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Chapter 17 Assisting with the Physical Examination 361
Procedure 17-5
Equipment: Stethoscope, ophthalmoscope, otoscope, penlight, tuning fork, nasal speculum, gloves, tongue blade,
laryngeal mirror, patient gown, drape, lubricant, vaginal
speculum, fecal occult blood test slide, and tissues.
1. Wash your hands and prepare the examination
room and patient. When the physician is ready
to begin the physical examination, you will assist
by handing the physician the appropriate instruments and positioning the patient appropriately.
Anticipating the physician’s needs saves time and
makes the procedure more efcient.
2. Begin by handing the physician the instruments necessary to examine different body areas. Although all
physicians follow a systematic procedure, the order
for examining different body areas may vary slightly
depending on the physician. Instruments and supplies
required to examine the different parts of the body are:
Head and neck—stethoscope.
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Eyes—ophthalmoscope, penlight.
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Ears—otoscope, tuning fork.
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Nose—penlight, nasal speculum.
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Sinuses—penlight.
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Mouth—gloves, tongue blade, penlight. Pass the
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tongue blade by holding it in the middle. When
it is returned to you, grasp it in the middle again
so that you do not hold the end that was in the
patient’s mouth.
Throat—glove, tongue blade, laryngeal mirror,
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penlight.
Assisting with the Adult Physical
Examination
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7. Prepare and position the patient for examination of
the genital and rectal areas.
For females:
Help the patient into the lithotomy position and
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drape appropriately.
Provide the physician with supplies and instru-
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ments used for examining genitalia and reproductive organs. These include gloves, lubricant,
a speculum, microscope slides or prep solution,
and a spatula or brush.
For the rectal examination, provide gloves, lubri-
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cant, and a fecal occult blood test slide.
After the examination, provide the patient with
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tissues to wipe off any excess lubricant.
For males:
Help the patient stand, if necessary. Have him
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bend over the examination table for a rectal and
prostate examination.
For a hernia examination, provide gloves.
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For a rectal examination, provide gloves, lubri-
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cant, and fecal occult blood test slide.
For a prostate examination, provide gloves and
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lubricant.
After the examination, provide the patient with
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tissues to wipe off any excess lubricant.
8. With the patient standing, the physician may assess
legs, gait, coordination, and balance.
3. Help the patient lower the gown to the waist for
examination of the chest and upper back. The physician will use a stethoscope during the chest exam.
Only the parts of the body being examined should
be exposed. Maintain the patients’ privacy by keeping them covered as much as possible.
4. Help the patient pull up the gown and remove the
drape from the legs. Hand the physician the reex
hammer to test patient reexes.
5. Help the patient into the supine position. Open the
gown at the top to expose the chest again. Place
the drape over the waist, abdomen, and legs. The
physician will examine the breasts and may again
listen to chest sounds.
6. Cover the patient’s chest. Lower the drape to expose
the abdomen. The physician will use a stethoscope
to listen to bowel sounds.
9. Help the patient sit on the end of the examination
table. The physician often discusses ndings with
the patient at this time.
10. Perform or schedule any follow-up procedures or
treatments.
11. Leave the room while the patient dresses unless the
patient needs assistance. It is important to protect
the patient’s privacy.
362 Section IV Clinical Medical Assistant Skills
Procedure 17-5
12. Return to the examination room when the patient
has dressed to answer any questions, reinforce
instructions, and provide patient education. The
patient’s ability to follow the treatment plan
depends on how well he understands it.
13. Escort the patient to the front desk. You can help
clarify any appointment scheduling or billing issues.
14. Properly clean or dispose of all used equipment
and supplies. Instruments, supplies, and equipment
that came in direct contact with the patient must
be cleaned, sterilized or disposed of appropriately.
Assisting with the Adult Physical
Examination
(continued )
15. Clean the counter surfaces of the room and the
examination table with a disinfectant and prepare
for the next patient.
16. Wash your hands and record any instructions
from the physician in the patient’s record. Note
any test results, specimens taken for testing, and
the laboratory where the specimens are being sent.
Remember that if procedures and instructions are
not recorded, they are not considered to have been
done.
Procedure 17-6 Measuring Distance Visual Acuity
Equipment: Snellen eye chart, eye occluder, and patient
record for charting.
1. Wash your hands and prepare the examination
area. Make sure the area is well-lighted.
A distance marker must be exactly 20 feet from
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the Snellen Eye Chart.
The chart must be at eye level.
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6. Stand beside the chart and point to each row as the
patient reads it aloud. Begin with the rst row, the
20/200 line. The line number is on the right side of
the chart next to each line. If the patient can read
these lines easily, move down to smaller gures. If
the patient has difculty reading the larger lines,
you will need to notify the physician.
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2. Identify the patient by name and explain the procedure. Patients who understand the procedure are
more likely to have accurate test results.
3. Position the patient at the 20-foot mark. The
patient may be standing or sitting, as long as the
chart is at eye level.
4. Note whether the patient is wearing glasses. If not,
ask about contact lenses and record the information.
Patients usually wear their corrective lenses during
the visual acuity examination. The patient record
must indicate if contact lenses or glasses were worn.
5. Have the patient cover the left eye with an eye
occluder.
To maintain consistency, the test always starts
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with the left eye covered.
The patient’s hand should not be used to cover
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the eye. Pressure against the eye or peeking can
affect the results.
Instruct the patient to keep both eyes open, even
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though one is covered. Closing one eye can cause
the other eye to squint, which can affect the results.
7. Record the smallest line the patient can read with
no more than one error or according to ofce policy. Record the eye tested, the line number, and the
errors. Use medical abbreviations. For example:
OD 20/40—1 (OD means right eye).
8. Repeat the procedure with the right eye covered.
Record the results using the abbreviation for the
left eye, OS. For example: OS 20/20—0.
Chapter 17 Assisting with the Physical Examination 363
Procedure 17-6 Measuring Distance Visual Acuity (continued )
9. Repeat step 6 with both eyes uncovered. Record
the results using the abbreviation for both eyes,
OU. For example: OU 20/40—1.
10. A reading of 20/20 means that the person tested
sees at 20 feet what the normal eye can see at
20feet. 20/40 means that a person can see from 20
feet what the normal eye can see from 40 feet away.
11. Be sure to document the procedure in the patient’s
record. Procedures are not considered to have been
done if they are not recorded.
Procedure 17-7 Measuring Color Perception
Equipment: Ishihara color plate book and gloves.
1. Wash your hands. Then put on gloves and get the
Ishihara color plate book. In this case, you wear
gloves to protect the color plates. Oils from your
hands can alter the colors and interfere with testing.
2. Identify the patient by name and explain the procedure. Make sure the patient is seated comfortably
in a quiet, well-lighted room.
Indirect sunlight is best. Sunlight should not
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shine directly on the color plates. The colors fade
with exposure to bright lights.
Patients who wear glasses or contact lenses
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should keep them on. Corrective lenses don’t
interfere with the color perception test.
3. Hold the rst plate in the book about 15 to
30inches from the patient. The rst plate should
be obvious to all patients and serve as an example.
Ask the patient if she can see the number formed by
the dots on the plate.
4. Record the patient’s results by noting the number of the gure the patient reports for each plate.
Write the plate number followed by the patient’s
response.
If the patient cannot see the pattern, record the
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plate number followed by the letter X.
The patient should not take more than three
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seconds to read the plate and should not squint
or guess. These behaviors indicate that the
patient was unsure and the plate should be
recorded as X.
5. Continue showing plates and recording patient
responses for plates 1 to 10. Plate 11 requires the
patient to trace a winding bluish-green line between
two X’s. Patients with a color decit will not be
able to trace the line.
If 10 or more of the rst 11 plates are read with-
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out difculty, the patient does not have a color
decit. No additional testing is needed.
Plates 12, 13, and 14 are usually used to assess
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the degree of deciency in patients with redgreen color deciencies.
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(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2013.)
6. Store the color plate book in a closed, protected
area to protect the integrity of the colors. Remove
your gloves and wash your hands.
364 Section IV Clinical Medical Assistant Skills
Procedure 17-8 Assisting with the Pelvic Examination
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Equipment:
Gown and drape
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Vaginal speculum. If a metal nondisposable specu-
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lum is used, it can be warmed under running water,
on a heating pad set on warm, or in a warming
drawer found on some examination tables.
Cotton-tipped applicators
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Pap smear collection materials
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Ayre spatula or histobrush
Microscope slides with xative solution or
prepared solution for suspension of the sample
Laboratory requisition
Water-soluble lubricant
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Examination gloves
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Examination light
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Tissues or wipes
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Basin or container for used instruments
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Biohazard waste container
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1. Wash your hands and assemble required equipment
and supplies.
2. If microscopic slides are used, label each slide
according to the ofce or laboratory policy. A pencil is used to write on the frosted end of the slide.
Each slide should be labeled C for cervical, V for
vaginal, or E for endocervical, the region at the cervical opening into the uterus.
3. Greet the patient by name and explain the procedure. Identifying the patient by name prevents
errors and may help put her at ease.
4. Ask the patient to empty her bladder and, if necessary, collect a urine specimen. An empty bladder
makes the examination more comfortable.
5. Provide the patient with a gown and drape and ask
her to disrobe. If she’s also having a breast examination, she needs to disrobe completely. The gown
should open to the front. If the patient is not having a breast exam, she need only disrobe from the
waist down.
8. Assist the physician with the examination by handing instruments and supplies as needed. Anticipating
the physician’s needs leads to a more thorough and
efcient procedure.
9. After putting on examination gloves, hold the glass
slides while the physician obtains and makes the
smears.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2013.)
10. Spray or cover each slide with xative solution.
Hold the slide 4 to 6 inches from the can and spray
lightly once. Or carefully drop the xative solution
onto the slide.
The xative preserves the cervical scrapings for
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analysis.
Spraying the solution too close may distort the
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cells or blow them off the slide.
11. When the physician removes the vaginal speculum,
have a basin or other container ready to receive it.
12. Apply about 1 to 2 inches of lubricant across the
physician’s two ngers. Lubricant helps make the
manual examination more comfortable. Don’t
place lubricant on the vaginal speculum before
insertion. It can cause inaccurate Pap smear results.
6. When the physician is ready, assist the patient into
the lithotomy position. Her buttocks should be at the
bottom edge of the table. This position may be embarrassing to the patient and may stress her back and
legs. Explain that she won’t need to stay in this position any longer than necessary for the examination.
7. Adjust the drape to cover the patient’s abdomen
and knees, exposing the genitalia. Adjust the light
over the genitalia for maximum visibility.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2013.)
Chapter 17 Assisting with the Physical Examination 365
Procedure 17-8 Assisting with the Pelvic Examination (continued )
13. Encourage the patient to relax during the bimanual
examination. Your support may help the patient
feel less anxious.
14. After the examination, help the patient slide to the
far end of the examination table. Then remove both
feet from the stirrups at the same time.
Moving the patient away from the stirrups helps
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prevent strain and possible injury while removing her feet from them.
Removing both feet at the same time also puts
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less strain on the patient.
15. Offer the patient tissues to remove excess lubricant.
Help her sit up if necessary. Watch the patient for
signs of vertigo. Some patients, especially if elderly,
may be dizzy when they sit up.
16. Ask the patient to get dressed and assist if needed.
Respect the patient’s privacy as she dresses.
17. Reinforce any instructions from the physician
regarding follow-up appointments. The patient
also will appreciate knowing when and how to get
laboratory results from the Pap smear.
18. After the patient leaves, properly care for and dispose of equipment. Clean the room and remove
gloves. Wash your hands. Document your responsibilities during the procedure, such as routing the
specimen to the laboratory and patient education
provided.
366 Section IV Clinical Medical Assistant Skills
Preparing for Externship
At some point of the externship, you will probably
be in the examination room with the physician or
provider during an exam of the patient. You need to
remember that you are there to assist the physician
with whatever they may need and you are there to
support the patient. Do not talk, unless the physician
Chapter Recap
● The purpose of the physical examination is to assess
general health and detect signs and symptoms of
disease.
● During a physical examination, the medical assistant’s
duties may involve taking a medical history, preparing
the patient for the examination, assisting during the
examination, and processing collected specimens.
● Depending on ofce policies, the medical assistant
may be asked to remain in the room during the
examination to serve as a witness and provide legal
protection for the physician.
● Medical assistants must be familiar with the
instruments and supplies used for a general physical
examination or a specialty examination.
● In preparing the examination room, the medical
assistant should check the examination table, the
equipment, and the supplies.
● The medical assistant has an important role in
preparing the patient for the examination. Duties
may include obtaining the medical history and chief
complaint, checking vital signs, and processing
specimens.
● The medical assistant ensures the patient’s privacy at
all times.
● As the physician examines different parts of the
body, the patient may be asked to assume different
positions. The medical assistant needs to be familiar
addresses you. Only answer and respond to what the
physician is asking. Always anticipate what is going
to happen next in the exam room before, during, and
after the exam. As you witness more exams, you will
become more comfortable and knowledgeable with
expectations.
with different examination positions to assist the
patient if needed.
● Elderly, disabled, and pregnant patients may need
extra assistance before, during, and after the
examination. The medical assistant must be sensitive
to patient needs.
● The physician follows a systematic order in examining
the patient. The examination typically begins with
the head and neck and progresses to the legs and feet.
● The physician uses six different techniques to gather
information during a physical examination—
inspection, palpation, manipulation, percussion,
auscultation, and mensuration.
● The medical assistant will be required to assist with
specialty procedures such as measuring distance
visual acuity, measuring color perception, or assisting
with pelvic examinations.
● After the examination, the medical assistant may need
to help the patient dress, give further instructions, or
perform follow-up procedures. The medical assistant
is also responsible for cleaning the examination room
and preparing it for the next patient.
● It is important to watch for opportunities to teach
patients about warning signs that can indicate health
problems. Medical assistants may provide patient
education regarding procedures including breast selfexamination and testicular self-examination.
Chapter 17 Assisting with the Physical Examination 367
Online Resources for Students
Resources for students available on thepoint.
lww.com include the following:
● Audio Glossary
● Animations
Exercises and Activities
Certication Preparation Questions
1. Which of the following examination methods
is used to determine the patient’s ability for
extension and exion?
a. Inspection
b. Palpation
c. Manipulation
d. Mensuration
e. Percussion
2. Which instrument is used to determine the
presence of cerumen in the ear canal?
a. Nasal speculum
b. Ophthalmoscope
c. Percussion hammer
d. Laryngoscope
e. Otoscope
3. Which of the following is a nondisposable supply
used during a physical examination?
a. Patient gown
b. Tongue depressor
c. Tape measure
d. Gloves
e. Patient drape
● Competency Evaluation Forms
● Harris CareTracker Case Studies
● Interactive Games & Activities
● Certication Preparation Question Bank
● Videos
4. Which of the following is a true statement
regarding a Snellen chart vision exam?
a. A person with 20/40 vision can see at 20 feet
what a normal person can see at 20 feet.
b. A person with 20/50 vision can see at 50 feet
what a normal person can see at 20 feet.
c. A person with 20/20 vision can see at 20 feet
what a person with corrective lenses can see at
20 feet.
d. A person with 20/200 vision can see at 200 feet
what a normal person can see at 20 feet.
e. A person with 20/70 vision can see at 20 feet
what a normal person can see at 70 feet.
5. Which of the following would be used to detect
abnormalities of the lungs, heart, large blood
vessels, ribs, and thoracic spine?
a. Complete blood count
b. Electrocardiogram
c. Urinalysis
d. Chest x-ray
e. Blood chemistry
6. Which of the following positions would be used to
examine the female genitalia?
a. Fowler’s
b. Lithotomy
c. Trendelenburg
d. Prone
e. Supine
368 Section IV Clinical Medical Assistant Skills
7. The purpose of the physical examination is to:
a. update the patient’s health history.
b. comply with insurance company annual
requirements.
c. assess general health and detect signs and symp-
toms of disease.
d. update immunizations.
e. review the patient’s health issues and surgeries
performed.
8. Which of the following examination methods is
used to evaluate the patient’s skin condition?
a. Inspection
b. Palpation
c. Manipulation
d. Mensuration
e. Percussion
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CareTracker Connection
Documenting Clinical Data Generated
From a Physical Examination
CareTracker Activities Related to
This Chapter
Case Study 5: Family Practice Patient Practicum
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Case Study 6: Pediatric Patient Practicum
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The physical examination typically marks the point in
an ofce visit when the primary care provider appears
for the rst time and takes charge of the patient. The
medical assistant’s role at this point is to assist in conducting the examination, document data that are generated from the examination, and order any medications
or tests that the primary care provider requests. Once
again, CareTracker provides the tools a medical assistant needs to carry out these tasks.
Tasks discussed in this chapter that can be performed
in CareTracker include the following:
Documenting the following patient clinical
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information:
Health history
Review of systems
Physical examination ndings
9. Which of the following items is required to
examine the ears?
a. Penlight and ophthalmoscope
b. Otoscope and tuning fork
c. Ophthalmoscope and Snellen chart
d. Laryngeal mirror and penlight
e. Tuning fork and ophthalmoscope
10. Which of the following is not a responsibility of
the medical assistant?
a. Perform Snellen chart exam
b. Interpret the electrocardiogram
c. Use mensuration to obtain patient’s height and
weight
d. Collect blood specimen for laboratory testing
e. Chart patient data in the EMR system
Tests and procedures completed during the visit
Diagnoses
Treatment plan
Ordering the following:
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Medications
Laboratory tests
Diagnostic tests
Many of these tasks are discussed in CareTracker
Connection features in other chapters. A task we’ll consider here is entering physical examination ndings.
The primary application in CareTracker for entering clinical data related to a physical examination is the
Progress Note, which may be accessed from the Medical
Record module. Although the primary care provider
typically enters data into the Progress Note, medical
assistants are sometimes required to do so.
The Progress Note contains many tabs, including
those related to the chief complaint, health history,
review of systems, physical examination, injections, tests
and procedures, diagnoses, and treatment plan. Many
data entered earlier in the patient’s visit, such as the
chief complaint, vital signs, and health history, appear
now in the Progress Note—both as a narrative summary
on the left side of the screen and within the corresponding tabs, as shown below.
Chapter 17 Assisting with the Physical Examination 369
On the physical exam (PE) tab, you may indicate
ndings related to each region, system, or organ of the
body examined, such as “N” for normal and “A” for
abnormal.
370 Section IV Clinical Medical Assistant Skills
More detailed ndings may be entered by clicking on
the gray arrow icon to the left of each area, which causes
a pop-up box to appear.
You’ll get a chance to practice this task in Case Studies
5 (Family Practice Patient Practicum) and 6 (Pediatric
Patient Practicum).
To access Case Studies 5 and 6, go to http://thepoint.
lww.com, log in using your username and password,
search for The Complete Medical Assistant, click on
“Student Resources,” nd the Harris CareTracker
materials, and click on “Case Study 5” or “Case
Study 6.”
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Visit the Internet to access information from various
Web sites for the following:
1. Recommended immunizations for infants, children,
2. Images of a healthy and an infected ear drum
Internet Activities
and adults, visit the Centers for Disease Control site
at www.cdc.gov/vaccines/schedules