Medical Assistant Exam: Clinical Procedures - Preparing the Patient and Assisting the Physician

Vital Signs
Taking a patient’s vital signs is one of the most important tasks a medical assistant will perform in the course of the day. These measurements provide valuable information about a patient’s health status.

Vital signs, sometimes called cardinal signs, include:
- temperature (T)
- pulse (P)
- respiration (R)
- blood pressure (BP)

Vital signs measurements fall within certain average ranges (called normal values) when a person is in good health. Measurements recorded at a person’s first visit provide a baseline for comparing measurements taken during subsequent visits. A baseline is a known, or initial, value to which later measurements can be compared.
Height and weight are also important for accurate diagnosis. Weight fluctuations can be a sign of disease, and the height-to-weight ratio gives information about a person’s nutritional status.

Exam Room Prep
Preparing and maintaining the treatment area provides a comfortable and healthy environment for the patient. To prepare the examination rooms, use the following guidelines:

1. Clean and disinfect exam tables, countertops, and faucets daily.

2. Change the exam table paper after each patient by unrolling a fresh length of paper.

3. Check the supply of gowns and drapes.

4. Remove dust and dirt from furniture and towel dispenser.

5. Replace biohazard containers as needed.

6. Empty waste containers frequently.

7. Check the exam room frequently to ensure that there are ample supplies and that equipment is properly cleaned.

8. Verify that each piece of equipment is in proper working order.

Temperature
A number of physiologic factors can affect temperature. Body temperature increases temporarily in response to infection, dehydration, hormonal fluctuations, and exposure to a warm environment. Normal body temperature—between 96° F and 99.5°F (36.4°C to 37.3°C)—varies with certain factors:
- time of day
- site of measurement
- gender
- temperature of the surrounding environment
- elderly persons may have an average temperature as low as 96.8°F
- diurnal rhythm, which causes body temperature to be lower in the morning and higher in the late afternoon

The body creates heat energy as a byproduct of metabolism and exercise. Three main factors affect the production and conservation of heat:
- Metabolism: Chemical processes in the body, such as digestion, respiration, and ovulation, produce heat.
- Muscle movement: Action of the muscles produces energy, which in turn creates heat; muscle activity can be both voluntary—as in exercise—and involuntary—such as shivering.
- Constriction of superficial blood vessels: Superficial blood vessels run close to the body’s surface; their constriction helps to keep the body’s internal heat constant.
The body loses heat in three ways: perspiration, elimination, and the dilation of the superficial blood vessels. Nearly 85% of the body’s heat is lost through the skin as a result of perspiration. The rest is lost through the lungs and the excretions of bowel and bladder.

Taking a Patient’s Temperature
Temperatures can be measured at different sites in the body:
- Oral temperatures are measured by placing the thermometer under the tongue. The patient should hold the thermometer with lips closed.
- Tympanic temperatures are measured by pulling the ear up and back for adults, and down and back for children, to straighten the ear canal. Press the button, and the results will be displayed.
- Rectal temperatures are measured by positioning the patient on his or her side. The left side is the preferred position because the rectum is angled in this direction. The rectal temperature is usually 1° higher than those taken through other routes because of the highly vascular, closed cavity of the rectum.
- Axillary temperatures are measured by placing the tip of the thermometer in the middle of the axilla. The patient’s upper arm should be crossed over the stomach to hold the thermometer in place. Axillary temperatures are usually 1° lower than those taken through other routes because this area is not a closed cavity.

Electronic and disposable are the two types of thermometers most commonly in use in medical facilities.
- Electronic, or digital, thermometers are battery operated and portable and can obtain a temperature in one minute or less. A disposable cover fits over the probe for sanitary use. A digital thermometer can be used orally (in the mouth), axillarily (under the arm), or rectally (in the rectum).
- Disposable thermometers are single-use thermometers, usually made of thin strips of plastic with specially threaded dot or strip indicators. The indicators change color according to the temperature. This type is used for oral, axillary, or skin temperatures.

Abnormal Temperature Fluctuations
In the response to infection or injury, the hypothalamus may raise the body’s core temperature. An individual who has a fever is said to be febrile or pyrexic. One who does not have a fever is afebrile. Shivering or chills produce heat, which is retained by the constriction of surface blood vessels, causing a higher temperature.
The higher temperature is believed to improve the body’s ability to fight off infection, but temperatures above 101°F to 102°F (39.3°C to 39.9°C) are usually treated.

Hyperpyrexia. 
A fever higher than 105°F, hyperpyrexia is a serious condition that may cause convulsions, brain damage, and even death. Hyperpyrexia or hyperthermia (excessive body heat) may occur in infants and young children with a fever because of infection or in people of any age who exercise vigorously in hot, humid weather, especially if they do not replace the fluids lost by sweating. The skin may be hot, flushed, and dry, the pulse rapid, and the person may experience a headache, dizziness, confusion, and visual disturbances.
Fevers can be characterized according to their duration and timing:

- A continuous fever stays at about the same elevation all the time or returns to the same level about four hours after being treated with medication.
- An intermittent fever rises (spikes) and returns to normal in a regular pattern.
- A remittent fever rises and falls, but always remains above normal.
- A relapsing fever appears to go away and then returns. This may happen once or several times.

Hypothermia.

A lowering of the core body temperature below 95°F (35°C), hypothermia is usually the result of long exposure to cold temperatures and occurs more quickly when a person is wearing wet clothing.
Early signs and symptoms of hypothermia include shivering, blue skin, mental confusion, numbness, and slurred speech.

Pulse
A pulse is the beat of the heart represented through the pulsating flow of blood through superficial arteries, that is, arteries close to the skin. The pulse rate, a calculation of the number of heartbeats in a set period of time, usually a minute, measures the two-phase action of the heart:
- Contraction: The heart contracts, pushing the blood through the arteries; this outward action is felt as outward pressure on the arteries.
- Relaxation: The heart momentarily rests, causing the artery walls to resume their original state.

The pulse is palpable, or able to be felt, in sites on the body where arteries can be compressed against bone. The most common methods for obtaining a pulse rate are:
- radial pulse: the most common site, located on the inside of the wrist, on the thumb side, about one inch from the thumb’s base
- carotid pulse: commonly used in emergencies, located on the throat, in the grooves between the larynx (Adam’s apple) and the long muscle on the front side of the neck (called the sternocleidomastoid muscle)
- brachial pulse: used typically for blood pressure measurement, located inside the elbow (a location called the antecubital space)

Other, less common methods for measuring the pulse rate are:
- temporal pulse: located at the temple, on the side of the head, in front of the ear
- femoral pulse: located in the groin; used to monitor circulation in the leg
- popliteal pulse: located at the back of the knee; also used to monitor circulation in the leg
- dorsalis pedis pulse: located on the top of the foot, between the first and second metatarsal; used to gauge lower limb circulation.
- apical pulse: located at the apex of the heart; used on cardiac patients; requires a stethoscope.

Respirations
Respiration involves the movement of air into and out of the lungs so that gas exchange can occur in the alveoli, which are the tiny air sacs in the lungs. A cycle of action and reaction takes place during respiration:

1. The buildup of carbon dioxide causes the pH level in the blood to drop.

2. As the pH level decreases, a message is sent to the medulla oblongata in the brain, which then sends out a message to the body to increase the rate and depth of respiration.

3. As a result, more carbon dioxide is eliminated from the body.

4. Blood pH rises back to a more normal level.

5. When pH levels rise too high, messages to and from the medulla oblongata stimulate a decrease in the rate and depth of respiration.

6. This allows the body to retain more carbon dioxide, lowering the pH level to normal.

Inspiration and Expiration
Two actions make up the respiration cycle.
- Inspiration, or the act of breathing in, occurs when the diaphragm and other muscles contract, pulling the thorax upward and outward. At the same time, the lungs expand, causing the air to be pulled in through the mouth and nose.
- Expiration, or the act of breathing out, is usually passive. The diaphragm and other muscles simply relax, allowing the rib cage to return inward and downward as air is expelled from the lungs.

Measuring Respiration
Respirations can be measured simultaneously with the pulse measurement. The medical assistant should continue holding the patient’s wrist while observing the patient’s chest. This will prevent the patient from altering the respirations.
The respirations have three characteristics: rate, rhythm, and depth.
Rate: The rate is the number of respirations per minute. The normal respiration rate for adults is 12 to 20 breaths per minute.

- Bradypnea is the term used for abnormally slow breathing.
- Apnea is the term used for absence of breathing.
- Tachypnea is the term used to describe rapid breathing. Tachypnea may be caused by asthma or emphysema.

Rhythm: The rhythm of respirations is normally described as even and regular. Abnormal variations of rhythm occur with injury or disease. Dyspnea is a condition of rapid respirations, and the expiratory phase becomes prolonged because the patient has to work harder to breathe out. This may be caused by lung disease and asthma or chronic obstructive pulmonary disease (COPD).
Depth: The depth of respiration may be described as normal, deep, or shallow. Respirations depth may be altered because of injury or disease. Respirations become deeper with physical exertion and become more shallow at rest.

Blood Pressure
Blood pressure reflects the pressure exerted against the arterial walls by blood and is recorded as a fraction. It is measured with the use of a stethoscope and a sphygmomanometer, which consists of an inflatable cuff, an inflation bulb with a control valve, and a pressure gauge, with a needle pointing to a scale showing millimeters of mercury (mm Hg).
- Systolic pressure, the top number, indicates the highest pressure exerted against the arterial walls during ventricular contraction.
- Diastolic pressure, the lower number, represents the lowest pressure exerted against the arterial walls when the heart is at rest between contractions.
- The difference between the two is the pulse pressure.

The sounds heard during blood pressure measurement are Korotkoff sounds. The Korotkoff sounds have five distinct phases.
- Phase I begins with the first sound heard when deflating the cuff. It is a sharp tapping sound. Note this first sound, as this will be the systolic reading of the blood pressure.
- Phase II is the result of more blood passing through the vessels as the cuff is deflated. The sound is that of a soft swishing.
- Phase III occurs when blood continues to travel through the vessels as the cuff is deflated. A tapping rhythmic sound can be heard.
- Phase IV is when blood is passing through the vessels fairly easily as the cuff is deflated. The sounds heard will be muffling and fading of the tapping sounds.
- Phase V is when the blood is flowing freely and all sounds have disappeared. This disappearance of sounds is noted and recorded as the diastolic pressure.
The blood pressure is recorded on the patient chart in a fraction format. The position of the patient (sitting or lying down) and which arm was used should be documented.

Normal blood pressure values are:
- systolic: less than 120 (millimeters of mercury)
- diastolic: less than 80 (millimeters of mercury)

Blood Pressure Abnormalities
There are two possible blood pressure abnormalities: hypertension, blood pressure that is consistently above normal, and hypotension, blood pressure that is consistently below normal.
Hypertension: The most commonly seen form of hypertension is primary, or essential. This type of hypertension has no apparent cause or cure, but is treatable.
Secondary hypertension is the result of some underlying condition such as renal disease, pregnancy, endocrine imbalances, obesity, arteriosclerosis, or atherosclerosis. Once the underlying condition has been removed, the blood pressure returns to normal. Secondary hypertension can be treated.
Hypertension that progresses slowly is referred to as benign—that is, the development of the disease takes a long time to cause serious problems.
Malignant hypertension, on the other hand, follows a quick line of progression and will cause serious cardiovascular damage.

Hypotension: Hypotension is blood pressure persistently below normal, usually below 90/60. Hypotension is defined as a blood pressure so low that the patient is unable to function normally. It is usually a result of various conditions such as hemorrhage, traumatic or emotional shock, central nervous system disorders, or chronic wasting disease. With treatment for the underlying problems, the blood pressure usually will return to the range of normal readings.
Orthostatic, or postural, hypotension occurs in several circumstances:

- when a person rapidly changes position from supine to standing
- when standing in one position for too long
- as a side effect of certain medications

Orthostatic hypotension happens when the blood pressure has momentarily dropped; the person will feel dizzy and may have blurred vision. Care should be taken when helping patients change to an upright position, as orthostatic hypotension can lead to syncope, or fainting.

Weight and Height
Height and weight are also important tools for diagnosis and treatment of patients, as both—and changes in either—can indicate alterations in health status.

Measuring Weight
In most acute and long-term care settings patients are weighed in kilograms. In ambulatory care settings, such as medical offices, patients may be weighed in pounds or kilograms, depending on office policy. However, the trend is changing toward using metrics across the board. Therefore, medical assistants must become familiar with the metric system and learn the formulas required for conversion.
In many cases, the patient’s weight is measured with each office visit. Accuracy in measuring and recording a patient’s weight is very important, because medications and procedures are commonly based on a patient’s weight. Any significant weight change since the last visit should be brought to the physician’s attention because it may indicate a health problem. Special attention should be paid to specific types of patients:
- A child’s weight is plotted on a growth chart along with his or her height to determine whether growth patterns are normal.
- A pregnant woman’s weight is carefully noted on each visit as part of the data needed to monitor the pregnancy.
- A patient on a weight-loss program must also have his or her weight closely monitored to determine the effectiveness of the program.

Measuring Height
Methods for measuring height vary, depending on the age and size of the patient.
- Infants are measured during each visit so that their growth can be plotted on growth charts. They are measured lying down, and the measurement is recorded as length in centimeters.
- When the child reaches toddler age and is capable of standing, a standing measurement may be taken.

Adult height is typically measured in feet and inches and is done on the first visit and then only as needed—for example, when there is concern about osteoporosis, or degenerative changes of the vertebrae. A slight decrease in the height of an elderly patient is not unusual, but may indicate a problem.

Body Mass Index
Body mass index is another method used to interpret body weight. The BMI expresses the correlation of an individual’s weight to his or her height, providing an indication of the risk of developing chronic health conditions associated with obesity. Many healthcare providers believe that the BMI is a more accurate standard for interpreting body weight than height and weight tables.
The BMI can be calculated, but charts are available—and are standard 'equipment' in a medical office—that show the results of the calculations. The charts show height on one axis and weight on another axis; the numbers at the intersection of the appropriate height and weight measurement indicate the BMI.