Medical Assistant Exam: Clinical Procedures - Physical Examinations

The physical examination provides much information about a patient’s health status. A medical assistant will be called upon to assist the physician or other healthcare providers during the examination. Knowing the basic components of the examination is important for deciding what equipment and supplies should be on hand, what position the patient should be in, and how the patient should be draped.

Techniques Used in a Physical Examination
The following describes the techniques used in an examination.
Inspection involves gathering information about the patient through observation. The physician will look at the patient’s general appearance and behaviors, including how the patient walks, talks, and makes eye contact.

Palpation involves the examination of the patient’s external body through touch with the hands and pads of the fingers. Palpation can include:
- skin, revealing information about temperature, moisture, and texture
- organs, feeling the size, shape, symmetry, and firmness of organs and to detect the presence of masses

Percussion involves tapping on body structures with the fingers or a small hammer to note the sound. The nature of the sound reveals information about the structures beneath. For example, the abdomen will usually have a more high-pitched, vibrating sound caused by greater air content; the area over the liver usually sounds duller because of its denser, vascular structure.
- Direct percussion involves tapping directly on the patient’s skin.
- Indirect percussion involves laying the nondominant hand or finger on the patient’s skin and then tapping it with the fingers on the dominant hand.

Auscultation involves listening to the sounds of the body with a stethoscope (see 'Stethoscope'). Sites and uses of auscultation are:
- lungs, to determine whether they sound clear or have abnormal sounds caused by narrowed airways or the presence of fluid
- abdomen, to assess bowel sounds. Normal sounds include stomach gurgling caused by intestinal peristalsis, the progressive, wavelike involuntary movement that propels the contents forward.
- vascular system (blood vessels), noting the rhythm as well as the presence of abnormal sounds, such as murmurs

Mensuration involves various body measurements, such as:
- height or length
- circumference of the head, chest, abdomen, and sometimes other extremities
- joint motion, to determine the degree of flexion and extension

Manipulation uses hands-on techniques to assess joint symmetry and to note passive range of motion, which is the distance and direction a joint can move to its full potential. It may also be used to employ therapeutic force to increase joint mobility and realign dislocated joints.
The medical assistant’s presence may not be required for every examination or treatment. However, in cases where the physician and patient are the opposite gender—especially when the procedure involves areas of the body usually considered private—the medical assistant should remain in the same room.

Components of the Physical Examination
The standard physical examination is organized according to body system and, to some extent, follows a head-to-toe order. However, the physician may vary the examination depending on many factors, including the patient’s age, primary complaint, and purpose for the visit.

The physical examination generally includes the following components in this order:
- general appearance
- skin
- arms and hands
- head and neck
- eyes
- ears
- nose
- mouth and pharynx
- chest and lungs
- cardiovascular function
- breasts
- abdomen
- genitalia and rectum
- legs and feet
- mental status

The physician will examine each component for normal and abnormal findings.

Body Positions
The medical assistant helps during the examination by instructing and assisting the patient in assuming various positions. The purpose of each position is to allow the physician better access to and visibility of the body part being examined. To help promote patient privacy and comfort, the medical assistant should provide careful draping.

Sitting Position
The sitting position is commonly used for examination of the upper body, including the head, eyes, ears, nose, throat, neck, chest, lungs, arms, and hands.
Common uses: Upper respiratory symptoms (such as sore throat, sinus pressure, cough, and earache) and painful or inflamed joints of the arms, hands, and fingers.

Supine Position
Also called the horizontal recumbent, the supine position is commonly used for examination of the breasts, anterior chest, heart, abdomen, and lower extremities. This is a position in which the patient is laying flat, face-up toward the ceiling.
Common uses: Breast cancer screening, heart problems, pain in the abdomen, lower leg, or foot.

Dorsal Recumbent
The dorsal recumbent position is sometimes used for rectal and vaginal examinations, particularly if the patient cannot tolerate lying on her back with her feet in stirrups. In the dorsal recumbent position, the patient is lying flat or nearly flat with legs apart, knees bent, and feet near the side edges of the examination table. It may also be used for patients with back or abdominal pain, because bending the knees relieves stress on the lower back and facilitates relaxation of abdominal muscles.
Common uses: Routine examinations and for those with vaginal or rectal pain, burning, or unusual discharge; also useful for those complaining of abdominal, pelvic, or back pain.

Lateral, or Sims, Position
In the lateral position, also called the Sims or side-lying position, the patient lies on his or her side with the upper arm forward on the table, lower arm behind, lower leg flexed slightly, and upper leg flexed deeply with his knee resting in front on the examining table.
Common uses: Anal and rectal examinations, some vaginal examinations, and such procedures as administering rectal suppositories and enemas; facilitates a better view of the patient’s urethral opening.

Fowler Position
The Fowler position is similar to the upright sitting position, except that the head of the examination table is elevated as close to 90° as possible to provide support for the patient to lean against it and to allow the legs to rest outstretched on the examination table. It is used for the same reasons as the sitting position and is particularly useful for patients who are feeling short of breath, because the upright position facilitates maximal lung expansion.
Common uses: Similar to the sitting positions; also for patients who are short of breath, as the upright position helps the patient expand his or her lungs to the maximum.

Semi-Fowler Position
The semi-Fowler position is similar to the Fowler position with the head of the examination table at only 45°. The patient reclines with legs outstretched on the examination table.
Common uses: Many purposes, including to examine the chest and heart; provides comfort for patients who need extra rest and relaxation.

Lithotomy Position
The lithotomy position is used for vaginal examinations and particularly useful when a speculum is required to examine the cervix and collect a specimen for a Papanicolaou (Pap) smear. In this position, the patient reclines face-up, with legs apart and feet placed in stirrups.
Common uses: Routine vaginal exams, the collection of cervical tissue sample for Papanicolaou (Pap) smears, for women who have complaints of pelvic pain or unusual vaginal pain, burning, or discharge.

Trendelenburg Position
In the Trendelenburg position, the patient lies with his or her head approximately 30° lower than his or her outstretched legs and feet. Many patients do not tolerate this position well or for long because it makes breathing more difficult. Therefore, the medical assistant should consult with the physician before assisting a patient into this position.
Common uses: Not typically used in the medical office; helpful for patients in shock or with extremely low blood pressure; also for abdominal surgery because gravitational force causes abdominal contents to shift toward the chest.

Knee-Chest Position
In the knee-chest position, the patient sits on his or her knees with the chest and face resting forward on a pillow, arms lying to either side of the head, and buttocks in the air. This position may be awkward, embarrassing, and difficult for many patients to assume. Therefore, the medical assistant must help the patient with positioning and remain with him or her for the entire time to provide stability and emotional support.
Common uses: For rectal and sigmoid colon examinations and, rarely, for vaginal examinations.

Instruments and Supplies Needed During the Physical Exam
The medical assistant helps with the examination process by keeping the examination room clean, disinfected, and restocked as needed between patients. The medical assistant should check the schedule ahead of time and note the purpose of each patient’s visit in order to anticipate the equipment and supplies that will most likely be needed, to prepare the patient for examination, and to assist the physician as needed. Having all items ready and close at hand saves time and earns the respect and appreciation of the physician and patient. The patient will also appreciate attention paid to his or her comfort and privacy needs.

Instruments used in the physical examination assist the physician to see, hear, or feel areas of the body. The instruments, supplies, and equipment are kept in a convenient location in each examination room. Supplies include a tape measure, gloves, tongue depressors, and cotton-tipped applicators. Instruments include the following:
- Laryngeal and pharyngeal mirrors are stainless steel instruments with long, slender handles and small, round mirrors. They are used to examine the pharynx and larynx.
- Nasal speculum is a stainless steel instrument that is inserted into the nostril to help in the visual inspection of the nasal lining, membranes, and septum. The tip of the instrument is inserted into the nose, and the handles are squeezed, which opens the end and allows for maximum inspection inside the nostril.
- An otoscope is used to visualize the ear canal and the tympanic membrane, i.e., the eardrum. Refer back to the information on otoscope.
- The tuning fork is used to test for hearing. It is a stainless steel instrument with a handle at one end and two prongs at the other end. The examiner strikes the prongs against his or her hand, causing them to vibrate and produce a humming sound. When the tuning fork is vibrating, the handle is placed against a bony area of the skull near one of the ears to test for hearing.
- An audioscope is also used to test hearing, specifically to screen patients for hearing loss. It is composed of a range of indicators and selection buttons, which are used to adjust the tones. The examiner places the tip of the instrument into the patient’s ear, produces various tones, and asks the patient to respond to questions about each of the tones.
- An ophthalmoscope is used to examine the interior components of the eye. Refer back to information on the ophthalmoscope.
- A penlight or flashlight provides additional light to a specific area during the examination. The penlight or flashlight is used to examine the pupils and provide additional light for examination of the throat or other body parts.
- A reflex hammer or percussion hammer is used to test neurologic reflexes. It has a stainless steel handle and a hard rubber head. The head is used to test the reflexes by striking the tendons of the ankle, knee, wrist, and elbow. The tip of the handle may be used to stroke the sole of the foot to assess the Babinski reflex (a reflex noted by extension of the great toe and abduction of the other toes).
- A stethoscope has a bell or diaphragm at one end that is placed on the patient’s body. Refer back to the information on the stethoscope.
- A vaginal speculum is inserted into the vagina to expand the opening to visually examine internal female reproductive structures and to collect samples of cells for Pap smears or discharge for diagnostic testing. To obtain the cervical cells, a spatula, cervical scraper, or histobrush is used.

The medical assistant must also keep the following smaller supplies stocked:
- alcohol pads, used to clean the skin prior to an injection or to clean medical equipment between patients
- gauze pads, used to dress a wound, stop bleeding, or apply medication
- cotton-tipped applicators, used to apply mediation or collect a specimen
- lubricant, used to reduce anticipated discomfort from rectal examinations
- tongue depressor, used to depress the tongue for easier examination of the throat

The following safety and hygiene supplies should also be monitored and maintained:
- antibacterial soap or cleanser
- paper towels
- examination gloves
- biohazard waste containers
- sharps containers
- gowns
- masks

The patient who must wait for a few minutes will also appreciate the medical assistant who provides reading material. Such material should include educational pamphlets as well as an assortment of current magazines.

Physical Therapy Modalities
Physical therapy modalities, or treatment methods, are often used in orthopedic, chiropractic, and physical therapy offices to treat orthopedic conditions.

Cold Application
The application of moderate cold to a localized area constricts blood vessels as the body attempts to prevent heat loss. This constriction leads to decreased blood supply to the area. The application of moderate cold for a short time is used to prevent edema, or swelling. Through the constriction of peripheral blood vessels, bleeding can be controlled. Cold also slows the movement of blood and tissue fluids in the affected area, resulting in less pressure against pain receptors and, therefore, less pain. In the early stages of an infection, the local application of cold inhibits the activity of microorganisms. In this way, suppuration, or discharge, is decreased and inflammation is reduced.
Cold application should always be placed in a protective covering, because applying cold directly to the skin could result in skin burn. The cold application should be administered in cycles limited to 20 minutes on and 20 minutes off.
Common uses: Immediately after direct trauma such as a bruise, minor burn, sprain, strain, joint injury, or fracture.

Heat Application
The application of moderate heat to a localized area of the body for a short period of time (15 to 20 minutes) produces dilation, or an increase in diameter, of the superficial blood vessels in the area as the body tries to rid itself of excess heat. This results in an increased blood supply to the area, accompanied by erythema, a reddening of the skin, along with an increase in tissue metabolism. Nutrients and oxygen are provided to the cells at a faster rate; wastes and toxins are carried away faster.
Heat promotes muscle relaxation and is often used for the relief of pain caused by excessive contraction of muscle fibers. Heat modalities can be either wet or dry. Edema, or swelling, in the tissue can be reduced through the application of heat because the increased blood supply functions to increase the absorption of fluid from the tissues through the lymphatic system.
Common uses: Reducing muscle spasms.

Ultrasound
An ultrasound is a treatment modality using high or low frequency sound waves transmitted to surrounding tissue. The sound waves penetrate the muscles to cause deep tissue or muscle warming and are used to treat muscle tightness and spasms. The warming effect also causes vasodilation (an increase in diameter of a blood vessel) and increased circulation to the area to assist in healing.
Common uses: Treatment of sprains, strains, and other acute ailments.

Transcutaneous Electrical Nerve Stimulation
Transcutaneous electrical nerve stimulation (TENS) is a machine that uses electricity, with electrodes applied to the affected area. The electrical signal disrupts the pain signal being sent from the affected area so that the patient experiences less pain.
TENS uses an electrical current to cause a single muscle or a group of muscles to contract. By placing the electrical current on the appropriate muscle fibers, the medical assistant can force a gentle muscle contraction, allowing the muscle to increase in strength. The contraction of the muscle also promotes blood supply, causing increased healing.
Common uses: Treatment of a pulled back muscle.

Paraffin Bath
A paraffin bath is useful in treating chronic joint inflammation. A mixture of seven parts paraffin and one part mineral oil is heated to approximately 125°F (52°C). The body part is placed in the paraffin and then removed, leaving a thin coating of paraffin on the skin. This is repeated several times until the body part is coated. It is then wrapped in plastic and a towel to allow the heat to penetrate into the tissue. The paraffin is kept on for 30 minutes before being peeled off.
Common uses: Reduction of pain, muscle spasms, and stiffness in patients with arthritis.

Patient Education
Patient education is performed under the direction of the physician. The amount and types of education the medical assistant will be expected to provide will vary. To educate patients, the medical assistant will need to help them accept their illness, involve them in the process of gaining knowledge, and provide positive reinforcement.
Changes in the nature of medical care are increasing the importance of patient education. More than ever before, patient education is now being conducted in office-based medical practices.

Health Maintenance and Disease Prevention
The roles a medical assistant takes in patient education include:
- giving all patients information about healthy habits and encouraging them to make lifestyle choices that will improve their general health
- providing information or answering questions about procedures, diagnostic tests, and follow-up care for acute illness or injury
- providing intensive one-on-one education for self-care and self-management of chronic illnesses such as asthma, diabetes, or hypertension

New information can be presented to patients in a range of ways: discussion and talk, information sheets and pamphlets, videos and websites, and so on. Therefore, the medical assistant should help the medical practice be prepared to provide instruction to patients in ways that are most useful to the individual patient. Preparing lists of approved websites or maintaining a file of approved information sheets on various conditions and treatments, for instance, will help the medical facility fulfill its role in educating patients about their health.

Preparation for Procedures
Before a diagnostic procedure, the patient must be instructed as to what the procedure is, where it will be performed, how long it will take, how to prepare for the test, and what will happen after the test. The medical assistant needs to become familiar with preparation for frequently ordered tests, but should check with the testing facility if he or she is unsure about that facility’s particular preparation protocols.
- Preparation for X-rays often requires dietary or bowel preparation, especially when they involve the gastrointestinal or urinary tract. The patient needs to understand what diet to follow and how to prepare the bowel, including what supplies are needed and where to purchase them.
- Preparation for blood tests may require that the patient fast. For example, a lipid profile usually requires an 18-hour-long fast, and an overnight fast is standard for a fasting blood sugar test. Other blood tests are repeated at regular intervals; for example, a prothrombin time is repeated monthly for patients taking the anticoagulant warfarin.
- Instructions for imaging tests vary. For a pelvic ultrasound, the bladder needs to be full. For an MRI (magnetic resonance imaging) or mammogram, the patient needs to be reminded not to wear any metal products. For mammograms, the woman should not use any antiperspirant on the underarm or under her breasts.
- Some tests require that the patient stop any medications or avoid certain foods in the days before the test, and patients need specific instructions when these tests are scheduled.

Patient Administered Medications
Although the doctor or other primary care provider instructs the patient about medications, the medical assistant may need to reinforce these instructions, such as:
- continuing to take the entire prescription even after feeling better, as is the case with antibiotics
- taking the presciption with food, as is the case with some antibiotics and most nonsteroidal anti-inflammatory drugs (NSAIDs)
- eating foods high in potassium, as is necessary when taking diuretics

Some medical offices and other facilities have instruction sheets for their medical assistants to use with specific medications. These sheets, prepared by a licensed healthcare professional, include specific points for instruction, including the patient’s understanding of the medication’s proper use, the medication’s actions, coping with the side effects, adverse reactions to report to the office, and how to assure understanding of following up lab work that may be necessary.
Pharmacies also often give instruction sheets to patients when a prescription is filled. The medial assistant should encourage patients to read these instruction sheets.

Patient History and Interview
The medical history includes all of the information a patient can give about previous healthcare, medical problems and potential medical problems, and previous and current treatment. This history becomes part of the patient’s medical record.
This information is necessary for the physician to evaluate the patient’s current condition and determine how to treat him or her.

Personal Data
Every patient fills out a patient information sheet at the first visit, with demographic, billing, insurance, and health information.
The demographic information includes name, address, telephone number, Social Security number, marital status, sex, age, date of birth, employer, employer address and phone number, and emergency contact information.

Chief Complaint
The chief complaint is the main problem that brought a patient to the medical office. If the patient has come for a routine physical examination, there may be no chief complaint. Important information to be recorded about the patient’s chief complaint include:
- Symptom: A change in the body that indicates altered function or disease and that the patient experiences through his or her senses or sensation. These changes are called subjective complaints, because they cannot be measured or validated.
- Sign: A change that can be observed and measured, such as weight gain. These changes are called objective complaints, which means they can be observed and measured.

Additional information to describe the chief complaint include:
- location: where the symptoms are located
- quality: how one would characterize the symptoms
- severity: quantitative aspects of the illness, that is, intense, moderate or mild pain
- chronology: when the illness began and how long it lasted
- source: what the patient was doing when the complaint began or was first noticed
- what makes it better or worse: what the patient has done to relieve symptoms or make them worse
- associated symptoms: what other symptoms the patient is having

Past, Present, Family, and Social History
A new patient will fill out a questionnaire about his or her past medical history, or the medical assistant will fill out the questionnaire by asking the patient questions regarding his or her medical history. There are three elements of past health history:
- family history: taken to understand the general health of family members and the diseases that run in families
- previous hospitalizations, surgeries, and injuries: including the date and reason for hospitalization or the date and type of injury; for women, also include hospitalization for childbirth and type of delivery
- illness or medical problems: should be as complete as possible, because something overlooked by the patient may be important in a current or future diagnosis

The present history includes:
- ongoing medical problems: should be as complete as possible
- current medications: including over-the-counter as well as physician-prescribed medications
- allergies: including all allergies, such as medication, food, materials (such as latex), and so on
- social history: including appetite, sleeping, diet, exercise, caffeine, smoking, alcohol, street drugs, and occupational history
If the patient fills out a questionnaire, the medical assistant will review the questionnaire with the patient and fill in any missing sections or clarify answers.

Review of Systems
A review of systems (ROS) is a systematic review of each body system to detect any symptoms that have not yet been revealed. The physician completes the review of symptoms by asking a series of questions related to each body system; the result is a preliminary assessment of the type and extent of physical examination required. The review of systems includes:
- head and neck
- eyes
- ears
- mouth
- nose and throat
- respiratory
- cardiovascular
- digestive
- urinary
- male genitals
- female genitals
- obstetric history
- musculoskeletal
- skin
- neurological