Whether a patient comes for a regular checkup or to have a problem diagnosed and treated, the physical exam is the first step in the process for the physician or practitioner. During the physical exam, the medical assistant must make the patient comfortable and assist the physician as necessary. A skilled medical assistant who is sensitive to patient needs plus proficient in performing these skills can create an atmosphere that results in a positive outcome for the patient during the physical exam.

Outline

• The Purpose of a General Physical Exam
• The Role of the Medical Assistant
• Safety Precautions
• Preparing the Patient for an Exam
• Exam Methods
• Components of a General Physical Exam
• Completing the Exam

Learning Outcomes

After completing Chapter 38, you will be able to:

 38.1 State the purpose of a general physical exam.
 38.2 Describe the role of the medical assistant in a general physical exam.
 38.3 Explain safety precautions used during a general physical exam.
 38.4 Outline the steps necessary to prepare the patient for an exam.
 38.5 Describe how to position and drape a patient in each of the ten common exam positions.
 38.6 Explain ways to assist patients from different cultures, patients with disabilities, pediatric patients, and pregnant women.
 38.7 Identify and describe the six examination methods used in a general physical exam.
 38.8 List the components of a general physical exam.
 38.9 Explain and perform the procedures for vision screenings.
 38.10 Explain and perform the procedures for hearing screenings.
 38.11 Explain the special needs of the elderly for patient education.
 38.12 Identify ways to help a patient follow up on a doctor's recommendations.

Summary

The general physical exam provides substantial information about a patient's overall health status and assists the physician in making a diagnosis, prognosis, and treatment plan. The general physical exam is the cornerstone of medical care.

The physician uses a number of assessment methods to gather information during the exam. Although one common order of exam is presented in this chapter, you should learn the order preferred by the physician(s) you assist. Be aware, too, that a physician may change the order of an exam to accommodate the needs of a particular patient.

During the exam, your first priority as a medical assistant is to address the comfort, privacy, and educational needs of the patient. You must also anticipate the needs of the physician throughout the procedure. In addition, you must be aware of the special needs of children, pregnant women, and the elderly and the areas in which patient education is likely to be needed.