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233 terms

CH 16 Preparing the Patient

STUDY
PLAY
Patient interview
The first step in the examination process. It establishes a relationship between the medical assistant and the patient, and it allows the medical assistant to collect information and data pertinent to the patient's well-being.
The health history form
The medical office usually has a standard medical history form that it uses for all patients. The specific arrangement and wording of items vary from office to office.
Personal data
This information is obtained from the administrative sheet and includes things like the patient's name, Social Security number, birth date, and other basic data.
Chief complaint
Abbreviated as CC, it is the reason the patient came to visit the practitioner. It should be short and specific and cover subjective and objective data.
History of present illness
This includes detailed information about the chief complaint, including when the problem started and what the patient has done to treat the problem (including any medications taken). For example, a chief complaint might be "sore throat," and the history of the present illness would include when the sore throat started, how severe the pain is on a scale of 1 to 10, and what treatments have been used.
Past medical history
The past medical history includes any and all health problems both present and past, including major illnesses and surgery. The past medical history also includes important information about medications and allergies.
Family history
This section includes information about the health of the patient's family members. Many times the family history can help lead a practitioner to the cause of a current medical problem. Obtain specific information about family members' current ages and medical conditions or, if deceased, their age at death and the cause.
Social and occupational history
Information such as marital status, sexual behaviors and orientation, occupations, hobbies, and use of chemical substances help determine a patient's risk for disease. Patients should be asked about their use of alcohol, tobacco, recreational drugs, or other chemical substances.
Six Cs of charting
•Client's words—The patient's own phrasing must be recorded exactly.•Clarity—Use precise medical terminology.
•Completeness—The chart must contain all pertinent information.•Conciseness—Use abbreviations where you can to save time and space.•Chronological order—Date all entries.•Confidentiality—Protect the patient's privacy.
Interviewing successfully
Do your research before the interview. Review the patient's medical history. Plan the interview. Plan what types of questions you want to ask. Approach the patient and request an interview. Make the patient feel part of the process. Make the patient feel at ease. Use icebreakers and casual conversation.Listen to the patient.Conduct the interview in private without interruption. Do not diagnose or give a diagnostic opinion. Summarize key points, and let the patient ask questions.
Methods that can further help you collect patient data include
Asking open-ended and hypothetical questions, mirroring the patient's explicit responses and verbalizing the implied responses, focusing on the patient, encouraging the patient to take the lead, encouraging the patient to provide additional information, and encouraging the patient to evaluate the situation. Make sure that you do not challenge the patient or probe in a manner that invades the patient's privacy.
Detect nonverbal clues
During the preexamination interview, you may note things that patients have not communicated to you verbally, such as anxiety, depression, signs of physical or psychological abuse, and signs of drug or alcohol abuse. If you suspect abuse, bring it to the physician's attention immediately. Provide such patients with support, advice, and the appropriate hotline number for your area if they want to seek help.
Purpose of the physical examination
The determination of the general state of health of the patient and the diagnosis of any medical problems and diseases the patient may have. The physician uses a variety of devices and laboratory tests to complete the physical findings. The majority of physicians usually start at the patient's head and end at the feet. Sometimes the physician may order some additional tests or procedures, such as blood sample testing, the collection of culture specimens, or X-rays.
Complete physical examination
Includes vital signs, examination of the patient's entire body, laboratory tests (complete blood count [CBC] and urinalysis); and diagnostic tests (X-rays).
Duty of a medical assistant
Preparing the room and equipment, getting the patient ready, and assisting the physician.
Emotional preparation
Begin by explaining what will happen during the examination. This step is especially important when dealing with children.
Physical preparation
The medical assistant is responsible for obtaining and recording weight, height, and vital signs; facilitating the examination; asking the patient to empty his or her bladder; asking the patient to disrobe completely; providing the patient with a full gown; and providing a drape sheet.
Examination methods
The six methods for examining a patient that are a part of a complete physical examination are inspection, palpation, percussion, auscultation, manipulation, and mensuration.
Inspection
Observing the patient's outer body and certain mental characteristics.
Palpation
Feeling with the fingers or hand to verify data seen during inspection.
Percussion
Tapping with the fingers and listening for sounds, particularly in the abdomen, back, and chest.
Auscultation
Listening to sounds with a stethoscope.
Manipulation
Skillfully using the hands in therapeutic or diagnostic procedures.
Mensuration
The act or process of measuring.
Symptoms
Subjective changes in the body felt or observed by the patient, such as headache, blurred vision, or dizziness.
Signs
Objective findings as perceived by another person such as a physician or medical assistant. Examples of signs include fever, blood pressure, and heart murmurs.
Diagnose
To determine the cause and nature of an abnormal condition. It's important to remember that diagnosis is not within the scope or training of a medical assistant. You should never give a diagnosis to a patient. If patients ask you, refer them to the physician.
Clinical diagnosis
Using the signs and symptoms of a disease to determine its cause and nature.
Differential diagnosis
The process of ruling out certain possibilities, used to determine the correct diagnosis when two or more diagnoses are possible.
Prognosis
The outcome of a disorder, or a predication of the probable course of a disease in an individual and the chances of recovery.
Examination tables
Usually adjustable to enable the patient to assume various positions. Tables are usually covered with disposable papers that must be changed after each patient.
Surfaces
Must be disinfected with products approved by the Environmental Protection Agency (EPA), such as 10% NaClO (sodium hypochlorite, the active ingredient in household bleach).
Accessibility
The ease with which people can move in and out of a space.
The Americans with Disabilities Act of 1990 (ADA) requires
•A doorway at least 36 inches wide to allow for the use of wheelchairs•A clear space in rooms and hallways 60 inches in diameter to allow persons using a wheelchair to make a 180-degree turn•Stable, firm, slip-resistant flooring
•Door-opening hardware that can be grasped with one hand and does not require the twisting of the wrist to use•Door closers adjusted to allow time for a person in a wheelchair to enter and exit•Grab bars in the lavatory
Instrument
A surgical device or tool to assist the physician in performing a specific function, such as measuring, examining, grasping, holding, cutting, or suturing.
Gloves
Should always be worn if the hands will come in contact with a patient's nonintact skin, blood, body fluids, or moist surfaces and if the patient is suspected of having an infectious disease.
Tongue depressors
Used in the examination of the mouth and tongue.
Gooseneck lamp
A movable light used to focus on a body area for increased visibility during physical examination.
Penlight
A small flashlight used to provide additional light during an examination, for example, to check pupil response.
Reflex hammer
A percussion mallet with a rubber head, used to tap tendons, nerves, or muscles to elicit reflex reactions.
Lubricants
Used in examination of the rectum and female genitalia.
Anoscope
An instrument used to open the anus for examination.
Speculum
An instrument that expands and separates the walls of a cavity (such as the ear, nose, and vagina) to make examination possible.
Nasal speculum
Used to enlarge the opening of the nose to permit viewing. This type of speculum may consist of a reusable handle with a disposable speculum tip, or it may be a disposable one-piece unit.
Vaginal speculum
Used to enlarge the vagina to make the vagina and the cervix accessible to visual examination and specimen collection.
Thermometer
Used to measure body temperature.
Otoscope
An instrument used to examine the external ear canal and tympanic membrane.
Ophthalmoscope
A handheld instrument, equipped with a light, used to view inner eye structures.
Tuning fork
A small, metal instrument consisting of a stem and two prongs that produces a constant pitch when either prong is struck. It is used by physicians as a screening test of air and bone conduction.
Inspecting and maintaining instruments
Before examination, check all instruments and sanitize, disinfect, and sterilize as appropriate. Also make sure that all of them are in good working order, and replace or repair instruments as necessary.
Arranging instruments
Arrange instruments so the physician may find them easily.
Disposable supplies used in physical examinations
Supplies that are used once and then discarded. They include: •Cervical scraper•Cotton balls•Cotton-tipped applicators•Curettes•Disposable needles•Disposable syringes•Gauze, dressings, and bandages•Glass slides•Gloves, both sterile and nonsterile•Paper tissues•Specimen containers•Tongue depressors
Consumable supplies
Supplies that can be emptied or used up in an examination.
They include:
•Sprays (chemical spray used to preserve specimens)
•Isopropyl alcohol (used to cleanse the skin)
•Lubricants
Draping
The placing of a sheet of fabric or paper during an examination to protect and cover all or a part of a patient's body, for the comfort and privacy of the patient.
Positioning
For physical examinations, the patient may need to be placed in a variety of positions to facilitate the examination of various parts of the body. The physician indicates which positions are needed for specific examinations, and the medical assistant helps the patient assume the positions. Cover the patient with a drape that will help keep the patient warm and maintain privacy. The patient can remain draped and gowned until the physician begins the examination.
Positions
Many positions are used for medical examinations, including sitting, supine, dorsal recumbent, lithotomy, Trendelenburg's, Fowler's, prone, Sims', knee-chest, proctological (jackknife), and standing.
Sitting position
The patient sits at the edge of the examination table without back support. This position is used for examination of the head, neck, chest, heart, back, and arms. In this position, the physician can evaluate the patient's ability to fully expand the lungs and can check the upper body parts for symmetry. The drape is placed across the lap of male patients and the chest and lap of female patients.
Supine position
Also called the recumbent position. The patient lies flat on the back (face up). This position is used for examination of the head, neck, chest, heart, abdomen, and arms and legs. The patient is normally draped from the neck or underarms down to the feet.
Dorsal recumbent
The patient lies face up while flexing the knees, with the soles of the feet flat on the table. This position is the same as the supine position except that the patient's knees are drawn up. It is used for examination of the head, neck, chest, heart, and lower extremities (vaginal, rectal, and perineal areas).
Lithotomy position
The patient lies on the back with the knees sharply flexed and the feet placed in stirrups that are set wide apart and away from the table. This position is used for examination of the vaginal and perineal areas. It is an embarrassing and physically uncomfortable position for most women, so you should not ask the patient to stay in this position any longer than necessary.
Trendelenburg's position
The patient lies flat on the back with the head lower than the legs. This position is used for abdominal surgery and for treatment of patients who are in shock.
Fowler's position
The patient lies face up on the examination table with the head elevated. Although the head of the table can be raised to 90 degrees, the most common position is 45°. This position is used for examination and treatment of the head, neck, and chest. This position is best for people with lower-back injury or for those experiencing shortness of breath.
Prone position
The patient lies face down on the table. This position is used for examination of the back and feet. It is not suitable for patients who are obese, pregnant (in the late stage), or elderly or who have difficulties of the respiratory system.
Sims' position
Also called the lateral position. The patient lies on the left side with the left arm placed behind the body and the left leg slightly flexed. The right arm is flexed toward the head, and the right leg is flexed. This position is used for examination of the rectum.
Knee-chest position
The patient rests on the knees and chest with the thighs slightly separated. Patients who have difficulty in maintaining this position can be placed in a knee-elbow position. The knee-chest position is used for examination of rectal, sigmoid, and vaginal areas.
Proctological position
The patient lies face down with both the torso and the legs lowered. The hips of the patient are flexed at a 90-degree angle. Adjustable tables can be raised in the middle with both ends sloping down. This position is used for rectal examination. It is also known as the jackknife position.
Standing position
Used for examination of the musculoskeletal system, the neurological system, hernias, and the peripheral vascular system.
Optometrist
A specialist who measures the eye's refractive power and prescribes correction of visual defects when needed.
Ophthalmologist
A medical doctor who specializes in diagnosing and treating disorders of the eye.
Ophthalmic assistant
Provides administrative and clinical support for an ophthalmologist; works with patients; assists with surgery; keeps instruments and equipment in proper working order; and may conduct distance acuity, near acuity, and color perception tests.
Visual acuity test
Used to measure the degree of clarity or sharpness of vision. There are many types of tests for visual acuity. The test most commonly used in the medical office and performed by the medical assistant is the Snellen eye test.
Snellen letter chart
A chart used to test the distance vision of adults. The distance between the patient and the chart should be 20 feet. Normal vision is recorded as 20/20. Have the patient read the chart, and record the smallest line read. If the patient misses only one or two letters on a line, record the results with a minus sign. For example, if one letter is missed on the 30-foot line from 20 feet away with the right eye, the result would be recorded as O.D. 20/30 -1.
Color blindness
The congenital or acquired inability to distinguish certain colors. Congenital color blindness is more common. This condition is seen in males more frequently than in females.
Color vision acuity test
Measures the patient's ability to determine and differentiate between colors. The medical assistant may be responsible for administering the color vision test. There are two common color tests, Ishihara and Richmond pseudoisochromatic, in which the individual must distinguish a figure made up of colored dots from a background made up of dots of another color. A score of 10 or above indicates average color vision. A score of less than 7 may represent a color vision deficiency.
Tonometer
An instrument used in measuring tension or pressure of the intraocular region. It is used for the detection of glaucoma.
Eye irrigation
The flushing of foreign materials from the eye with a sterile solution formulated for this purpose.
Audiologist
A specialist who evaluates and corrects hearing problems.
Hearing loss
An inability to perceive the entire range of sound heard by a person with normal hearing. There are two types: conductive and sensorineural.
Conductive hearing loss
Caused by damage to the middle ear.
Sensorineural hearing loss
Caused by damage to the inner ear (the cochlea or the auditory nerve).
Audiometer
An electronic device that measures hearing acuity by producing sounds in specific frequencies and intensities.
Audiology tests
Tests to determine the presence of conduction defects or nerve impairment. They are used to evaluate hearing loss and disturbances in equilibrium.
Weber's test
A method of evaluating auditory acuity. The test is performed by placing the stem of a vibrating tuning fork against the center of a person's forehead, or the midline vertex. The loudness of the sound is equal in both ears if hearing is normal.
Rinne test
Compares bone conduction hearing with air conduction hearing. A vibrating tuning fork is held on the mastoid process of the ear until the patient no longer hears it. Then it is held close to the external auditory meatus.
Ear irrigation
Flushing of the ear canal to remove impacted cerumen, to relieve inflammation, or to remove a foreign body. The solution used should be warmed to room temperature before administration. To perform the irrigation for adults, the earlobe should be pulled upward and outward. For infants and children, the earlobe should be pulled down and back.
Ear instillation
Applying eardrops to treat an ear disorder. The medication should be warmed to room temperature before application.
Cardiologist
A physician trained in the treatment of heart diseases.
Medical assistant's role
To assist with and perform tests, to keep equipment properly maintained and calibrated, to educate patients about diet and exercise, and to provide emotional support to patients.
General cardiovascular examination
Taking a blood pressure reading, auscultation of heart sounds, palpating the chest wall and the vessels in the extremities, and recording an electrocardiogram (ECG).
Cardiac stress test
Recording an ECG while a patient is exercising on a treadmill, stationary bicycle, or stair-stepping ergonometer. The test determines the capacity of a patient to respond to an increased demand for energy. Performing this test helps diagnose diseases of the heart.
Echocardiography
The process of obtaining echoes with the use of ultrasound and recording them on paper. It is used to evaluate the inner structures of the heart.
Phonocardiography
A process that graphically records the cardiac cycle sounds as heard through a stethoscope.
Cardiac catheterization
A diagnostic procedure in which a catheter is introduced through an incision into a large vein (in the arm or leg) and sent to the chambers of the heart. The procedure takes about 1 to 3 hours.
Angioplasty
The reconstruction of blood vessels damaged by disease or injury.
Pulse oximeter
A machine that measures the oxygen level of the blood. This device measures the pulse and oxygen saturation of the blood.
Eupnea
Normal breathing.
Throat culture
A commonly performed diagnostic test for determination of infection.
Sputum culture
Difficult to obtain. The patient must cough deeply and expectorate material from the lungs. Early morning is the best time to collect sputum.
Pulmonary function tests
Tests performed to measure the amount of air a patient can inhale and exhale.
Spirometer
An instrument that measures the air taken into and expelled from the lungs.
Spirometry
The measuring of breathing capacity.
Forced vital capacity (FVC)
The greatest volume of air that can be expelled when a person performs rapid, forced expiration.
Total lung capacity (TLC)
The total volume when lungs are maximally inflated.
Laryngoscope
An endoscope for examining the larynx.
Bronchoscopy
Visual examination of the tracheobronchial tree by means of the standard rigid, tubular metal bronchoscope. The procedure also may be used for suctioning or biopsy.
Cheyne-Stokes respiration
A breathing pattern marked by a period of apnea lasting 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations.
Gastroenterologist
A physician who diagnoses and treats disorders of the gastrointestinal tract.
Proctology
The branch of medicine concerned with treating disorders of the colon, rectum, and anus.
Medical assistant's role
To tell patients how to prepare for examinations, to order informational brochures, and to answer patients' questions.
Endoscopy
Visual examination of the interior of cavities and organs of the body with an endoscope. The purpose of this procedure is the diagnosis of disorders. Endoscopy also can be used for biopsy.
Gastroscopy
Examination of the stomach and abdominal cavity with a type of endoscope called a gastroscope.
Sigmoidoscopy
Inspection of the rectum and sigmoid colon with the aid of sigmoidoscope. The medical assistant should assist the physician with the procedure and clean the equipment.
Colonoscopy
Visual examination of the large intestine by means of a colonoscope inserted through the anus.
Anoscope
A speculum used to examine the anus and lower rectum.
Proctoscopy
Examination of the lower rectum and anal canal by means of a protoscope.
Cholecystogram
An X-ray of the gallbladder, made after injection of a radiopaque substance, usually a contrast medium containing iodine.
Barium swallow
Also called an upper GI series, used to diagnose abnormalities in the esophagus, stomach, and small intestine. The patient swallows a liquid containing barium, and X-rays are taken to record the diagnostic images.
Barium enema
Also called a lower GI series, used to detect abnormalities in the large intestine. Barium is given as an enema.
Gastric lavage
Obtaining a sample of stomach contents with an orogastric tube, which suctions the contents up for analysis.
Occult blood test
A chemical test or microscopic examination for blood, especially in the feces, that is not apparent on visual inspection.
Laparotomy
Surgical incision into the peritoneal cavity.
Urologist
A physician who specializes in the study of the urinary system.
Medical assistant's role
It is important to be thorough in taking a patient's history in order to obtain information about changes in frequency or urgency of urination, difficulty or pain with urination, and incontinence.
Urinalysis
Physical, chemical, and microscopic examination of urine to find bacteria, blood, or other substances and to monitor for dysfunctions of the prostate gland and for sexually transmitted diseases. The medical assistant collects the urine specimen for chemical or physical analysis.
Urine culture
The placement of urine samples on special media that promote the growth of microorganisms and thus facilitate bacterial analysis. It requires special training and equipment but may be performed in the office.
Cystoscopy
Visual examination of the bladder by means of a special instrument called a cystoscope.
Pyelogram
An X-ray image of the bladder made by using an opaque dye for visualization. The dye may be injected into the patient's vein, or the physician may insert a small catheter into the urethra through a cystoscope and inject the dye through the catheter.
Urinometer
A device for determining the specific gravity of urine. It is also called a urometer.
Vasectomy
A sterilization procedure for men in which a section of each vas deferens is removed.
Obstetrician/gynecologist (OB/GYN)
A physician who specializes in the female reproductive system.
Role of the medical assistant
The medical assistant collects a urine specimen; interviews the patient about her health and any changes in appetite, weight, and emotional status; and asks about the date of the patient's last menstrual period. If the doctor is male, a female medical assistant should be present during the examination not only to assist but also to provide legal protection.
Pelvic examination
The physician checks the external genitalia, cervix, vaginal wall, internal reproductive organs, and rectum via palpation and inspection with a speculum.
Papanicolau test (Pap test or smear)
Used to determine the presence of abnormal or precancerous cells in the cervix and vagina. A Pap test is done during the pelvic examination. The patient is instructed not to douche, use vaginal medications, or have intercourse within 48 hours before the examination. The test should not be done during a patient's menstrual period.
Wet mount
A method of adding liquid, usually saline or formalin, to a specimen on a slide for examination and preservation. The specimen is placed on a slide and one drop of saline (for diagnosis of trichomonas vaginalis) or potassium hydroxide (for diagnosis of vaginal yeast infections) is applied and mixes with the specimen. It is then covered with a coverslip and examined microscopically.
Pregnancy test
A test to determine whether the hormone human chorionic gonadotropin, which is produced during pregnancy, is present in a woman's blood or urine. False negatives and false positives can occur.
Ultrasonography
The process of imaging deep structures of the body by measuring and recording the reflection of pulsed or continuous high-frequency sound waves. It is a valuable tool to diagnose fetal abnormalities, gallstones, heart defects, and tumors. It is also called sonography.
Mammogram
A low-dose X-ray of breast tissue to detect early cancer. A mammogram is first taken on women between the ages of 35 and 40 years.
Colposcopy
The examination of the vagina and cervix with a colposcope.
Schiller's test
Iodine staining of cervical and vaginal areas to diagnose cancer of the cervix or vagina.
Laparoscopy
Examination of the abdominal cavity with a laparoscope through one or more small incisions in the abdominal wall. The incisions are usually at the umbilicus. A general anesthetic is used. This procedure is also called an abdominoscopy.
Dermatologist
A physician who diagnoses and treats skin diseases and disorders.
Medical assistant's role
To assist with positioning and draping during a skin examination, to take skin scrapings and wound cultures, to administer sunlamp treatments, to apply topical medications, and to instruct patients about caring for a skin condition or wound at home.
Whole-body skin examination
An examination of the entire surface of the skin, including the scalp and the areas between the toes, to look for lesions, especially suspicious moles or precancerous growths.
Wood's light examination
A type of dermatological examination in which a physician inspects the patient's skin under an ultraviolet lamp in a darkened room for certain fungal cultures.
Tuberculin skin test
Administered intradermally, a test performed to detect exposure to tuberculosis. This test is routinely performed on all individuals who have contact with children, on those working in health-care fields, and on patients with a positive X-ray suggestive of infection. Current TB testing involves intradermal injection to test for a skin reaction to tuberculosis. Two to three days after the injection, the result must be measured. The skin is observed for results after 48 to 72 hours.
Scratch test
A test for specific allergies. The skin is scratched with a sterile lancet, and a drop of allergen (antigen) is added to the site. Results are recorded in 30 minutes.
Patch test
A test for hypersensitivity allergy. Antigens are applied to the skin and covered with gauze patches and tape. The site is checked in 48 hours, and results are recorded. This type of test is used to discover the cause of contact dermatitis.
Tissue biopsy
There are three types, or methods: excision biopsy, punch biopsy, and shave biopsy.
Neurologist
A physician who diagnoses and treats diseases and disorders of the central nervous system and associated systems.
Medical assistant's role
To ready equipment for use; to position the patient; to hand tools and other items to the physician; to perform visual acuity tests or audiometry; to assist with electroencephalography; and to instruct and educate patients and their families about procedures, disorders, and treatments.
Neurological examination
A complete examination evaluates cognitive function, cranial nerves, the motor system, reflexes, and the sensory system.
Myelogram
An X-ray taken after the injection of a radiopaque medium into the subarachnoid space to demonstrate any distortions of the spinal cord.
Magnetic resonance imaging (MRI)
Medical imaging that uses radio-frequency radiation as its source of energy. It has become an important tool in musculo-skeletal and pelvic imaging.
Computed tomography (CT)
A radiographic technique that produces a film representing a detailed cross section of tissue structure.
Electroencephalogram (EEG)
A graphic chart on which the electrical potential produced by the brain is traced, detected by electrodes placed on the scalp. The resulting brain wave patterns are called alpha, beta, delta, and theta rhythms.
Carotid angiogram
A radiographic image of the carotid artery, into which a contrast medium has been injected.
Alpha-fetoprotein (AFP) testing
Measurements of AFP in amniotic fluid are used for early diagnosis of fetal neural tube defects, such as spina bifida and anencephaly.
Lumbar puncture
A diagnostic and therapeutic procedure done by a physician, involving the introduction of a hollow needle and stylet into the subarachnoid space of the lumbar part of the spinal canal.
Pediatrician
A physician who specializes in the health care of children, monitoring their development and diagnosing and treating their illnesses. Subspecialties include surgery and oncology.
Medical assistant's role
To prepare the child for examination; to discuss eating habits, sleep patterns, daily activities, immunization schedules, and toilet training with the caregiver or child; to measure the infant's head, length, and weight; and to help relieve the child's fear by calmly explaining procedures.
Well-baby examination
Regular checkups when the infant is 2 weeks, 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, and 18 months old. Starting at age 2, children should have checkups every year.
Scoliosis examination
An assessment of a child of 10 years of age or older for abnormal curvature of the spine.
Measurement
Examination and measurement of the circumference of the infant's head to determine normal growth and development. The size of the child's head reflects the growth of the brain. The length and weight measurements in pediatrics are also important. The medical assistant may record and use a physical growth percentile chart to determine the growth value.
Child abuse and neglect
Watch for signs of physical injury, dirty or neglected appearance, hunger, extreme sadness or fear, or inability to communicate. Note suspicions on the chart, and report them to the doctor. Physicians are legally responsible for reporting suspected child abuse or neglect to your community's child protection agency or to the police.
Immunizations
Usually given during routine office visits to protect children against hepatitis B, diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, chickenpox, and influenza. The child should not have an illness or fever at the time of immunization.
Surgery
The branch of medicine that treats conditions, diseases, deformities, and injury using instruments and operative procedures. Also, the surgical treatment or procedure itself. Generally, the place for major surgery is in a hospital, but minor surgery commonly is performed in a doctor's or dentist's office. Minor surgery may include removal of a sebaceous cyst, wart, or foreign object. Other minor surgeries include circumcision, vasectomy, skin biopsy, dilation and curettage.
Medical assistant's role
To complete forms for insurance; to obtain signed informed consent forms from the patient; to explain the procedure to the patient; to answer questions; to make sure that the doctor is informed about medications the patient is taking; to make sure that the room is clean; to make sure that all supplies are clean, disinfected, or sterilized, as appropriate, and that all supplies are properly arranged.
Outpatient surgery
A surgical procedure that requires less than 1 day and for which the patient does not need to stay in the facility overnight.
Ambulatory surgery
A surgical procedure for which the patient is able to walk into and out of the surgical facility on the same day.
Invasive procedure
A diagnostic or therapeutic technique that requires entry into a body cavity or interruption of normal body functions. Examples include the Pap test, sigmoidoscopy, colonoscopy, and intravenous pyelography.
Anesthesia
Partial or complete loss of sensation. It is induced to permit the performance of surgery or other painful procedures. Local anesthesia provides loss of sensation in a particular location without loss of consciousness; it is used for diagnostic procedures or minor surgery. Techniques for administering local anesthetics include topical application, infiltration, and block. Types of block anesthesia include regional, spinal, epidural, and saddle.
Anesthetic
A drug or agent used to prevent the sensation of pain and, depending on the situation, to achieve adequate muscle relaxation during surgery, to calm fear and anxiety, and to produce amnesia for the event.
Needle biopsy
The removal of a segment of living tissue for microscopic examination by inserting a hollow needle through the skin or the external surface of an organ or tumor.
Cautery
An agent or device used for scarring, burning, or cutting the skin or other tissues by means of heat, cold, electric current, or caustic chemicals.
Cauterization
The destruction of tissue with a cautery.
Electrocautery
An instrument for directing a high-frequency current through a local area of tissue.
Electrosurgery
The use of electrical current in surgical procedures such as electrocoagulation to cauterize blood vessels and electrocision to excise tissue.
Cryosurgery
The destruction of tissue (e.g., abnormal cells) by the use of freezing temperatures.
Laser
The acronym for light amplification by stimulated emission of radiation. Thermal lasers are used to heat tissue at a microscopic level, causing vaporization and coagulation of the target area.
Disinfection
The destruction or inhibition of pathogenic organisms by physical means or by chemical germicides. Two common disinfectants are zephrin chloride and chlorophenyl. Contaminated instruments are completely immersed in a germicidal solution for from 1 to 10 hours. The chemical disinfection process is referred to as a "cold" process because no heat is used.
Surgical asepsis
Used when sterility of supplies and the immediate environment is required. This technique is necessary during any invasive procedure. It requires sterile hand washing (surgical scrub), sterile gloves, special handling procedures, and sterilization of materials. Most dangerous bacteria are destroyed at a temperature of 50° to 60°C (122° to 140°F). Pasteurization of a fluid, which is the application of heat at about 60°C, destroys pathogenic bacteria. However, temperatures of 120°C are usually required to destroy spore cells.
Surgical scrub
Hand washing to remove all dirt and microorganisms from the surface of the skin and the fingernails. Materials needed include a sterile surgical scrub brush, a dispenser with surgical soap, orange sticks, and sterile towels.
Sterilization
The process of destroying all microorganisms and their pathogenic products. Methods of sterilization include the application of steam under pressure, dry heat, bactericidal chemical compounds (in liquid or gas form), and radiation.
Moist heat sterilization
A method of sterilization that uses steam under pressure. This method kills all pathogens and spores and is the best and most accepted type of sterilization.
Autoclave
An appliance used to sterilize medical instruments. It allows steam to flow around each article placed in the chamber. The vapor penetrates cloth or paper used to package the articles being sterilized.The amount of time and the temperature necessary for sterilization depend on the articles to be sterilized and whether they are wrapped or left directly exposed to the steam under pressure.
Dry heat sterilization
A method of sterilization that uses heated dry air at a temperature of 160° to 180°C (320° to 356°F) for 90 minutes to 3 hours.
Sterilization indicator
Any material that undergoes a change in appearance (usually a color shift) when it is exposed to a predetermined combination of temperature, pressure, and time. Indicators are used to confirm that the sterilization process has been completed. The most common forms of indicator include autoclave tape and sterilization indicator strips.
Autoclave indicator
A change of color or the appearance of dots on an indicator strip, tube, tape, or tag shows that steam has entered the chamber, not that the instruments are sterile. Autoclave indicator tape turns black after autoclaving.
Shelf life
The amount of time during which an item may be expected to retain its useful characteristics (such as sterility). Packages that have been autoclaved are stored with the date visible, and the oldest package is placed in front so that it is used first. Sterilized instruments are considered to have a shelf life of approximately 1 month. Autoclaved packages cannot be re-autoclaved without washing, rinsing, drying, and rewrapping the items.
Surgical setup tray
Instruments that may be required for a specific minor surgical procedure should be gathered together into a pack, sterilized, and made ready for use as needed. Specialized trays are used for such procedures as incision, vasectomy, suture removal, and laceration repair.
Clean gloves
Worn to protect health-care personnel from urine, stools, blood, saliva, and drainage from patients' wounds and lesions.
Sterile gloves
Used to prevent contamination of areas that need to be sterile on the patient.
Sterile field
The area immediately around a patient that has been prepared for a surgical procedure. The sterile field includes the scrubbed team members, who are properly attired, and all furniture and fixtures in the area.
Formalin
A dilute solution of formaldehyde used to preserve biological specimens.
Surgical scissors
A sharp instrument composed of two opposing cutting blades, held together by a central pin on which the blades pivot, used to dissect and cut tissues. See Figure 16-13 on the next spread.
Operating scissors
Straight or curved, with a combination of blades such as sharp/sharp (s/s), blunt/blunt (b/b), or sharp/blunt (s/b).
Suture scissors
Used to remove sutures. The hook on the tip aids in getting under a suture, and the blunt end prevents puncturing of the tissues.
Bandage scissors
Inserted beneath a dressing or bandage to cut it for removal.
Scalpel
A small, straight surgical knife consisting of a handle and a sharp blade that has a convex edge used to make surgical incisions. There are both reusable and disposable scalpels. Blades are numbered according to size. A number 15 blade is often used in performing minor surgeries.
Retractors
Used to hold tissue aside to improve the exposure of operative areas.
Probes
Long, slender instruments used to explore wounds or body cavities.
Forceps
A surgical instrument with two handles, each attached to a dull blade, used to grasp, compress, pull, handle, or join tissue, equipment, or supplies. See Figure 16-15 on the next spread. Grasping types include thumb forceps and tissue forceps. (The word forceps, like scissors, is plural.)
Thumb forceps
Also called smooth forceps, used to pick up tissue or to grasp tissue between the adjacent surfaces of the blades.
Splinter forceps
Thumb forceps with sharp points that are useful in removing foreign objects.
Tissue forceps
Have teeth to prevent them from slipping. They are used to grasp tissue.
Holding forceps
Have handles that can lock the blades closed.
Dressing forceps
Used in the application and removal of dressings.
Hemostatic forceps or hemostats
Used for clamping and grasping blood vessels.
Towel forceps
Used to keep towels in place during a surgical procedure.
Needle holders
Surgical forceps used to hold and pass a suturing needle through tissue. They are also called suture forceps.
Surgical suture needle
A sharp instrument used for puncturing and suturing. The needle carries suture material, also called ligature. Needles vary in their piercing ability (pointed or blunt-tipped), shape (straight or curved), and size, depending on their use. See Figure 16-16. A swaged needle has no eye; instead, the needle and suture material are combined in one length.
Suturing
Using sterile suture material and a needle to close a wound. Ligature (suture material) is of two types: absorbable and nonabsorbable.
Absorbable sutures
Used for internal suturing. They are digested by tissue enzymes and absorbed by the body tissues. Absorption usually occurs 5 to 20 days after insertion. Surgical catgut made from the intestinal lining of sheep is used for the bladder, intestines, and subcutaneous tissue.
Nonabsorbable sutures
Generally used for outer tissues of the body. These types of suture must be removed after the wound begins healing. They may be made of polyester, steel, silk, nylon, and vicryl.
Suture size
In the United States, the size designation of sutures decreases as the thickness (diameter) decreases. Size 7 is the largest generally available. Size 3 is thinner; size 0 is thinner still. Sizes smaller than 0 are indicated by additional 0s: 00 (or 2-0), 000 (or 3-0), and so on. Few sutures are smaller than size 11-0. Sizes 2-0 through 6-0 are the most commonly used.
Staple
A piece of stainless steel wire used to close certain surgical wounds. It is used in major surgery and is the strongest of all suture material.
Suture removal
After surgery, nonabsorbable sutures generally remain in place from 5 to 6 days and then have to be removed. If they are not removed, they can cause infection and skin irritation.
Puncture
A wound made by a sharp-pointed object, such as a needle, bullet, carpentry nail, knife, or animal tooth, that pierces the skin layers.
Laceration
A wound in which the tissues are torn apart rather than cut. The edges of the wound are irregular. Dull knife blades and other objects that tear into the skin produce lacerations.
Abrasion
A wound in which the outer layers of the skin are rubbed off, resulting in an oozing of blood from ruptured capillaries. Many falls cause abrasions, such as skinned knees and elbows.
Incision
A clean, smooth cut, as is caused by a sharp knife edge, a razor, or a piece of glass. Also, a cut produced surgically with a sharp instrument that creates an opening into an organ or space in the body. There are two types of incisions: superficial and deep. Generally, a deep incision is accompanied by profuse bleeding with damage to tissues such as muscles, tendons, and nerves.
Contusion
A wound in which the tissues under the skin are injured, as by a blunt object. Blood vessels rupture, allowing blood to seep into the tissue.
Wound healing
The healing process serves to restore the structure and function of the damaged tissue. This process takes place in three phases: lag, proliferation, and maturation.
Lag phase
During the initial phase, bleeding is reduced because of blood vessel constriction.
Proliferation phase
During the second phase, new tissue forms.
Maturation phase
The last phase involves the formation of scar tissue.
Dressing
Sterile material used to cover a surgical or other wound.
Bandage
A strip of woven material used to wrap or cover a part of the body. A bandage causes pressure to control bleeding, protects a wound from contamination, holds a dressing in place, or supports or immobilizes an injured part of the body.
Types of bandage
Four types of bandage are often used in the medical office: roller, elastic, triangular, and tube gauze.
Roller bandages
Long strips of soft material that are coiled to form rolls. They are often used to apply pressure (i.e., as pressure bandages).
Elastic bandages
Made of woven cotton containing elastic fibers. They are typically used on swollen extremities or joints, on the chest to treat empyema, on fractured ribs, and on legs to support varicose veins. They are expensive, but they can be washed and reused.
Triangular bandages
Usually made of muslin and measuring approximately 55 inches across the base and 40 inches along the sides. They are frequently used in first aid.
Tube gauze bandage
Seamless tubular gauze bandage, with or without elastic, is superior material for covering round narrow surfaces such as fingers or toes. It can be used as either a dressing or a bandage. A tubular gauze bandage is applied with a cagelike applicator.