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Medical Assisting

Medical Assisting. HCT I. Physical Exam. A complete PE consists of 3 parts: ·health history· physical exam of each body system· lab and diagnostic tests The MA assists the physician in all 3 aspects. *. Physical Exam Terms. acute illness- Rapid onset (cold, flu, sinus infection )

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Medical Assisting

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  1. Medical Assisting HCT I

  2. Physical Exam A complete PE consists of 3 parts: ·health history· physical exam of each body system· lab and diagnostic tests The MA assists the physician in all 3 aspects *

  3. Physical Exam Terms acute illness- Rapid onset (cold, flu, sinus infection) chronic illness- gradual onset, A disease or illness lasting more than 3 months therapeutic procedure- Done to treat the condition, eliminate or correct the cause. (promotes recovery) diagnostic procedure- Test done to find the cause of an illness. lab testing- analysis of the tests to determine a specific causative agent

  4. clinical diagnosis- Initial diagnosis based on the patient's signs and symptoms differential diagnosis - use labs and diagnostic tests to rule out a similar injury or illness. final diagnosis (the diagnosis) prognosis - outcome or course of a disease risk factor - physical behaviors that increase the risk of a disease.

  5. Preparation of Exam Room room should be well lit, free from clutter restock supplies daily keep trash cans empty; replace full biohazard containers room should be well-ventilated use air fresheners to eliminate odors keep room comfortable temp for pt. clean & disinfect exam table, counters and faucets qd change exam paper after each pt. prepare equipment, instruments & supplies; arrange in order for physician to use knowledgeable on operation/use of equipment

  6. PREPARATION OF THE PATIENT. • Escort pt to exam room • ID patient by name and birth date • Obtain VS, Ht & Wt (mensuration)and chart results in medical record • explain procedures in a friendly manner· • ask patient to void (if a urine spec is needed this is the time!) • Instructions on disrobing • maintain pt privacy • provide physician w/ pt's medical record (HIPPA) • assist pt w/positioning on exam table

  7. Positioning & Draping: provides visualization of body part being examined; draping provides modesty, comfort & warmth Sitting position - drape over pt thighs and knees Fowler's - semi = 45; full = 90 Supine (horizontal recumbent) - remember to pull out table extension; drape length-wise Prone - place in supine then assist them to roll onto stomach, hands at side or folded above head dorsal recumbent - have pt. bend knees & place each foot @ edge of table; drape diagonally Lithotomy - have pt. slide bottom to edge and rotate thighs out ward, feet in stirrup; diagonal drape Sim's - Right leg flexed sharply over slightly flexed left Knee-chest - Place supine, roll towards you into prone, have them bend arms @ elbow and elevate buttocks keeping back straight; diagonal drape

  8. Assessment Techniques: inspection palpation percussion auscultation

  9. Assisting the physician: • assisting with position changes& draping • handing instruments and supplies • reassure patient to decrease apprehension • review treatment plan, patient education, and instructions for a return visit –chart this in the medical record • escort patient to reception area

  10. Height and Weight • Measurements are a procedure common for different types of office visits / physical exams. • Special Points: • Conversions – kg to pounds, pounds to kg • Height vs. length, feet and inches. • Types of scales • Head Circumference • Abdominal Girth • Chest Circumference

  11. From To Multiply by Centimeters Inches 0.3937 Formula. lbs / 2.2 = kilograms. kg x 2.2 = pounds ...

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