Lesson 6 — The Physical Examination
All procedural steps, PURPOSE rationales, and topic content below are verbatim from MedCerts HLT420A Storyline modules. Quiz items have been normalized to multiple-choice format with verbatim source rationales. Reference textbook: Niedzwiecki & Pepper, Kinn's The Clinical Medical Assistant, 15th ed., Chapter 6. No outside material added.
- Define a primary care provider
- Discuss preparing for the physical examination and assisting the provider
- Describe methods and sequence of a complete physical examination
- Summarize the physical examination and the medical assistant's role
Wellness Assessments
Wellness assessments are tools to evaluate factors related to the patient's overall health status. These screenings help identify health risks. Recognized risk allows physicians to make preventive recommendations and suggest ways to improve health. Physicians use these tools to detect and diagnose problems in their early stage.
The clinical medical assistant, or M-A, may assist the physician in conducting a variety of screenings both in the office and through telehealth. These screenings are performed or ordered based on physician guidance and individualized need. Chosen assessments may depend on psychosocial history, gender, and age.
The M-A should create a neutral screening environment. Both verbal and nonverbal communication should be judgement-free. Building authentic rapport allows the patient to be honest. The physician can assess associated health risks with the screening information. The M-A may be instructed to provide educational materials and resources to the patient.
Screenings can be specific to male and female needs. Mammograms screen for breast cancer. The Papanicolaou test, or pap test, screens for cervical cancer. Men are monitored for prostate cancer through blood testing and physical examination. Men and women may also be screened for sexually transmitted infections, or S-T-Is.
General screenings include those that may be performed regularly. The clinical medical assistant will collect information when measuring blood pressure, pulse, and respiration. Tests for diabetes and cholesterol are additional examples. Electrocardiograms, or E-C-Gs, screen for cardiac health or irregularities. Mental health screenings assess for depression, anxiety, and more.
Physicians may order an assessment at any age depending on individual patient needs. Some screenings are standard based on age. Colonoscopies screen for colorectal cancer. Cardiac stress tests evaluate heart health during physical exertion. Bone density scans are usually performed in elder years when risk of osteoporosis is more prevalent.
Screening information is collected using a variety of approaches. Interview-style questions are one way to gather information. A patient may also be given a pre-printed form with assessment questions to answer, which will be evaluated by the physician. Procedures like a capillary stick for blood glucose measurements provide in-office readings. Blood tests for a sexually transmitted infection, or S-T-Is, are drawn in physician office laboratories, or P-O-L, and at off-site lab facilities. Screenings like a colonoscopy or mammogram are performed as outpatient procedures.
Clinical medical assistants are involved in a variety of wellness screenings. Substance use screenings consider social habits. The M-A may ask questions related to tobacco or nicotine use. They may inquire about alcohol or drug use as well.
Telehealth screenings provide self-reported information. Physical and mental health status, as well as psychosocial risks or behaviors, may be discussed. Patients may self-report activities of daily living, or A-D-L. Family history and current medication may be reviewed. Physicians use this information to make recommendations, diagnoses, prescribe medications, and order testing. The patient may be asked to schedule a follow-up appointment.
Physical Exam Assisting
Goal: To aid the provider in the examination of a patient by preparing the patient and the necessary equipment and ensuring the patient's safety and comfort during the examination.
- Patient's record
- Stethoscope
- Gauze sponges
- Ophthalmoscope
- Pen light
- Scale with height measurement bar
- Tuning fork
- Tongue depressor
- Biohazard container
- Cotton balls
- Examination light
- Laboratory request forms
- Percussion hammer
- Specimen bottles and laboratory requisitions
- Lubricating gel
- Disposable gloves
- Patient gown
- Sphygmomanometer
- Drapes
- Otoscope with disposable speculum
- Thermometer
- Cotton-tipped applicators
- Tape measure
- Fecal occult blood test supplies
- Disinfectant wipes
- Table paper
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Check the examination room at the beginning of each day and between patients to make sure it is completely stocked with equipment and supplies and that the equipment functions properly.Purpose
The room must be ready for patient services.
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Check expiration dates on all packages and supplies regularly and discard expired materials.Purpose
To ensure the patient's safety.
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Prepare the examining room before and between patients according to acceptable medical rules of asepsis.Purpose
The room must be aseptically clean to prevent the spread of infection.
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Sanitize your hands.Purpose
To ensure infection control.
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Locate the instruments for the procedure. Set them out in order of use within reach of the provider and cover them until the provider enters the examination room.Purpose
To promote time management and ensure that all needed equipment and supplies are ready.
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Greet and identify the patient, introduce yourself, and determine whether the patient understands the procedure. If the patient does not, explain what to expect. Refer any unanswered questions to the provider.Purpose
To promote the patient's understanding and cooperation during the examination.
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Review the medical history with the patient and investigate the purpose of the visit. Review current medications, and document any changes or prescription refills needed. Document the interview results.Purpose
To verify that all information is current and complete.
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Measure and record the patient's vital signs, height, weight, and body mass index (BMI).
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Instruct the patient on how to collect a urine specimen, if ordered, and hand the patient a properly labeled specimen container. Obtain blood samples for any tests ordered.Purpose
To gather data needed before the examination begins.
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Hand the patient a gown and drape. Explain what clothes should be removed for the examination and whether the gown should open in the front or the back. Help the patient with undressing as needed (most patients prefer to undress in privacy). Knock on the door before re-entering the room to protect the patient's privacy.Purpose
To assist the patient in preparing for the examination and to safeguard the patient's privacy, comfort, and safety.
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Assist the patient as needed in sitting at the foot of the examination table; place the drape over the patient's lap and legs. If the patient is elderly, confused, or feeling faint or dizzy, do not leave him or her alone.Purpose
To provide for the patient's warmth and privacy and to prevent a fall or injury.
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Place the patient's paper health record in the designated area or make sure the computer is ready for the provider to log in and access the patient's electronic health record (EHR). Be careful to safeguard patient confidentiality during this step of the procedure.
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Assist during the examination by handing the provider instruments as needed and by positioning and draping the patient.
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When the provider has completed the examination, allow the patient to rest for a moment, then help the patient from the table. Assist with dressing, if necessary. Use proper body mechanics if assistance in transfer is needed.Purpose
To ensure the patient's stability and safety and to protect yourself from injury.
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Return to the patient and ask whether he or she has any questions. Give the patient any final instructions, and schedule tests as ordered by the provider and/or the next appointment.Purpose
To clarify instructions, eliminate any misunderstandings, and allow the patient to discuss any concerns.
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If the patient's misunderstandings or concerns are beyond your scope of experience or skill, arrange for the provider to speak with the patient again.
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Put on gloves and dispose of used supplies and linens in designated biohazard waste containers. Dispose of exam table paper. Use disinfectant wipes to clean the examination table and any other potentially contaminated surface. Disinfect all equipment.Purpose
To prevent cross-contamination with any potential infectious materials.
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Remove the gloves, discard them in the biohazard waste container, and sanitize your hands.Purpose
To ensure infection control.
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Cover the exam table with fresh paper, replace used supplies, and prepare the room for the next patient.Purpose
Medical exam preparation.
Knowledge-check items
Click an answer to lock it in — you'll see the rationale below. Reset any time to re-attempt. Items originally formatted as true/false, fill-in-blank, or drag-and-drop have been normalized to multiple choice; the source format is noted in the eyebrow.
L06-01 · Wellness Assessments
"Wellness assessments are tools to evaluate factors related to the patient's overall health status."
Wellness assessments are the specific type of screening tool used to evaluate the patient's overall health status, identify health risks, and allow physicians to make preventive recommendations.
"Telehealth screenings obtain self-reported information. The medical assistant asks a patient interview-style questions and reports back to the physician."
Telehealth is the other primary method through which clinical medical assistants conduct screenings in addition to in-office screenings.
"The clinical medical assistant should provide judgement-free verbal and nonverbal communication. Building authentic rapport frees the patient to be honest."
A judgment-free environment is essential to building authentic rapport and allowing patients to provide honest responses during screenings.
"Colonoscopies screen for colorectal cancer."
Colonoscopies are the standard outpatient procedure performed to screen for colorectal cancer.
"Bone density scans are usually performed in elder years when risk of osteoporosis is more prevalent."
Bone density scans are the specific screening used to assess the risk of osteoporosis, particularly in elder patients.
L06-02 · Physical Exam Assisting
"Check the examination room at the beginning of each day and between patients to make sure it is completely stocked with equipment and supplies and that the equipment functions properly."
The exam room must be checked both at the beginning of each day and between patients to ensure readiness and proper stocking for the next patient.
"Assist during the examination by handing the provider instruments as needed and by positioning and draping the patient."
The clinical medical assistant has multiple responsibilities including obtaining vital signs, preparing the patient record, cleaning the exam room, and assisting during the examination.
"Help the patient with undressing as needed (most patients prefer to undress in privacy). Knock on the door before re-entering the room to protect the patient's privacy."
Knocking before re-entering protects the patient's privacy and dignity while undressing and preparing for the examination.
"Put on gloves and dispose of used supplies and linens in designated biohazard waste containers. Dispose of exam table paper. Use disinfectant wipes to clean the examination table and any other potentially contaminated surface."
Gloves must be worn when disinfecting the examination room and handling potentially contaminated surfaces to prevent cross-contamination and ensure infection control.