2.4 Assisting with Physical Examinations and Specialty Procedures

2.4 Assisting with Physical Examinations and Specialty Procedures

Core Practice Scope: Assisting the healthcare provider during physical examinations and specialty procedures requires thorough knowledge of patient positioning, examination techniques, specialty tray setup, diagnostic screening, and precise EMR documentation.

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Clinical Patient Positions & Applications

Proper positioning exposes the targeted body area while maintaining patient dignity through drape placement.

The Four Fundamental Examination Techniques

During a general physical examination, providers utilize four distinct physical assessment techniques in a structured order (except during abdominal exams, where auscultation precedes palpation and percussion to prevent altered bowel sounds).

1. Inspection: Visual examination of the patient's body, demeanor, skin color, symmetry, posture, and movement. Begins the moment the patient enters the room.
2. Palpation: Examination using touch. The provider uses fingertips and palms to evaluate texture, temperature, organ size, shape, rigidity, and tenderness.
   • Light Palpation: Depressing tissue ~1 cm.
   • Deep Palpation: Depressing tissue 2–4 cm (performed solely by provider).
3. Percussion: Tapping body surfaces with fingers to produce sound waves. The resulting resonance reflects the density of underlying tissues (e.g., hyperresonant over emphysematous lungs, tympanic over air-filled stomach, dull over solid organs like liver/heart).
4. Auscultation: Listening to internal body sounds using a stethoscope (heart valve closure, lung breath sounds, abdominal bowel sounds, vascular bruits).

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Specialty Exam Preparation & Procedures

1. Gynecological Examination & Pap Smear

• MA Responsibilities: Have patient empty bladder prior to exam. Prepare equipment: speculum (warmed under warm water, no lubricant on tip prior to Pap collection to prevent cell distortion), spatula/cytobrush, liquid-based cytology vial (ThinPrep), lubricant, cotton-tipped applicators, and gloves.
• Chaperone Requirement: A female Medical Assistant should serve as an official chaperone during pelvic examinations for patient comfort and legal protection.

2. Ophthalmologic Screening

• Snellen Visual Acuity Test: Measures distance visual acuity. Patient stands 20 feet from the illuminated Snellen chart. Test each eye individually (right eye, left eye, then both) with non-tested eye covered by an opaque occluder. Record line in which patient makes no more than 2 errors (e.g., 20/30 -1). Interpretation: 20/30 means the patient sees at 20 feet what a normal eye sees at 30 feet.
• Ishihara Color Vision Test: Assesses color blindness using polychromatic plates. Patient identifies numbers embedded within colored dots under natural lighting within 3 seconds per plate.

3. Otologic Screening & Ear Irrigation

• Tuning Fork Tests:
  • Weber Test: Base of vibrating tuning fork placed on midline vertex of skull. Assesses lateralization of sound.
  • Rinne Test: Base of vibrating fork placed on mastoid bone until sound ceases, then held 1 inch outside auditory meatus. Normal result: Air Conduction (AC) is twice as long as Bone Conduction (BC) ($AC > BC$).
• Ear Irrigation (Lavage): Performed to remove impacted cerumen or foreign bodies.
  • Critical Rule: Solution temperature MUST be warmed to body temperature (37°C / 98.6°F). Cold or hot solution stimulates the inner ear endolymph, causing severe vertigo, nausea, and nystagmus (caloric reflex).
  • Contraindications: Perforated tympanic membrane or tympanostomy tubes.
  • Technique: Pull pinna up and back for adults, direct irrigating stream at the upper/posterior wall of ear canal, never directly at the eardrum.

4. Eye Irrigation

• Indications: Chemical exposure, foreign body sensation (provider-directed), or ordered irrigation after ocular contamination.
• Technique: Position the patient with the affected eye downward so runoff does not contaminate the unaffected eye. Use sterile saline or ordered irrigating solution directed from the inner canthus (near nose) toward the outer canthus.
• Critical Rule: For chemical splash injuries, begin irrigation immediately and continue for at least 15 minutes (or per protocol/SDS) while arranging urgent provider/ophthalmology evaluation. Never place pressure on the globe.

5. Suture and Staple Removal

Medical assistants commonly remove simple, healed skin closures under provider order. Confirm the order, verify patient identity, and inspect the wound before removing any closure material.

• Timing: Facial sutures are often removed earlier (about 3–5 days); scalp/trunk/extremity sutures typically remain 7–14 days depending on tension and provider preference. Never remove closures from a wound that is erythematous, draining purulent fluid, dehisced, or incompletely epithelialized—notify the provider.
• Suture Removal Technique:
  1. Perform hand hygiene, apply clean gloves, and cleanse the site with antiseptic.
  2. Using sterile suture removal scissors and forceps, grasp the knot, cut the suture close to the skin on one side, and pull the suture out toward the wound (so contaminated external suture material does not drag through tissue).
  3. Count and document the number of sutures removed; compare with the placement note when available.
  4. Apply adhesive wound-closure strips (Steri-Strips) if ordered, and provide wound-care instructions.
• Staple Removal Technique: Position the jaws of a staple remover under the staple crossbar, squeeze to bend the staple ends upward/outward, and lift the staple straight out. Do not pry staples with hemostats. Count staples removed and assess approximation.

6. Respiratory Tests and Inhaled Medication Assistance

Under provider order and within state/scope limits, medical assistants assist with oxygen therapy, spirometry/peak-flow measurement, and nebulizer treatments.

• Oxygen Therapy: Verify the ordered flow rate (L/min) and delivery device (nasal cannula typically 1–6 L/min; simple mask higher rates). Check tank volume/wall outlet, tubing integrity, and patient comfort. Never adjust oxygen based on personal judgment alone—follow the written order and report desaturation or distress immediately.
• Spirometry / Peak Expiratory Flow: Coach the patient to inhale fully and exhale forcefully and completely into the mouthpiece with a tight lip seal. Obtain the required number of acceptable efforts, record the best value, and note effort quality. Contraindications (recent eye/abdominal/chest surgery, active hemoptysis, unstable angina) require provider clearance.
• Nebulizer Treatments: Assemble the nebulizer cup, add the ordered medication volume, attach to compressed air/oxygen at the manufacturer-recommended flow (commonly ~6–8 L/min) until misting stops (usually 5–15 minutes). Instruct slow, deep oral breathing. Monitor pulse and respiratory status before and after bronchodilator therapy; report tachycardia, tremor, or increased dyspnea.

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Electronic Medical Record (EMR) Documentation

All clinical observations, vital signs, and procedures must be charted immediately following the encounter in accordance with legal documentation standards.

• Objective Documentation: Record measurable facts, not subjective opinions (e.g., "Surgical site clean, dry, intact without redness" instead of "Wound looks good").
• SOAP Note Structure:
  • S (Subjective): Patient's stated symptoms, CC, and HPI.
  • O (Objective): Measurable vital signs, physical exam findings, lab results.
  • A (Assessment): Provider's diagnosis or clinical impression.
  • P (Plan): Treatment recommendations, prescriptions, patient education, and follow-up timing.