Charting: To maintain a medical record' All charting is done in black pen' Write clear and legible'

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Patient Examination By Dr. Jay Shahed
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Charting

• To maintain a medical record.
• All charting is done in black pen.
• Write clear and legible.
• Sign, initial and date.
• Documentation of patients words is to be between
  quotations.
• Never erase, it is illegal. Cross over word
  once.

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• Steps in Patient Examination

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Review of system

• The overall questions that are asked by the MA to
  the patients about any physical complaints from
  head to Toe.
• All information must be documented on the form.
• Example
• Q Do you or did you ever have a problem with
  your eye.
• A No

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Progress Notes

• Chief complaint
• What Signs and Symptoms brought in the patient to
  the office or clinic.
• Example The patient is complaining of pain in
  the RUQ , nausea,vomiting and diarrhea for the
  past week.

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• Vital Signs
• The MA tales the Vital Signs and document them
  under the C.C.
• Example
• Temperature ( T ) 98.6 F ( Fahrenheit )
• Pulse ( P ) 68 B/m ( Beats/minutes)
• Respiration ( R ) 16 b/m ( Breaths / Minute)
• Blood Pressure(BP) 120/80mm/Hg
  ( millimeter / Mercury LT.ARM.

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Blood Pressure
Systolic The pressure of the arteries when the
heart is pumping Diastolic The pressure in the
arteries when the heart is at rest.

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Physical Examination

• Physician will examine patient and document his
  or her information in the progress notes in the
  SOAP order
• SSubjective symptoms (what the patient feels)
• O Objectives signs (physical findings)
• A Assessment( Tests to confirm diagnosis e.g.
  lab work up, X- Rays)
• P plan treatment

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• Patient Examination Positions

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• Fowler
• sitting on examining table in an up right
  position
• Used in
• Normal physical exam
• COPD patient
• Breast exam

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• Supine
• lying face up (horizontal recumbent)
• Used in
• Surgeries
• Radiological positioning
• Abdominal chest exams

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• Prone
• lying on back face down
• Used in
• Back exam
• Radiological positioning

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• Sims
• lying face down on left side with right leg
  flexed and left arm behind body
• Usage in
• Spinal tap
• Pelvic exam on elder woman
• Perineal exam
• Rectal examination and scoping

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• Lithotomy
• legs on stirrups
• Usage
• Most frequently used in OB/Gyn clinics
• Pelvic exam

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• Dorsal Recumbent
• lying on back with both knees flexed with sole of
  feel on table.
• Relaxation of abdominal muscles.
• Usage
• Abdominal exam

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• Trendelenburg
• Supine tilted head down with elevation of
  legs.(head lower than heart)
• Usage
• When need to increase oxygen to head
• shock
• phlebotomy
• abdominal surgery

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• Jackknife
• Reclining position (supine) knees flexed up
• Usage
• Passing of urethral catheter
• Perineal exam

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• Knee Chest
• knees, chest and arms, face down touching table
• Usage
• Gynecological pectoral exam

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• Proctologic Exam
• Bending down on knees.
• Usage
• Anoscopy
• Rectoscopy
• Sigmoidoscopy
• Rectal exam
• Hemorrhoids exam

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Assisting In Physical Exam
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Methods of Examinations

• Types
• Inspection
• Palpation
• Percussion
• Mensuration
• Manipulation

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Inspection

• General Appearances
• Physicians visualization of the patients
  general health, appearance, posture and symmetry.

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Types

• Gait style of walking limping, walk on one
  foot etc.
• Ataxia
• Steppage
• Slapping
• Dragging
• Spastic
• Stature abnormal height - proportions e.g.
  gigantism, dwarfism

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• Posture
• Rigidity Vs. flexibility
• e.g. Torticollis
• Symmetry curvature of the spine
• e.g. kyphosis, scoliosis, lordosis

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• Body Movement
• Involuntary body movements
• e.g. ticks, tremors
• Speech
• Abnormal speech
• e.g.
• Aphonia no speaking, loss of voice ,slurred.
• Aphasia loss of power of expression through
  speech
• e.g.writing, signing. (brain injury).

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• Breath Odor
• Abnormal breath smell
• e.g.
• Fruity - diabetes
• Acetone - acidosis
• Ammonia - uremia

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• Nutrition
• Weight in relation to height and age
• Malnutrition
• Obesity
• Endogenous - endocrine
• Exogenous - food intake

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• Edema
• Pitting
• Non pitting
• Skin
• Color cyanosis, jaundice, pallor
• Texture dry Vs. soft
• Lesions scars, loss of pigmentation
• (vitiligo)

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• Nails
• Clubbed heart
• Spooned anemia
• Cracked decrease calcium

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• Hair
• Distribution
• boldness
• Fungal
• Genetic
• Increase in hair
• Endocrine
• Cushings
• Hirsitism

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Palpation

• Using tactile motion
• Physician Feels body parts looking for masses,
  skin temp, vibration, deformities,rigidity.
• Types
• Manual
• Bimanual

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Percussion

• Tapping motion with fingers
• Dullness
• Resonance
• Striking with hammer
• Knee joint

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Mensuration

• Measurements
• Fundal height
• Head circumference
• Wrist thickness
• Chest expansion
• Abdomen.

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Manipulation

• Range of motion
• Orthopedic exams.
• Neurological exams.

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• Specialty
• Exam

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Eye exam

• Ophthalmoscope
• To examine interior of eye
• Accommodation
• The adjustment of eye to variations in distances
• Visual acuity
• The extent of clearness and sharpness of vision
  (focusing in retina)
• Color vision
• Ability to see colors using the Rods and Cons of
  the eye ball.

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• corneal reflex
• Touch cornea cotton swap,blink
• Pupil reflex
• Pupil response to light
• Normal
• Constrict if flash light
• Dilate in dark

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Distance Visual Acuity

• Snellen Chart
• Alphabetical
• Elderliness
• Letter E
• Non English speaking patients
• Objects
• Children

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Procedure

• maximum light in room
• 20 feet away
• Standing or sitting
• Cover one eye with card at a time
• Start with right eye
• If the patient has glasses, test with glasses
  first then without.

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• Start with top letter then move down
• With E chart patient point 3 finger (up, down or
  side)
• M.A must stand next to chart

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Documentation and Interpretation

• 20/30 standard distance/ readable
  distance(unchangeable)
• OD Right eye
• OS Left eye
• OU Both eyes
• -1,-2 etc. the number of letters missed by the
  patient at the best read line.
• Example
• 20/40 OD -1

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Ishihara

• Color Acuity- 3 second to ID plate- 30 inches
  away- Both eyes opened - Ask to tell . Record
  answer.- Continue sequence and record ( x ) if
  can't tell or wrong answer.
• Example
• Plate 112
• Plate 28 X
• Record any unusual symptoms (rubbing eyes,
  squinting, ex. blinking tears).

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Eye Irrigation

• Purposes
• Relieve inflammation.
• Promote drainage.
• Dilute chemicals.
• Wash away foreign bodies.
• Sterile technique equipment.
• MA could do it.

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Procedure

• Solution warmed to 95 - 105 F or as prescribed
• Check what eye to do.
• Sitting or supine position.
• Turn head toward affected eye.
• Drape neck shoulder.
• Cross contamination of good eye.
• Start inner Canthas by the nose to outer Canthas.

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Eye Instillation

• Purpose
• Apply Medications.

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Procedure

• Sterile solution must be used in case of
  ulceration
• Sterile instruments- (spud).
• Use that medication on one Pt. only preserve
  for that Pt. only.
• Tilt head backward sitting or supine.
• Pull lower conjunctivas down with gauze.

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• Drop in center of Conjunctiva.
• Hold dropper parallel to eye 1/2 inch away.
• Never touch eye with dropper.
• Instruct PT. to close eye rotate eyeball.
• Dry excess drainage.

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Disorders

• Myopia Near sightedness
• Able to see close objects only.
• focusing object in front of retina
• Elongation of eye ball
• Able to see close only
• Hyperopia Far sightedness
• Able to see far objects only.
• Focusing object behind of renal
• Shortness of eyeball
• Able to see far away only

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• Presbyopia
• old age farsightedness
• Ptosis
• Eyelid drop
• Third cranial nerve damage
• Sty ( Hordelum)
• Eyelash infection
• Small pustule

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• Chalazion
• Fatty nodule in eyelid (not painful)
• Conjunctivitis
• Inflammation of the conjunctiva (pink eye)
• Glaucoma
• Increase ocular pressure
• Strabismus
• Crossed eyes

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• Exophthalmosis
• protrusion of eye (hyperthyroidism)

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Ear Examination

• Using the Otoscope.
• Check the auditory canal
• Normally contains small amount of wax (Cerumen).
• Cerumen protects the ear)
• Cotton tips can injure the canal and impair
  hearing.

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Irrigation

• Purpose
• Clean ear
• Treat the ear with medication using the flushing
  method.

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Procedure

• Use warm solution.
• Pull auricle upwards and back in children and
  adults.
• Pull auricle downwards and back in infants.
• Direct flow upward
• Dry with Q-tip
• Inspect with an Otoscope.

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• The
• SPIROMETER

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SPIROMETER

• An instrument that measures and records the
  volume of inhaled and exhaled air, used to assess
  pulmonary function.

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ABNORMAL READINGS

• Obstruction
• Example COPD
• a) mild
• b) moderate
• c) severe
• Restriction
• Example Pulmonary Fibrosis
• a) mild
• b) moderate
• c) severe

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RESPIRATORY AIR VOLUMES AND CAPACITIES

• Name
• Tidal volume (TV)
• Volume (Average)
• 500 ml
• Description
• Volume moved in or out of the lungs during a
  respiratory cycle

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• Name
• Inspiratory reserve volume (IRV)
• Volume (Average)
• 3,000 ml
• Description
• Volume that can be inhaled during forced
  breathing in addition to tidal volume

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• Name
• Expiratory reserve volume (ERV)
• Volume (Average)
• 1,100 ml
• Description
• Volume that can be exhaled during forced
  breathing in addition to tidal volume

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• Name
• Residual volume (RV)
• Volume (Average)
• 1,200 ml
• Description
• Volume that remains in the lungs at all times

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• Name
• Inspiratory capacity (IC) ( FEV1)
• Volume (Average)
• 3,500 ml
• Description
• Maximum volume of air that can be exhaled
  following including the tidal volume.
• ICTVIRV

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• Name
• Functional residual capacity (FRC)
• Volume (Average)
• 2,300 ml
• Description
• Volume of air that remains in the lungs following
  exhalation of tidal volume
• FRCERVRV

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• Name
• Vital capacity (VC) ( FVC)
• Volume (Average)
• 4,600 ml
• Description
• Maximum volume of air that can be exhaled after
  taking the deepest breath possible
• VCTVIRVERV

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• Name
• Total lung capacity (TLC)
• Volume (Average)
• 5,800 ml
• Description
• Total volume of air that the lungs can hold
• TLC VCRV

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Examination of the Male and Female
Reproductive System
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Obstetrics and Gynecology
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General Examination

• Includes
• 1st Breast Exam
• 2nd ABD Exam
• 3rd Pelvic Exam

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Breast

• Self exam- monthly
• Detect over 90 of initial findings.

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Pathological Signs and Symptoms

• .Lumps
• .Change in shape and size
• .Change in appearance of skin
• .Chance in ski temp
• .Drainage or discharge
• .Chance in nipple shape

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• Recommendation by the American cancer
  association
• Perform a Mammogram annually after age 40 if
  patient has no Family history
• Perform a Mammogram annually after age 20 if
  patient has a Family history

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Abdominal exam

• Palpation
• Manual
• Bimanual
• Look for masses and enlargements.
• If uterine enlarged R/O Pregnancy or Pathology.
• Hands on sides to achieve better muscle relaxation

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Pelvic Examination

• MA remains in room if physician is opposite sex
  (preferable female MA.)
• Lithotomy
• MA places the patient in the Lithotomy position
  and cover patient properly.
• Physician will inspect external genitalia
• Looking for laceration of perennial body area
  episiotomy or any pathology.

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• Physician will also inspect internal genitalia
  Using a vaginal Speculum
• Cervix smooth, pink points posterior,
• Erosions (ulceration's) polyps.
• Increase size in pregnancy
• Hormone causes atrophy
• Vagina wall reddish pink
• Perform a Pap Smear

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• OBSTATRICS
• GYNECOLGICAL
• Disorders

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Premenstrual syndrome ( PMS )

• Occurs 1-2 weeks before menstruation
• SS
• Bloating / irritability
• Nervousness
• Numbness
• Fatigue
• Depression
• Rhinitis
• Change in appetite
• Tx. Salt restrictions

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Spontaneous Abortion?

• Miscarriage
• If less than 20 weeks
• Still birth
• If after 20 weeks
• Symptoms
• Bleeding, cramps, rupture of membrane
• Management
• If Incomplete abortion Do DC (dilation
  curettage)

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Causes

• Congenital defect development
• Abnormal Placenta Previa
• Abrupta Placenta
• Endocrine problems
• Malnutrition
• Infections
• Drugs
• Blood disorder (Erythro Blastosis Fetalis)
  mother ( Rh-) , father ( Rh) child ( Rh)

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Amenorrhea

• Absence of menstruation
• Primary
• the failure of menstruating
• Stress, hormonal imbalance, genetic, brain tumors
• Secondary
• Loss of 3 or more cycles
• Weight loss, pregnancy, lactation, menopause,
  pathological.

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Dysfunctional Uterine bleeding (DUB)

• Irregular or excessive uterine bleeding
• Cause
• Hormonal imbalance
• Hyperplasia of the uterus

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Toxic Shock syndrome

• Allergic reaction to the tampon fibers
• Staphylococcus infection
• Super infection, septic shock

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Vaginitis

• Inflammation or infection of the vagina
• STD, Yeast infection

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Cervicitis

• Abnormal Thick, purulent white discharges.
• Dysuria pain on urination.
• Most frequent after vaginal erosion during
  delivery.

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Cystocele

• Protrusion of bladder into vagina
• Causes
• injury during birth
• obesity
• heavy lifting
• chronic coughing
• Aging (decrease muscular tone).

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Dysmenorrhea

• Spasmodic pelvic pain during menstruation
• M/F young females (12-14 hrs) start before
  menstrual cycle and last for 24-48hrs.
• Decrease in elderliness
• Headaches
• Dizziness.
• Nausea / Vomiting diarrhea
• Fatigue.
• Low back pain
• Could also follow an organic Disease.
• . TX. Surgery

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Pelvic inflammatory disease( PID).

• Multiple pelvic organs are involved.
• Acute or chronic
• cervix- Cervicitis
• Uterus- endometritis.
• tube - salpangitis
• Ovaries- oophoritis.

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• Most Frequent causes
• Gonorrhea
• After the insertion of an IUD
• Post - operative.
• Abortion.
• S S
• discharge, fever, pain, Dysuria, bleeding, N/V

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Rectocele

• Protrusion of the rectum into vagina
• Post menopausal
• After pregnancy due to (instruments)

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• OB/Gyne
• Cancers
• Tumors

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Ovarian cancer

• Affect 1/70 woman in the USA
• Usually caused by adenocaricenoma
• Difficult to detect early
• Risk factors
• Age 40 and over
• Infertility
• Nullipara
• Hx of miscarriages
• Endometriosis

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Cervical cancer

• Ages 30-50
• Often Dx. Early
• Pap smear
• Risk factors
• Multiple partners
• Sexually active
• Early age sex
• Orientals

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Breast cancer

• Most common type of cancer in women
• Common age 40
• Early detection
• Self Examination
• Mammogram annually after age 40 if there is a
  family Hx.

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Endometriosis

• Presence of endometrial tissues outside uterus.
  (Menstrual fragments)
• Causes
• possible after uterus surgery
• poor nutrition
• hormonal influence
• intercourse during menstruation
• use of tampons

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• SS
• Lower abdominal pelvic pain.
• Profuse menses.
• Rectal bleeding
• N/V
• Abdominal cramps.
• Treatment
• Hormones therapy
• Surgery Hysterectomy.

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Fibrocystic Disease

• Multiple palpable lumps
• - breast pain, sacs filled with fluid
• High Risk of Cancer

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Fibroid Tumors

• Benign tumors of smooth muscles or connective
  tissue
• M/F pelvic tumor in females.
• Cause unknown
• Menorrhagia increase menstruation volume.
• Bladder or rectal pregnancy
• Pain
• abdominal symptoms
• Tx. - surgery

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Ovarian Cysts

• Sacs (follicles) filled with blood pus or fluid.
• Occurs before menopause.
• Tx Surgery

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Signs Symptoms

• Bleeding
• Nausea
• Vomiting
• Pelvo-abdominal pain
• Dx Ultra Sound.

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Polyps

• Second Most Frequent abnormality during
  reproductive years (13-40)
• SS
• Bleeding after intercourse, douching or tampon
  insertion
• Tx. Surgery

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• Sexually Transmitted Disease
• ( STD )

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Acquired Immunodeficiency Syndrome

• ( AIDS)
• Causative agent
• HIV virus

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Transmission

• Direct contact of body fluid
• (Serum, CSF, Sperms )
• Mechanism
• HIV attacking the T-Helper cell (CD4, CD8) which
  assist the bodys antibodies fight infections.

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Phases Of AIDS

• Incubation period
• Latent stage
• Persistent generalized lymphadenopathy stage (
  PGL )
• AIDS- related complex stage

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• HIV detection
• Seropositive test
• Positive antibody titer
• Seronegative test
• Negative antibody titer
• Possibly did not reach the titer level to test
  positive ( 1-3 months)
• ELISA
• Enzyme-linked immunosorbent assay
• Blood test ( HIV antibodies)
• Western blot
• Blood test to confirm ELISA

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Herpes Simplex II (Genital Herpes)

• Cause
• Varecella virus
• SS
• Labial vesicles.
• Tx.
• Zovirax

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Gonorrhea

• MF. Neisseria Gonorrhea.
• Greenish, yellowish discharge
• Tx.
• Ceftriaxone Doxycycline IM
• Dx.
• Microscopic.

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Syphilis (spirochetes).

• Chancre painless, non-itching lesion
• Lymph nodes, skin, mucous is involved
• Goes to brain and other systems
• Test
• FTA-ABS (Fluorescent Treponemal Antibody with
  Absorbed Serum)
• VDRL (Venereal Disease Research Lab). Dark Field
  Microscope
• Tx. Benzathine ( Penicillin)

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Trichomoniasis Vaginalis

• Parasite.
• Yellow foul discharge
• Dx.
• Microscopic
• Tx.
• Metronidazole
• Tx both sexes

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Canadidiasis ( Candida Albican )

• Yeast like fungus
• Normally in mouth, skin, GI, vagina
• Overgrowth can be caused by
• Long-term antibiotics.
• Estrogen levels.
• Diabetes
• Tight clothes.
• SS
• itching, dry white thick discharge
• Tx.
• Miconazole (Nystatin).

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Chlamydia Trachomatis (
Lymphogranuloma-venereum)

• Specialized bacteria.
• Affects the lymph nodes
• Causes infection
• Associated disorders
• Conjunctivitis
• Vaginitis
• Infertility
• Proctitis.
• Endometritis
• Pneumonitis
• Can transmit to newborn through vagina.

111

• SS -
• vaginal discharge
• Dysuria
• Frequency in urination.
• Tx
• Tetracycline

112
Chancroid

• Bacteria
• Starts with a small papule on the skin
• Changes to a painful coin shape ulcer
• More frequent in men.
• Tx.
• Ceftriaxone

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Genital warts

• HPV-6 HPV-7
• Caused by Papillomavirus
• Nipple like genital lesions
• Tx.
• Surgery
• Interferon

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Giardiasis

• Protozoan ( Giardia lamblia )
• Sexual transmission causes intestinal infection
• Could be Asymptomatic
• If symptomatic
• Diarrhea
• Malabsorbtion
• Tx Quinacrine

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Hepatitis

• HBV
• Causes liver disease
• Fever
• Jaundice
• Tx
• Symptomatic
• Prevention
• Vaccination.

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Scabies

• Mites, lice
• Pubic skin rash
• Secondary bacterial infection
• Transmitted through touch
• TX
• Special shampoo and comb for 7-10 days ( Sulfur )
• Steroids
• Oral antibiotics if another infection occurs
• Treat all other family members involved
• Wash all clothes, furniture, carpet

117

• Pregnancy
• Labor Delivery

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Pregnancy

• 1st trimester -
• Last menstrual period to 14 week.
• 2nd trimester -
• 15th week to 28th week.
• 3rd trimester -
• 28th week to delivery.

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Labor

• 1st stage
• onset F labor (complete dilation)
• 2nd stage
• complete dilation to birth.
• 3rd stage
• birth to expulsion of placenta membrane.

120
Placental Abnormalities

• Placenta Previa
• Misimplantation of the placenta
• Abrupta Placenta
• Detachment of the Placenta.

121

• Male
• Reproductive System Examination

122
Testes -

• Interstitial Cells
• (make testosterone)

123
Epididymitis

• Sperm mature develop the ability to swim
• Causes
• Bacterial infection
• SS
• Pain inguinal canal
• Swelling in groin scrotum
• Decrease Spermatozoa (infertility).
• Tx.
• Antibiotics Pillow under scrotum

124
Prostate

• Produces white-fluid that consist of 30 of
  seminal fluid
• Causes
• viral infection
• Urethral Catheter.

125
Testicular Cancer

• M/F of male cancer
• Black twice frequent white
• Genetic diet.
• MF form adenoma sarcoma
• Tx.
• Surgery
• Chemotherapy

126
Impotence

• Inability to achieve or maintain an erection.
• Causes
• 50 psychological 50 physical.
• Nerve damage
• Decrease testosterone
• Decrease sperm count.
• Decrease normal Temp.( 1C, 3F cooler than body).

127
Pediatrics
128

• Birth to Puberty
• 1st physical
• performed at delivery
• assess the newborn ability to thrive outside the
  uterus
• APGAR Score-
• System of scoring the infants physical condition
  at 1 min 5 min.
• Total score (0-10).

129
APGAR Score

• Heart Rate
• Possible scores 1 ( poor), 2 ( fair), 3 (
  normal)
• Respiration
• 1 ( poor), 2 ( fair), 3 ( normal)
• Muscle Tone
• 1 ( poor), 2 ( fair), 3 ( normal)
• Reflex Irritability response to stimuli
• 1 ( poor), 2 ( fair), 3 ( normal)
• Skin Color
• 1 ( poor), 2 ( fair), 3 ( normal)

130
Recommended Age Physicals

• 2 Weeks,
• 3 weeks
• 4 months
• 1 year
• 2 years
• 5 years
• 10 years
• 15 years

131

• MA
• Weighs measures infants records in chart
• Checks whether immunizations are due.

132

• Physician
• Checks for alertness of childbirth
• Ask parent how pt-eating.

133

• Positions To Hold Infants
• Cradled position -
• Holds or cradles infant's arms.
• Upright position -
• Hold infant standing
• Football position
• Carry infant facing you in lap.

134
Well Baby Exam

• Measure Circumference
• of head until 3 years or 36 months
• Abnormalities
• Hydrocephalic
• Microcephaly

135

• Growth Rate Charts
• Girls and Boys growth compared to other children
  in their age.
• Type charts
• HEIGHT X AGE
• WIEGHT X AGE
• (Birth-36 months) (2-18 years)

136
Delayed growth depend on

• Gross motor -
• large muscle coordination walking, throwing,
  running, swimming.
• Fine motor
• writing, buttoning, cutting.
• Language.
• Personal social development.

137
Immunization

• Birth HBV
• 2 months HBV ,DPT, OPV, HIB
• 4 months DPT, OPV, HIB
• 6 months HBV
• 12-15 months MMR, OPV, HIB
• 18 months DPT
• 4-6 years DPT, OPV, MMR
• 11-16 years TD ( T every 10 years)

138
Other Immunizations available

• Cholera
• Plague
• Rabies
• Chicken pox (Varicella)
• Small pox
• Typhoid
• Yellow fever
• Hepatitis A ( Immune serum globulin)

139

• Phenylketonuria
• (PKU)

140
Definition

• This is an inherited disease that must be
  diagnosed early to avoid serious brain damage and
  
• Mental Retardation.

141
ETIOLOGY

• Deficiency in Phenylalanine Hydroylase that
  converts Phenylalanine to Tyrosine.
• Autosomal Recessive

142
SYMPTOMS AND SIGNS

• Arrested development of brain
• Elevated PA in brain
• Toxic
• Onset of symptoms after 4 months
• Musty breath and urine odor
• Rash, irritability
• Hyperactivity

143
DIAGNOSIS

• Guthrie Test
• Collect drops of blood from infants heel and
  apply it in the circles on the special PKU test
  filter paper.
• Send to the lab a dry sample within 48 hours.

144
TREATMENT

• Diet free of Phenylalanine
• Protein restricted died
• Genetic counseling