Primary Physical Examinaton CMA
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| Auscultation | The act of listening to body sounds, typically with a stethoscope, to assess various organs throughout the body
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| Bruit | An abnormal sound or murmur heard on auscultation of an organ, vessel, or gland
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| Clubbing | Abnormal enlargement of the distal phalanges (fingers/toes) associated with cyanotic heart disease or advanced chronic pulmonary disease
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| Colonoscopy | A procedure in which a fiberoptic scope is used to examine the large intestine
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| Electrocardiogram | A graphic record of electrical conduction through the heart
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| Emphysema | The pathologic accumulation of air in the alveoli, which results in alveolar destruction and overall oxygen deprivation: In the lungs, the bronchioles becomes plugged with mucus and lose elasticity
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| Gait | The manner or style of walking
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| Hematopoiesis | The formation and development of blood cells in the red bone marrow
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| Intercellular | A term referring to the area between cells
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| Intracellular | A term referring to the area within the cell membrane
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| Manipulation | Movement or exercising of a body part by means of an externally applied force
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| Mastication | Chewing
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| Murmur | An abnormal sound heard during auscultation of the heart that may or may not have a pathologic origin; it is associated with valve disease or a congenital heart defect
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| Nodules | Small lumps, or lesions, or swellings that are felt when the skin is palpitated
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| Palpitation | The use of touch during physical examination to assess the size, consistency, and location of certain body parts
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| Peristalsis | The rhythmic contraction of involuntary muscles lining the gastrointestinal tract
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| Sclera | The white part of the eye that forms the orbit
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| Transillumination | Inspection of a cavity or organ by passing light through its walls
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| Trauma | Physical injury or a wound caused by an external force or violence
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| Vasoconstriction | contractions of the muscles lining blood vessels, which narrows the lumen
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| Anatomy | The study of how the body is shaped and structured
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| Physiology | Study of body functions
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| Cells | Basic unit of life
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| Tissues | Cells of similar structure and function that are placed together
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| Epithelial Tissue | makes up the skin, glands, and linings of body parts and organs
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| Squamous | flat
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| Cuboidal | square
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| Columnar | long/ narrow
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| Transitional | vary shapes that can stretch
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| Connective Tissue | support and binds other body tissues. Types include: collagen, bone, cartilage, adipose, ligaments, tendons, blood, and lymph.
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| Muscle Tissue | produces movement
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| Plasma Membrane | surrounds the cell and creates an outer covering
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| Intracellular Area | includes the cytoplasm that contains living material to carry out function
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| Nucleus | contains the genetic code of the cell that determines the cells function
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| Skeletal Muscle | (striated, voluntary) attached to bones, produces voluntary body movements when contracted
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| Cardiac Muscle | (striated, involuntary) forms the heart muscle wall
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| Smooth Muscle | (nonstriated, involuntary) lines the walls of blood vessels and hollow organs. Causes peristalsis and vasoconstriction.
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| Nervous Tissue | conducts nerve impulses between the periphery and central nervous system
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| Organs | composed of two or more types of tissue bound together to form a more complex structure for a common purpose or function
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| Systems | composed of several organs and their associated structures
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| Blood Cells, Organs, and Structures | arteries, arterioles, veins, venules, white blood cells, red blood cells, platelets, plasma
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| Blood Functions | transport material/ collect waste throughout the body, white blood cells fight infection, red blood cells carry oxygen, platelets help form clots, plasma carries dissolved nutrients/ other materials
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| Cardiovascular Cells, Organs, and Structures | heart, valves, arteries, arterioles, veins, venules
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| Cardiovascular Functions | circulatory system transports materials in the blood throughout the body, veins return deoxygenated blood to the heart, which pumps it into the lungs, oxygenated blood is pumped into the aorta and branching arteries to cells in the body
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| Endocrine Cells, Organs, and Structures | pituitary, pineal gland, hypothalamus, thyroid, pancreas, adrenal cortex/medulla, parathyroid, thymus, ovaries, testes
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| Endocrine Functions | produces hormones that circulate in the blood to target tissue that stimulates a certain action
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| Integumentary Cells, Organs, and Structures | skin, subcutaneous tissue, sweat/sebaceous glands, hair, nails, sense receptors
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| Integumentary Functions | protection, temperature regulation, senses organ activity
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| Gastrointestinal Cells, Organs, and Structures | mouth, tongue, teeth, pharynx, esophagus, stomach, small intestine, large intestine, liver, gall bladder, pancreas, appendix
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| Gastrointestinal Functions | mastication, swallowing, digestion, absorption of nutrients, excretion of waste materials
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| Lymphatic/Immune Cells, Organs, and Structures | lymph, lymph vessels, lymph nodes, thymus, tonsils, spleen, lymphocytes, antibodies
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| Lymphatic/Immune Functions | maintains fluid balance; protects internal environment; defends against foreign cells/disease; provides immunity to some diseases
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| Musculoskeletal Cells, Organs, and Structures | bones, joints, muscles, tendons, ligaments, cartilage
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| Musculoskeletal Functions | movement, posture, heat production, support protection, mineral storage, hematopoiesis
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| Nervous Cells, Organs. and Structures | brain, spinal cord, neurons, neuroglial cells, peripheral nerves, autonomic nerves
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| Nervous Functions | controls body structures to maintain homeostasis; higher-order thinking and reflex centers that control autonomic processes; carries sensory stimulus to the brain and motor impulse to the periphery
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| Reproductive Cells, Organs, and Structures | Female: estrogen/ progesterone, ovum, ovaries, fallopian tubes, uterus, vagina, vulva, mammary glands
Male: testosterone, sperm, epididymis, vas deferens, prostate gland, testes, scrotum, penis, urethra
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| Reproductive Functions | produces hormones, reproduction
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| Respiratory Cells, Organ, and Structures | nose, sinuses, pharynx, larynx, trachea, bronchi, lungs, bronchioles, alveoli
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| Respiratory Functions | responsible for inhalation of oxygen/ exhalation of carbon dioxide externally and exchange of oxygen/carbon dioxide internally at the cellular level; acid-base regulation
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| Sensory Cells, Organs, and Structures | eyes, ears, taste buds, olfactory receptors, sensory receptors
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| Sensory Functions | helps sense changes in the external/internal environments through vision, hearing, balance, taste, smell
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| Urinary Cells, Organs, and Structures | nephron unit, bilateral kidneys, ureters, urinary bladder, urethra
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| Urinary Functions | filters waste material from blood; reabsorbs fluid/electrolytes as needed; excretes waste in urine; maintains electrolyte, water, and acid-base balances; regulates blood pressure; activates red blood cells
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| Primary Care Physician (PCP) | treat patients of all ages for a broad ranges of diseases and complaints. qualified to provide care from birth to old age.
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| Physical Examination | determines the patients overall state of well-being. all major organs and body systems are checked during this time
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| Preparing for Physical Examination | make sure patient feels comfortable. verify insurance information and necessary medical information (current medications, allergies, etc.)
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| Room Preparation | the exam room should be checked periodically to ensure it is fully stocked and equipment is functioning. MA must be aware of how to operate all equipment beforehand. exp. dates must be checked. private, well lit, comfy temp. clean & disinfected
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| Patient Preperation | medical record complete. consent forms signed. introduce yourself. use pt preferred name. respect. watch nonverbal cues. verify insurance accuracy. obtain specimens. take vitals. investigate. help prepare. questions. positions. privacy. document. assist.
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| Assisting The Physician | hand instruments on request. alter lamp. position drape. collect and label specimens. conduct follow up. schedule post exam diagnostic procedures
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| Ophthalmascope | used to inspect the inner structures of the eye
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| Tongue Depressor | a flat, wooden blade used to hold down the tongue during a throat exam
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| Otoscope | used to examine the external auditory canal/tympanic membrane
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| Nasal Speculum | used to examine the lining of the nose, nasal membranes, and internal septum
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| Tuning Fork | used to check the patients auditory acuity and to test bone vibration
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| Tape Measure | measuring device, typically used to assess length/head circumference of infants or wound size
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| Stethoscope | used during auscultation to hear internal body sounds
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| Reflex Hammer | used to strike the tendons of the knee and elbow to test nuerologic reflexes
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| Gloves | used whenever the potential exists for contact with body fluid or contaminated items exist
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| Additional Supplies | gauze, cotton balls, cotton tipped applicators, specimen containers, hemocult packets, pap smear supplies, lubricating jelly, and laboratory request forms must be readily accessible during the examination
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| Inspection | ranges from focusing on patients general appearance (posture, mannerisms, grooming), to more detailed observations such as body contour, gait, symmetry, visible injuries, deformities, tremors, rashes, and color changes
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| Palpation | uses sense of touch. perceptions include: temperature, vibration, consistency, form, elasticity, moisture, texture, position, and contour. performed with one hand, both hands (bimanual), one finger (digital) fingertips, or the palmar aspect of the hand
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| Percussion | involves tapping or striking the body to elicit sounds/vibrations. can determine the position, size, and density of organs/cavities.
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| Auscultation | the physician uses a stethoscope to listen to sounds that originate within the body. mostly used for sounds originating in the lungs, heart, and abdomen
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| Mensuration | the process of measuring. measurements that are recorded: height/weight, length/diameter of an extremity, size of the uterus (pregnancy), size/depth of a wound, and the pressure of the grip. this is usually recorded in centimeters
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| Manipulation | the passive movement of a joint to determine the range of extension or flexion of a part of the body. may be performed using the range-of-motion (ROM) exercises
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| Positioning/Draping the Patient for the Physical Examination | the medical assistant is responsible for instructing and assisting the patient into various positions for the exam. do not place the patient in an uncomfortable position or a privacy compromising position. dont leave if patient is in a dangerous position
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| Fowlers Position | the patient sits on the exam table with the head of the table elevated to 90 degrees, or he/she sits on the edge. this position is useful for exams of the head, neck, and chest as well as for patients with orthopnea. drape placement varies
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| Semi-Fowlers Position | head of table is positioned at a 45 degree angle. useful for postoperative exams, patients with breathing disorders, patients with elevated temperature, those suffering from head trauma. the drape should cover the entire patient from the nipple line down
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| Direct Percussion | performed by striking the body with a finger
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| Indirect Percussion | requires the physician to place his/her hand on the patient and strike the placed hand. this allows the physician to hear and feel the vibration. pitch, quality, duration and resonance are measured
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| Supine (Horizontal Recumbent) Position | lying horizontally with the face and torso facing up
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| Dorsal Recumbent Position | individual (usually a patient) lies on their back with their knees bent up in an outward position while their feet are planted flat on the ground, a bed, table or resting platform allowing the pelvic area to be easily examined and observed.
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| Lithotomy Position | a supine position of the body with the legs separated, flexed, and supported in raised stirrups, originally used for lithotomy and later also for childbirth.
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| Sims Position | usually used for rectal examination, treatments and enemas. It is performed by having a patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent. It is also called lateral recumbent position.
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| Prone Position | a body position in which one lies flat with the chest down and the back up. In anatomical terms of location, the dorsal side is up, and the ventral side is down. The supine position is the 180° contrast.
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| Knee-Chest Position | individual rests on the knees and upper part of the chest, assumed for gynecologic or rectal examination.
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| Tredelenburgs Position | the body is laid supine, or flat on the back with the feet higher than the head by 15-30 degrees.
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| Principles of Body Mechanics | used when sitting, standing, lifting, carrying, pushing, pulling, or transferring patients. starts at good posture. keeps spine balanced and aligned. avoid twisting when reaching. do not cross legs. head erect, face forward, chin up, shoulders relaxed.
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| Transferring a Patient | body mechanics. wheelchair pt, chair close to table, wheels locked, foot rests lifted. support pt strong side. stepstool. pt close to your side. bend at knees. signal and lift. help step up with strong leg. shoulder or waist never neck.
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| Safe Lifting Techniques | get help if heavy. maintain alignment. do not reach. bend at knees. keep weight close to body. keep back straight. slide, roll, push heavy item if possible
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| Examination Sequence | if pt is female and physician is male, female ma must be present. keep convo to minimum. exam begins at fowlers position
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| Presenting Appearance (General Appearance) | whether patient shows good health (disoriented, in distress, well nourished, answers questions with ease or confusion). the gait is body movements are monitored for unusual muscle action. posture is checked for pain, stiffness, or limb movement difficulty
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| Nutrition and Stature | the body build and proportion is noted. any gross (immediately obvious) deformities are recorded. height/weight is recorded before the exam
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| Speech | may reveal a pathogical condition
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| Breathe Odors | often associated with poor oral hygiene/dental care. a musty odor is associated with liver disease. an ammonia smell may be caused by uremia. acidosis/smell of acetone may be the result of diabetes mellitus, starvation, or renal disease
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| Skin | skin turgor for dehydration. dryness, scaling, lengthy healing, frequent skin breaks for systemic disease. brittle, grooved, or lined nails for local infection or systemic disease. clubbing for heart lung disease. spooning for iron deficient.
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| Head | face reflects how pt deals with stress. skull, scalp, and face palpated for size, shape, and symmetry. distribution/lack of hair indicate hormonal changes. excessive hair (facial hair in girls) for hormonal imbalance. signs of trauma and nodules
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| Eyes | pupils checked for light reaction. sclera checked for color. inflammation apparent in sclera. yellow sclera indicate liver disease. movement tested. diabetes damage blood vessels of eye. ophthalmoscope used to examine eye
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| Ears | examined with otoscope. external ear checked first. eardrum is pearly gray. scars usually from ear infections. may indicate blood or pus in middle ear. swallowing allows movement observation. movement from pressure change. equalizes air pressure
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| Nose/Sinuses | mucosa examined for color/texture. can not see sinuses, frontal/maxillary examined by palpitation and transillumination. if in need of specialist, pt referred to ophthalmologist or otorhinolaryngologist.
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| Mouth/Throat | oral hygiene and dental care. includes condition of teeth, how pt cares for teeth/gums, whether upper/lower jaws meet ok for chewing. healthy=pale pink, glossy, smooth, do not bleed with pressure. palatine tonsils visible. cheeks checked for marks/color
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| Neck | ROM. thyroid gland for symmetry, size, texture. check thyroid through palpitation and swallowing. carotid artery palpitated. lymph nodes palpitated. lymphadenopathy=infection in face, head, neck.
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| Reflexes | biceps checked while pt sitting. knee jerk(patellar), ankle jerk(Achilles) checked using tapotement (tapping) with fingers or hammer. plantar reflexes (Babinski and chaddock) tested while pt is supine or upright.
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| Chest | sitting. exam for symmetric expansion. emphysema cause barrel shaped chest. percussion used to determine density of lung . stethoscope to auscultate lung sounds. abnormalities cause for further tests.
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| Abdomen | arms may be at side, across chest, or under head. relaxation necessary. dorsal recumbent position. auscultates abdomen in all quadrants to hear bowel sounds. palpates for abnormalities. percussion used for density, position, and size of organs.
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| Breast/Testicles | breasts are examined symptomatic or not. examined visually and palpated in supine and high fowler. breast cancer most common in women. males at 15 will receive testicular exam.
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| Rectum | exam gloves and lubricating jelly is used. exam light should be directed at perineal area. hemmocult specimens may be collected at time of digital exam
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| Legal and Ethical Issues | MA must uphold the standards of the code of ethics of the American association of medical assistants (AAMA)
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| HIPAA Applications | conversations can be overheard. guard confidentiality by ensuring privacy glass is closed, turn away from waiting room while on phone. physician schedule faced away from pt areas. medical records face door of exam room. EMR use, close files, lock computer
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| Aphonia | inability to speak due to loss of the voice (commonly seen with overuse or laryngitis)
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| Aphasia | loss of expression by speech/ writing due to an injury/disease of the brain
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| Dysphasia | lack of coordination; failure to arrange words in proper order (usually caused by brain lesions)
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| Motor Aphasia | the patients knows what he/she wants to say but cannot use muscles properly to speak
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| Sensory Aphasia | the patient pronounces words easily but uses them inaccurately
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| PERRLA | pupils are equal, round, respond to light, adjust/focus on objects
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