the growth of the uterus during pregnancy or to note length and diameter of an extremity or a wound.
Use tape measure or small ruler
Manipulation
Systematic moving of a patients body part
Check for abnormalities that affect movement, determine a joints range of motion (ROM)
General Physical Exam in Order/ Components and Materials
Begin by assessing patients overall appearance and condition of skin, nails, and hair (No special materials).
1. Head (No special materials)
2. Neck (No special materials)
3. Eyes (Penlight, ophthalmoscope, and vision/color charts)
4. Ears (Otoscope and a
General Apperance
Noting whether the patient appears to be in good health and of acceptable weight.
Whether the patient appears to be distressed or in pain and assesses the level of patients alertness.
Skin
Notes skin color, texture, moisture level, temperature, and elasticity.
Nails
Looks at nails and nail buds. Indicate poor nutrition, disease, infection, or injury
Hair
Notes pattern of hair growth and texture of the hair on scalp and on rest of the body. Sudden hair loss or changes in hair growth could be cause of disease
Head
Looks for abnormal condition of the scalp or skin, puffiness around eyes or lips or other areas of face, and any abnormal growths
Neck
Check for symmetry and rang of motion.
Palpate the neck to check lymph nodes, thyroid glands, and major blood vessels.
Enlarged lymph nodes sign of infection or blood cancer
Eyes
For presence of disease or abnormalities, checks eye muscles, checks pupils for response to light (should become smaller)
Uses ophthalmoscope to examine retinas and other internal structures
Perform vision tests either before or after GPE
Ears
Checks outer ears for size, symmetry, presence of lesions, redness, or swelling.
Using otoscope examines the inner structures
Checks ear canal for redness, drainage, lesions, foreign objects, or presence of excesive cerumen (earwax)
Assesses the color, sh
Nose and sinuses
Checks for presence of infection or allergy.
Use penlight to view the color of the nasal mucosa (lining of nose)
Notes discharge, lesions, obstructions, swelling, or inflammation
Mucosa that is red or swollen and accompanied by a yellowish discharge indic
Mouth and throat
Overall health and hygiene
Use tongue depressor to draw back the patients cheek to exam the lining of the cheek, under the tongue, and floor of the mouth
Color or any lesions may indicate possible infection or oral cancer
Asses the condition of the teeth
Chest and lungs
Asks the patient to breath normally or take deep breaths
Becomes dizzy during deep breathing may be hyperventilating
Inspects the patient chest from back, side, and front. Checks shape, symmetry, and postural position and looks for the presence of ant typ
Hyperventilating
overly deep breathing that leads to a loss of carbon dioxide in the blood
Kyphosis
Humpback, commonly seen in elderly
Heart
Immediately after lung exam
Palpate the area first to locate correct anatomical landmark for placing stethoscope
Percussion to check size, patient should not speak
Notes heart rate, rhythm, intensity, and pitch
Breasts
Patients holds arm to side while breasts are inspected for symmetry, contour, masses, and retracted area. Then raises arm above head while palpates lymph nodes. Then lies down for first side to be examined.
Procedure allows breast tissue to flatten evenly
Abdomen
Should be completely relaxed
Inspection and auscultation, followed by percussion and palpation.
Listen to bowel sounds before palpating the abdominal organs. Palpating can change the bowel sounds
Inspection of the skins color and surface and follows inspe
Female Genitalia
Lithotomy position
Patient relax
Performed by a specialist or by a primary care physician
Male Genitalia
Supine Position
Visually inspects penis for signs of infection or structural abnormalities, palpating any lesions. Examines the scrotum the same, palpating testicles for lumps.
Stand while the physician checks for any bulges in the groin that indicated he
Rectum
Perform a digital exam to palpate the rectum for lesions or irregularities. Older than 40 have a yearly one for early detection of colorectal cancer.
May request any stool be tested for presence of occult blood using guaiac based fecal occult blood test.
Musculoskeletal System
Checks for good posture from back and side. Patient walks to assess gait. Child bends at the waist so can check for scoliosis.
Determines ROM, strength of various muscle groups, and body measurements. Examines arms, legs, hands, and feet for lesions, defo
Neurologic System
Evaluation reflexes, mental and emotional status, and sensory and motor function.
Same time as Musculoskeletal both systems are involved in movement and coordination
Children intellectual assessment
Test mental status and memory of older adults to detect
Scoliosis
Lateral curvature of the spine
After the Exam
Assist into a sitting position
Allow the patient to perform any necessary self-hygiene measures
Allow patient to dress
Perform additional tests or procedures
Additional Test and Procedures
Before Patient Dresses
-cold or heat therapy
-apply any bandage
-collect specimen
-administer any medications
After Patient Dresses
-Urinalysis
-Pulmonary function test
-administration of oral meds
-eye or ear irrigation or meds
Patient Education
Assess needs
-Risk factors for disease
-Medication administration
-Self-help or diagnostic techniques
Use proper language level
Ensure understanding
Give written instructions
Follow-Up
Scheduling appointments
-Future office visits
-Outside appointments
Helping plan for home nursing care
Helping the patient obtain assistance
Purposes for General Physical Exam
Confirm overall state of health, diagnose a problem
When are general exams performed?
Once a year or before new job, school, etc.
What is the role of the MA during the physical exam?
Assist the physician and make patient comfortable
Most safety measures are outlined by who?
OSHA (protect employees from safety hazards) and CDC (protect employees and patients from medical hazards)
What safety precautions must you take during a physical exam?
Handwashing, gloves, instruct patient on hygiene and etiquette, wear mask and PPE when appropriate, discard things in appropriate containers, and sanitize, disinfect, and sterilize appropriate equiptment.
What is emotional preparedness?
Letting the patient know what to expect from the procedure so they can emotionally prepare for it.
What is physical preparation for an exam?
Give patient opportunity to empty bladder/bowels, ensure room temp is comfortable, ask patient to disrobe and put on an exam gown if necessary, giving patient privacy to do so unless they need your assistance, be aware of patient modesty.
How do you comfort a patient who is embarrassed in a particular position?
Explain the need for the position, protect their modesty, and make sure they spend as little time in the position as necessary.
How do you comfort a patient who is physically uncomfortable in a position?
Put a pillow under appropriate body area to ease pain or ask the doctor about an alternate position.
What should you take into consideration when choosing a drape for a patient?
Privacy and warmth
What is a fenestrated drape?
A drape with an opening for the area to be examined.
What kind of patients need special considerations?
Patients with physical disabilities and patients from different cultures
What are the six methods used in an examination?
Inspection, Auscultation, Mensuration, Palpation, Percussion, and Manipulation
What is Inspection?
Visual examination of the patients overall body and state of well-being. Posture, mannerisms, hygiene. Size, shape, color, position, symmetry. Presence of abnormalities
What is Auscultation?
Listening to body sounds
What is Palpation?
Touch. Texture, temperature, shape, and presence of vibrations or movements.
What is Percussion?
Tapping or striking the body to hear sounds
What is Mensuration?
Measuring the body
What is Manipulation?
Moving the patient's body parts, assessing ROM (range of motion)
What are the basic items needed for a physical exam?
Penlight, otoscope, vision char, color vision chart, audiometer, nasal speculum, gloves, tongue depressor, stethoscope, vaginal speculum, lubricant, tape measure
What are the components of a physical exam?
Head, neck, eyes, ears, nose/sinuses, mouth/throat, chest/lungs, breasts, heart, abdomen, genitals, rectum, musculoskeletal system, neurological system, and general appearance.
What is nasal mucosa?
The lining of the nose
What is kyphosis?
Humpback
What is a digital examination?
Inserting fingers into a body canal to inspect for abnormalities.
What is scoliosis?
Lateral curvature of the spine
What may be needed after an exam?
Additional tests or lab work, patient education, or prescriptions