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Physical Examination

CMA 110

TermDefinition
PE: PURPOSE Detect disease or illness. Prevent exacerbation of conditions. Prerequisites for: Employment Athletics Camp School
PE; WEIGHT Changes in weight is often correlated with selected disease processes. Necessary to monitor weight management and diet therapy. Prenatal assessment of fetal development. Necessary to monitor pediatric development. Correlated with height as a data poin
PE;WEIGHT PROCEDURE ID patient, explain procedure. Balance the scale. Assist the patient on the scale. Position the lower calibration bar (50 lbs) as far to the right in the notches before the bar falls. Position the upper calibration bar (1/4 lbs) to the right until the
PE;WEIGHT CONVERSIONS 1 kg = 2.2 lbs. Kg x 2.2 = lbs lbs ÷ 2.2 = kg 220 lbs = ___ kg: 220 ÷ 2.2 = 100 kg 80 kg = ___ lbs: 80 x 2.2 = 176 lbs.
PE; HEIGHT Adults are usually only measured on the first visit. Children have their heights measured at each visit to monitor development. Height and weight are correlated to identify health concerns. May be measured in inches or centimeters
PE;HEIGHT PROCEDURE ID patient, explain procedure. Lift the height bar above the patient's head. Instruct patient to remove shoes. Assist patient on the scale facing you. Lower the height bar until it rests horizontally on the patient's head. Note the height on the scal
BODY MASS INDEX (BMI) BMI expresses the correlation between weight and height. Except for athletes, the BMI correlates with total body fat content in adults. BMI is viewed as a more accurate correlate of obesity and associated health risks than height-weight tables. (Weight
BMI >25 RISKS Hypertension CVD Hyperlipidemia Type II DM Cholecystopathy Colon, breast, and endometrial cancer Sleep apnea Osteoarthritits
GOWNING Factors to consider: Patient comfort and privacy. The type of examination or procedure. The patient's age and gender. The accessibility of the body part to be examined
PATIENT POSITIONS Factors to consider: Patient comfort and privacy. The type of examination or procedure. The patient's age and gender. The accessibility of the body part to be examined
ERECT (STANDING) The patient assumes the anatomic position. Patient stands upright with arms at sides and palms facing forward. Patient may be asked to bend over, walk, or move specific body parts. Used to assess musculoskeletal and nervous system for coordination, str
SITTING Patient sits upright on the examination table, with legs dangling over the side. Patient covered with a drape sheet across the lap. HEENT, torso, axilla, breasts, upper extremities, lungs, and heart are examined. Vital signs measured
SUPINE (HORIZONTAL RECUMBENT) Patient lies on back with arms at the side. Drape sheet extends from under the axilla. Chest, heart, lungs, abdomen, extremities, and genitalia are examined.
TRENDELENBURG Patient lies supine with foot of table elevated. Draping same as supine. Used to treat shock and during certain abdominal surgeries.
PRONE Patient lies flat on abdomen with head turned to the side. Arms may be flexed above the head or at the sides. Drape sheet extends from the waist to the knees. Used to examine the back, spine, and lower extremities.
DORSAL RECUMBENT Patient lies supine with knees flexed and feet flat on the table. Drape sheet is placed diagonally so that the lateral corners wrap around each leg; upper corner cover the chest and abdomen while the lower corner covers the pubic region. Used to examine
LITHOTOMY Female patient assumes the dorsal recumbent position while feet are placed in stirrups. Buttocks are moved to the edge of the table and legs spread apart. Draping is same as dorsal recumbent. Used for vaginal, pelvic, and rectal exams. Collection of P
SIMS' (LATERAL) Patient lies on left side with left arm behind the body and right arm flexed forward. Knees are flexed with the right knee more sharply flexed than the left. Drape sheet is placed to afford maximum coverage. Used to examine the vaginal and rectal area.
GENUPECTORAL (KNEE-CHEST) Patient lies on left side with left arm behind the body and right arm flexed forward. Knees are flexed with the right knee more sharply flexed than the left. Drape sheet is placed to afford maximum coverage. Used to examine the vaginal and rectal area.
PROCTOLOGIC The knee-chest position is assumed more sharply with a special table. Draping the same as knee-chest. Used for proctological exams and procedures
JACKKNIFE (RECLINING) Patient lies on back, shoulders elevated, knees flexed, and thighs flexed perpendicular to the trunk. Draping the same as dorsal recumbent. Used to pass a urethral sound
FOWLER'S Patient sits on the exam table with the back supported at a 90 degree angle. Drape sheet extends across the lap. Used to examine the upper body of patients with CVD and respiratory problems. Semi-Fowler's: Same as Fowler's except the back is supported
PE:OBJECTIVE New patients generally require a general, comprehensive exam. Objective: Early detection of disease or the signs indicating the potential for disease. A general PE may be performed when Sx are not associated with a particular system or body part. Effec
Symptom Unobservable conditions and feelings experienced by the patient that indicate abnormality, e.g. pain, nausea, vertigo, diplopia, etc.
SIGN Observable or detectable characteristics or events that indicate abnormality, e.g. erythema, CCE,WBC count, etc.
Differential diagnosis Ruling out certain diseases having similar Sx to narrow the possible diagnoses, e.g. R/O cholecystitis.
Clinical (tentative) diagnosis Temporary, initial, working diagnosis that is subject to change as more data is collected, e.g. possible appendicitis
Definitive (final) diagnosis : The final conclusion reached by the physician after analysis of all clinical data, e.g. final diagnosis: amebic dysentery
Prognosis : Probable course and outcome of a condition including the prospects for recovery.
Acute An illness characterized by rapid onset, severe, and intense symptoms that is generally short in duration
Chronic Characterized by insidious, slow onset symptoms that persist over a long period
PE: MENSURATION The process of measuring. Typically includes body parts, movements, and body fluid constituents. HT, WT Head circumference. Goniometry. Lab assays
PE: INSPECTION Visually observing for abnormalities in size, shape, color, continuity, position, movement, and symmetry.
PE: PALPATION Process of touching and feeling to detect abnormalities of movement, size, shape, texture, temperature, and tenderness. Verifies data obtained through inspection. Light to deep palpation may be applied. Size of organs. Presence of lumps or masses. Br
PE; PERCUSSION Tapping body parts (especially body cavities such as chest and abdomen) with the hand, fingers, knuckles, or instruments to evaluate the internal structures based on sound and vibration. Used to determine size, density, and location of organs. Dense str
PE: MANIPULATION Physically moving or probing body parts such as the extremities and joints to check for abnormalities. ROM Goniometry Movements that produce pain
PE: AUSCULTATION Using a stethoscope to listen to body cavities, especially the heart, lungs, and abdomen. BP Apical pulse. Bowel sounds
PE: COMMON EQUIPMENT & MATERIALS Ophthalmoscope Otoscope Vaginal speculum Reflex hammer Tuning fork Stethoscope Pen light Ruler / tape measure Sphygmomanometer ETOH wipes Specimen container Nasal speculum Tongue depressors Gloves Lubricant Tissue Gauze squares
PE: GENERAL ROLE OF MA Preparing the patient and exam room. Handing instruments and materials to the physician as needed. Assist the patient in assuming positions and expose body parts for examination. Provide reassurance and comfort. Preparing the room for the next patient
PE: ASSISTING THE PHYSICIAN Neatly organized and assemble the equipment. Pass instruments to the MD as requested or anticipated. Pass the tongue depressor while holding its center
PE: EXAM SEQUENCE Health history. Specimen collection: May occur before health history or after PE. Vital signs and anthropometric measurements. Diagnostic tests: ECG, PFTs, x-ray, audiometry. These may occur after the PE. Physical examination. Postexam discussion.
HCM: HEALTH CARE MAINTENANCE Health promotion and disease prevention. Immunizations up to date. Proper nutrition—food pyramid. Regular exercise. Maintaining healthy weight. Mental health: Managing stress—coping mechanisms; self-esteem. Avoid tobacco and drugs. Moderation in ET
Created by: Brianna1997