 Hi everyone, I'm Leah, your lead course instructor here at Advanced E-Clinical Training and welcome back to our lecture series. Today we are going to go over your responsibilities during the adult assessment. Alright, so during the adult assessment, some intake tasks that are going to be more common duties for you while working alongside the provider such as the physician's assistant or the nurse practitioner or the doctor may include checking vital signs such as their blood pressure, temperature, heart rate, performing tasks such as measuring height and weight. Also, a big part of your responsibility during the adult assessment will be to record different things such as the chief complaint, their past medical history, they're documenting their current medical conditions, their medications, their allergies, and then also documenting any type of family history of diseases and also their social history. So caring for patients who need help with mobility will be another task. So this might be helping an elderly person to, you know, from the waiting area back to the exam room and maybe helping them up onto the exam table, helping them onto the scale. So a big part of that responsibility will rely on you. And then also you will be assisting the provider with the actual physical exam. You won't be doing a physical exam. That is the provider's responsibility, but you will be assisting the provider with the physical exam. So first and foremost, the chief complaint. So the chief complaint can be described as a concise statement describing the symptom, the problem, condition, diagnosis, or other factors or reasons why that patient is there today in the office. So you want to try to document the chief complaint in the patient's own words. So that will be a brief statement of their primary condition or their primary concern. And it might include something like in quotation marks, I've had a productive cough for the past three weeks. That might be something that a patient would say you want to document that as their chief complaint. If that's the fact what it is, if that's the reason why they are there, they might say I'm here for my annual physical. Well, then you want to document that in quotation marks as the chief complaint. All right, so moving on to past medical history. So documenting a patient's past medical history during the assessment is very, very important because this is going to give the provider a very good idea of how they can help assist with a diagnosing and treating the patient now. So a past medical history for a patient might include chronic health conditions such as high blood pressure or diabetes or they have a history of cancer. All of those things are very important to document. Also, you want to document any allergies they have. New allergies, current allergies, allergies in the past. Any childhood diseases. So if this person had chicken pox as a child or if this patient had tuberculosis as a child. So you want to document those past childhood diseases as well. So any vaccinations that they have, that they have now or they are current with, a good rule of thumb is to always ask patients, especially during flu season, which usually runs from September until March, have you had your flu vaccine? Are you updated with your flu vaccine? Another one, of course, is the COVID vaccine. Are you up to date with your COVID vaccine? And you want to document all of that. Also, vaccines such as shingles, the pneumonia vaccine as well. Any surgical procedures. So has this patient had any surgery in the past? It could have been for any type of traumatic event such as a fall in a broken hip and they required surgery for a new hip or they have their appendix removed or they have their gallbladder removed. So any past surgical procedures they had, you want to document any injuries to the body. So again, so the patient fell at one point they had a broken hip or if they were in a car accident and they had a broken arm or a broken nose. So any type of injury to the body and the burns and then of course any current medical, any current medications, including any over the counter medications such as Tylenol, ibuprofen, aspirin is a big over the counter medication that a lot of people take and that doesn't often get documented any vitamins and then of course any oral contraceptives as well. Alright, so moving on to family medical history. So I think sometimes students want to know why is the family medical history important if we're talking about a specific patient? Well, family history will include any health status of siblings, parents and grandparents and this is important because many diseases are hereditary and are passed down from parent to child. So and then there are other conditions or other diseases that are familial and can occur within a particular family. And so information about hereditary and familial medical issues will help again the provider to better diagnose and treat the patients. So it's also important to note that if a if the patient's parent is deceased you will want to note the age and the cause of death as well for this family medical history. So just in just to give you a little bit of an example. So a lot of times heart disease, high blood pressure, diabetes, kidney disease, these are all things that can be within a family. So things that are could be like a familiar familial disease things genetic disorders such as sickle cell anemia. I just talked about that actually in our webinar here in October sickle cell anemia is a genetic disorder that's passed down from parent to child. So you know we're going to want to know for sure if this if this patient if their mom or their dad had sickle cell or they had another type of hereditary disease or disorder. All right. So personal and social history this is these are just as important as going over the chief complaint and also the past medical history. So personal and social history. So you want to identify habits of lifestyle and patterns such as sleeping patterns. So how many hours on how many hours on average are they sleeping at night? Do they have a difficult time falling asleep? Do they have a difficult time waking up? You want to document their exercise habits are they how active are they? Are they sedentary or are they working out five days a week or are they you know moderately working out also you want to document any activities or hobbies? Definitely nutrition and eating habits. Are they eating heart healthy? Are they eating low sodium? Are they following their low carb diabetic diet? Are they on a regular diet? Very important to know. Also you want to document any alcohol use including frequency amount and type. So this sometimes can be a little bit of an awkward question to ask our patients but it's you know really important and I usually just slide it in there with the eating habits or also you can slide it in with are you a smoker because you want to document if they are a smoker. So what are they smoking and how long have they been smoking and how much are they smoking? And then I usually ask any alcohol use for you and that's where you can document their alcohol use how frequent and how and how much. And another thing about alcohol use is you want to note the type of alcohol that they are typically drinking is it vodka is it beer or is it wine? You also want to ask about any illicit drug use and this is illegal drugs but also improperly used prescription medications as well. So I want to ask the patient about their marital status. Are they married, single or they divorced? You know what is the nature of their family relationships? What's the nature of their support system? Do they have a support system? That's important to know. Also any type of socio-economic status such as their source of income. Are they retired? Do are they still working full-time? Are they working part-time? Are they receiving social security benefits? So we want to get a good idea about their socio-economic status because that definitely plays a role in their overall health status. Also talk about their living arrangements. Do they live alone? What is their housing like? Are they all on one floor? Do they have many stairs to get up? If they're in a wheelchair is it wheelchair accessible? Is their home wheelchair accessible? That's important to know. You want to ask about you know any type of safety issues like have you had any falls recently? Important to know. We kind of already went over the occupation you know but if they are working what are the working conditions? Do they work in a plant or a mill where it's very loud or they're exposed to dust and chemicals? Are they exposed to a lot of stress? Are they in a high stress position? Very important to know. And then also what are their cultural and religious beliefs because that will definitely affect how we are caring for the patient and what is acceptable for them while we're caring for the patient but also religion plays a big role in a lot of people's lives and how they deal with their health and their wellness and also their illness as well. So that's very important to understand. All right so we did talk about vital signs and I'm going to go ahead and move me up here. I can see you guys can see. So you can see this graph here. So the adult assessment like I said in the beginning you're going to be documenting vital signs. You'll be doing vital signs before you you know document anything else probably and you want to obtain you know their their blood pressure, their temperature, their pulse and then the respiration rate. Some doctors and facilities will have you also document a pulse oximetry as well. So just keep in mind and of course we know by now that vital signs are crucial for assessing general health and is also used to help indicate illness and also to monitor effectiveness of treatment. So of course you'll need your thermometer, you'll need a stethoscope, you'll need a blood pressure cuff and a stopwatch or a timing device so you can measure respirations. So here you can see what a normal temperature is for an adult, what a normal respiration rate is for adults, a normal pulse that is for an adult and as well as a normal blood pressure for an adult. All right so measuring weight. So like I said you will also most likely always be taking a weight on a patient when they come in to the office or the facility. So knowing a patient's height or their weight and I apologize we're going to start with height here. So knowing a person's height is very important to a very important observation to make about their overall health. So you want to use what's called a statiometer and this is an essential piece of equipment that most medical practices and facilities and I've probably all seen one by now you know when you stand on the scale it goes up behind you. So you want to have the patient sit or stand on the scale tell the patients to stand erect then you want to raise the measuring bar until it touches the top of the head extend the horizontal bar and then lower the bar until it touches the top of the patient's head. So then that will help you read the patient's height. So if you click on this link here you can watch this video on how to do that exactly visually that'll give you a better idea. And now on to weight. I was ahead of myself there before but here we are with weight. So we'll also be measuring a weight on every encounter with a patient. Of course accurate body weight is you know very important for the physical assessment and overall physical health. So when selecting the equipment is important to consider the patient's clinical condition and mobility. So there are different types of scales that are available to use including standing scales, chair scales, wheelchair scales, hoist scales and bed scales. So depending on what type of facility you're working in you know if you're working in a doctor's office it's very unlikely that they're going to have a bed scale. But all hospitals now have a scale on those hospital beds already. So if the patient is unable to stand you'll be using the bed scale. So again it's very important to understand and determine you know what the patient's clinical condition is and their mobility. But you always want to ask the patient to remove any heavy clothing or shoes. You want to make sure that the scale any scale that you're using is set to zero and is reset if required before weighing the patient as this will help to ensure an accurate reading. Also if required you want to help the patient onto the scale and ask them to remain as still as possible with their feet off of the floor if using a sitting scale. So very important and if you're weighing a patient in a sitting scale make sure you ask them to bring their feet up off of the floor. And then again here is a video for you to watch if you click on that link so you are able to see how to accurately measure a patient. So assisting with the physical exam. So again the medical assistant may assist the provider while performing the physical exam. And so while what you'll be responsible for during this time is handling the proper instruments and supplies to the provider disinfecting and sanitizing the instruments and preparing them for the next physical exam. Also assisting the patient to the appropriate position for the provider onto the exam table. Also assisting and collecting and properly labeling any specimen such as a urine sample a pap smear specimen or a throat culture. And then also conducting any follow-up diagnostic procedures as ordered. So this might include an EKG or an eye or ear screening or a urine analysis or phlebotomy you know drawing blood so whatever the doctor is asking you to do as long as it's within your scope of practice always remember that. And then of course scheduling any post examination procedures that the doctor has ordered after the physical exam such as a mammogram or an x-ray or a colonoscopy. All right so I'm just going to show you a couple of pictures of some common tools that you might be seeing or using to help assist with the physical exam. So first we have the audioscope here and this tool is used to screen patients for hearing loss. We have the nasal speculum and of course this tool is inserted into the nostril to assist the provider with visualizing and assessing the lining of the nose and nasal membranes. Moving on here we have the otoscope and this allows the provider to view the ear canal and then to panic membrane. So the otoscope has a magnifying lens and a light and a cone shaped insert to examine the inner ear. We have a tuning fork so this tool is used to test a patient's hearing so the provider will strike the prongs using them to vibrate, I'm sorry, causing them to vibrate and it will produce a humming sound so the prongs are then placed next to the patient's skull near the ear and then the patient indicates when they stop hearing the humming. So then the physician or the provider may order additional hearing tests depending on the results of this test using the tuning fork. All right so the percussion hammer, this tool was used to test neurologic reflexes so the head of the instrument is used to test reflexes by striking the tendons of the ankle, the knee, the wrist and the elbow. Of course we have the sphid monometer and this is used to measure a patient's blood pressure and I think we've all seen this in the vital signs lesson but so this is composed of an inflatable rubber cuff, a ball that inflates and then releases pressure from the cuff and you use the stethoscope to listen to the arterial blood flow of the patient and that will give you the inaccurate blood pressure reading. So the physical assessment. So this is more, the next few slides are just more for your information. You don't need to necessarily memorize this but for testing purposes but I just wanted to bring it to your attention to make you aware so when you do begin working in the field it's not foreign to you how the doctor will conduct the physical assessment. So the examination will begin obviously with the patient on the table and the provider will examine a patient in an orderly and methodical sequence. So first the viewing the patient's head and neck then examining their eyes and ears and their nose and their sinuses, their mouth and throat onto the chest, the breast and the abdomen and then the legs and then lastly the provider will check the patient's reflexes. So this again these next few slides you don't necessarily need to know this for the exam but I just wanted to share this information with you so you know you were familiar with it when you begin working in the field. So just the review of the systems as I said the provider will start with the head they want to look at their skull their scalp their hair and face they're all inspect you know assessed for size shape and symmetry the provider will also look for any nodules masses or any kind of trauma and how assess for any headaches dizziness syncope which is passing out or any head injuries and then the provider will assess any fibrous tissues covering the eye for normal coloring the pupils are assessed with the pen light to view to view their size and see if they react normally to light. The patient will then follow the provider's finger to examine proper eye movement the ears are assessed for size and symmetry lesions nodules and then this is when the provider will use the otoscope to examine the interior of the ear and any auditory acuity is tested at this time with the tuning fork or the audio scope that we just had a look at and you can click on this link here click on this link here and this will take you to a video that will show you actually how a provider uses the tuning fork to assess for hearing and a patient. So moving on to the review of systems nose and sinuses so the nose is examined for any abnormalities using the nasal speculum and pen light the doctor will assess for you know sense of smell frequency of colds any epitaxis which are nosebleeds any postnatal post nasal discharge or sinus pain also they'll be looking at he or she will be looking at the patient's mouth and throats looking at their mucus membranes and their gums and their teeth and their tongue and their tonsils and their throat looking for any abnormalities of color ulcerations nodules and then moving on to chest breasts and abdomen so the provider will look for any obvious masses or swelling with the stethoscope the provider will listen for any abnormal sounds in the lungs in the heart they'll listen to the apical pulse and that apical pulse is done here on the left side underneath in in the intercostal space here while the patient takes deep breaths so then the breasts of the male and the female patients will be examined for any abnormalities or masses the abdomen is assessed for contours symmetry and movement from the aorta because as we've learned the aorta does move it is all the way down into the abdomen so the provider will also use the stethoscope to listen for bowel sounds and lastly the provider will examine the abdomen organs for any enlargement masses pain or tenderness and then of course lastly the legs are assessed for any abnormalities the doctor or the provider I should say would check for pulses and posterior pulses or femoral pulses and then the measure the extremity of blood flow so the legs will also be assessed for any varicose veins and then lastly the provider would check reflexes with the percussion hammer that we saw a few slides back and here is a video that you can access and you can see how the provider actually does the check for the reflexes and again these next three slides you don't need to memorize any of this for the exam and this is not anything you will be doing but I just wanted to bring it to your attention again so when you are assisting a provider with an adult assessment especially the physical assessment part this isn't going to be so unfamiliar to you so there are methods of examination that the doctor will use while conducting the physical assessment first is inspection and of course this just begins with you know looking at the patient looking at their overall body and their behavior so this will come with knowledge and experience but the provider will become highly attuned and highly sensitive to any visual cues that are out of the norm and then they'll use a method of examination called percussion so by setting underlying tissues in motion percussion helps in determining the density of the underlying tissue and whether it is airfield fluid filled or solid so audible sounds and palpable vibrations are produced which can be distinguished by the provider and the five basic notes produced by percussion can be distinguished by differences in the qualities of the sound pitch duration and intensity so again this isn't something you need to know but I just wanted to bring it to your attention so when you're with the provider and you see them doing these things that it's not so unfamiliar to you moving on with the methods of examination of course we have auscultation so this method is used with the stethoscope and that's the stethoscope stethoscope is used to increase the sense of hearing so with the stethoscope your pieces should be comfortable the length of the tubing should be 10 to 15 inches and the head should have a diaphragm and a bell and the bell part of this stethoscope is used for a low pitch sound such as certain heart murmurs and the diaphragm screams out low pitch sounds it is good for hearing high frequency sounds such as breath sounds so if the doctor is assessing lung their lungs they will use this part of the stethoscope the diaphragm and then there's palpation the provider will touch the body part or region of the body and note whether it is tender to touch in addition to what the various structures feel like so it is performed in an organized manner from region to region and again the provider with experience comes the ability to determine any variation from normal so lastly once the provider ends the exam part of your responsibility is then of course to perform any follow-up treatments and procedures as ordered by the provider such as you know the administration of vaccines or maybe performing an EKG or collecting blood work and then you know once you're finished with that you'll ask the patient to redress and wait for further instructions once the patient is dressed you can escort the patient to the front desk where they can schedule follow-up appointments or testing that has been ordered by the provider that can't be completed in the office and then lastly you want to dispose of any disposable supplies and equipment used during the physical examination and the assessment and then prepare the room for the next patient so that is the end here of the adult assessment of course if you have any questions or concerns about it anything or you need clarification you know that you can always email me I have an open door policy so I'm available to you Monday through Friday from 8 a.m. to around 9 p.m. Eastern standard time and then on the weekends a little bit more frequent but again if you need any clarification please do reach out to me but thanks for joining us and I'll see you all again. 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