Chest-to-rectum assessment and patient care
Chest
While the patient is still in the sitting position, the chest, heart, and lungs are examined. The chest is examined for symmetric expansion. A tape measure may be used, especially if variation exists between the upper and lower chest expansion. A patient with a history of emphysema may have a barrel-shaped chest. The provider may use percussion to determine the density of lung tissues.
Placing a stethoscope on the patient’s back, the examiner auscultates lung sounds. The patient is asked to take deep, regular breaths. This may produce slight dizziness, but the patient should be assured that it is only the result of the deep respirations and will rapidly pass. The provider notes the types of respirations and the presence of lung sounds in all lobes.
Because considerable concentration is required to interpret heart sounds, the provider must have complete silence when listening to the patient’s heart. In patients with heart disease, the provider may spend an extended time listening to heart sounds. If lung or heart abnormalities are found, the provider typically orders further diagnostic tests, including blood analysis, x-ray evaluation, and an ECG. Once the results of these studies have been analyzed, the provider may refer the patient to a cardiologist for treatment of a heart condition, or a pulmonologist or a respiratory care specialist for treatment of a breathing disorder.
Abdomen
Before the abdominal examination begins, the patient is asked to empty their bladder for comfort and to allow accurate palpation of the abdominal organs. For the abdominal part of the examination, the patient is lowered to the dorsal recumbent or supine position, and the drape is lowered to the pubic hairline. The gown is raised to just under the breasts. The patient’s arms may be placed at the side or the hands crossed over the chest or under the head. Relaxation of the abdominal muscles is needed for the abdominal examination. To assist in this goal and to promote patient comfort, a small pillow can be placed under the head and knees. The provider auscultates the abdomen in all quadrants before palpating or percussing it, because manipulating the abdomen can stimulate or alter bowel sounds and produce a false reading; this sequence confirms the presence of complete bowel sounds before the provider palpates the abdomen for any abnormalities. The provider also may use percussion to determine the density, position, and size of underlying abdominal organs.
Reflexes
The patient’s reflexes are checked with the patient sitting, in the Fowler position, or supine. While the patient is sitting, the biceps are checked with the patient’s arm flexed and supported by the examiner. The knee jerk (patellar reflex) and the ankle jerk (Achilles reflex) are checked using tapotement (a tapping or percussing movement) with either the fingers or the reflex hammer. The plantar reflexes (Babinski reflex and Chaddock reflex) are tested with the patient in an upright or a supine position.
Breasts and testicles
Careful breast examination is part of the physical examination for every female, even if she is asymptomatic. The breasts are examined by inspection and by palpation with the patient in the supine position. The arm on the side that is being examined is bent and tucked under the head. Breast cancer is the most common malignancy in women, and early detection is the key to successful treatment. This is a good opportunity to discuss and reinforce the consistent use of monthly breast self-examination (BSE). For male patients who have reached puberty or are 14 years of age or older, the provider performs a testicular examination. The testicular self-examination (TSE) is an important self-examination for all males to perform each month because testicular carcinoma is a major health risk that has a high cure rate if discovered early.
Rectum
The rectal examination usually follows the abdominal examination or may be part of the examination of the genitalia. Preserving the patient’s comfort and dignity is vital. For this part of the examination, the provider needs gloves and water-soluble lubricating jelly (e.g., K-Y Jelly). The examination light should be directed at the perineal area during the examination.
Fecal occult blood test (FOBT) specimens are often collected during the digital rectal examination. The guaiac FOBT is a CLIA-waived test, so a trained medical assistant may perform it under the provider’s direction - this is why the necessary collection folder must be included with the examination equipment. Patients diagnosed with gastrointestinal (GI) disorders may be referred to a gastroenterologist.
Patient coaching
The physical examination process is an excellent time for the medical assistant to assess the need for patient education. This assessment should be performed to identify the best ways to meet the patient’s needs. When identifying these needs, consider the following:
- The information the patient needs to know
- How to convey the information so that the patient understands it
- How the patient will use the information
- Whether any community resources are available that might help the patient understand and learn more about health problems or treatment protocols
Develop a plan to teach the patient. Think about the different modalities available, such as pamphlets, pictures, DVDs, demonstrations, websites, and community resources. Presenting information in an engaging format improves patient understanding and retention. Many facilities keep patient education files that contain handouts on a wide range of health issues. The medical assistant should always review teaching plans with the provider and follow the provider’s direction in patient education.
Legal and ethical issues
The medical history is a confidential record that can be shared only with healthcare personnel directly involved in the patient’s care. Data provided to you by the patient or that you read in the patient’s health record is confidential; you must not share any of this information with anyone. The consequences for disclosing private information to individuals not involved in the patient’s care can be very serious and can result in the loss of your job, court-imposed fines, and even imprisonment.
In addition to maintaining patient confidentiality, consistently implementing correct documentation procedures is crucial for medical practices. The medical record is considered a legal document, and court cases can be won or lost based on the clarity and completeness of staff documentation. It is essential that medical assistants document all patient information in a factual, nonjudgmental manner.
Patient-centered care
The ability to communicate effectively is crucial to the role of the professional medical assistant and allows for excellent customer service. Effective communication includes the use of all of the therapeutic tools discussed in this chapter. The professional medical assistant should do the following:
- Watch for nonverbal behaviors to verify congruence between what the patient states verbally and demonstrates via body language.
- Modify communication methods as needed to meet the needs of a diverse patient population.
- Use restatement, reflection, and clarification to gather pertinent and comprehensive patient information.
- Use electronic communication appropriately and effectively.