CHAPTER
39
Assisting with
Examinations in the
Basic Specialties
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39-2
Learning Outcomes
39.1 Describe the medical specialties of internal medicine,
obstetrics and gynecology, and pediatrics.
39.2 Identify the types of examinations and diagnostic tests
performed in internal medicine, obstetrics and
gynecology, and pediatrics.
39.3 Discuss the role of the medical assistant in working in
internal medicine, obstetrics and gynecology, and
pediatrics.
39.4 Identify common diseases related to internal
medicine, obstetrics and gynecology, and pediatrics.
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39-3
Learning Outcomes (cont.)
39.5 Describe typical treatments for diseases related to
internal medicine, obstetrics and gynecology, and
pediatrics.
39.6 Identify common signs of domestic violence, elder
abuse, and child abuse.
39.7 Carry out the procedure for assisting with
gynecological examinations and procedures.
39.8 Carry out the procedure for meeting the needs of a
pregnant patient during an examination.
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39-4
Introduction
• Specialties
– Specialist – physician with additional training,
residencies, and certification
– Types of examinations and diagnostic tests
– Common diseases and disorders
• Medical assistant
– Assist with specialty examinations
– Observe for signs of domestic violence and child
abuse
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The Medical Assistant’s Role in Specialty
Examinations
•
Medical practice
act
–
Defines the exact
duties of physicians
and other healthcare personnel
•
39-5
Medical assistants
–
May perform
clinical procedures
only under the
supervision of the
physician
State laws vary. You will need to know the scope of
practice for medical assistants in the state where you
work.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
The Medical Assistant’s Role in Specialty
Examinations (cont.)
39-6
• Providing emotional
support
• Providing patient
education
– Effective communication
– Provide educational
materials
– Verify understanding
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39-7
Apply Your Knowledge
What defines the procedures health-care
personnel can perform, and how do you determine
what you are able to do as a medical assistant?
ANSWER: In addition to education, training, and certification,
the state’s medical practice act defines what duties and
procedures health-care personnel can perform. As a medical
assistant, you have to know your scope of practice for the state
where you work.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-8
Internal Medicine
• Diagnosis and treatment of
disorders and diseases of the
body’s internal organs
• Internist
– Often first to see patient
– Uses medication and/or
treatment modalities
– Refers to a specialist
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39-9
Assisting with the Physical Examination
• Usually the same as a general
physical examination
• Medical assistant
responsibilities
– Gathering information
• Detect substance abuse, domestic
violence, or elder abuse
– Preparing patient for the
examination
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39-10
Detecting Substance Abuse
• Signs vary and depend on
– Type of drug
– Patient’s response to the drug
• Report suspicion of substance abuse
to the physician
• Know state requirements for
reporting
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39-11
Detecting Substance Abuse (cont.)
• Signs of abuse
– Alcohol – depressed pulse rate, respiration,
and blood pressure
– Cocaine – excitation, increased pulse rate
and blood pressure
– Hallucinogens – hallucination, poor
perception of time and distance, severe
panic, violent and bizarre behavior
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39-12
Detecting Substance Abuse (cont.)
– Inhalants – muscle
weakness, hearing
loss, changes in
heart rate, nausea,
and dizziness
– Narcotics –
drowsiness,
depressed respiration,
constricted pupils,
nausea, vomiting,
constipation
– Marijuana –
reddening of the
eyes, increased heart
rate, heightened
appetite, muscular
weakness
– Sedatives – nausea,
slurred speech,
drunken behavior with
no odor of alcohol
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39-13
Detecting Domestic Violence
• Signs of domestic violence – bring to doctor’s
attention
–
–
–
–
Injuries that the patient tries to hide or excuse
Unusual bruising
Signs in a patient’s tone of voice or choice of words
Self blame
• Reporting suspected domestic violence is
mandatory in some states
• Keep a list of services available for a victim of
abuse
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39-14
Detecting Elder Abuse
 Difficult to detect –
no uniform
definition
 Can be mistaken for
falls or chronic
illnesses
 Categories
 Domestic
 Institutional
 Self
– Types
• Physical, sexual,
psychological
• Neglect
• Abandonment
• Exploitation
• Occurs in all racial,
socioeconomic, and
religious groups
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39-15
Detecting Elder Abuse (cont.)
•
Most victims are older women with chronic
illness or disabilities
•
Risk factors
–
–
–
–
History of alcoholism, drug abuse, or violence in the
family
History of mental illness in the abuser or victim
Isolation of the victim from family members and
friends other than the abuser
Recent stressful events affecting the abuser or victim
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39-16
Detecting Elder Abuse (cont.)
•
Observe interactions
between patient and
caregiver
•
Signs of neglect
–
–
•
Take careful history
–
•
Report suspicions of
abuse to physician
–
–
Foul odor from the
patient’s body
Poor skin color
Inappropriate clothing
for the season
Soiled clothing
Extreme concern
about money
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39-17
Diagnostic Testing
• Radiologic testing
– X-rays
– CT scans
– MRI scans
– Ultrasound
– Nuclear imaging
• Medical assistant
– Set up
appointments
– Explain procedures
and preps to
patient
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39-18
Diseases and Disorders
•
Diseases of aging
–
–
–
–
Constipationdiarrhea cycle
Hyperlipidemia
Osteoporosis
Alzheimer’s
disease
•
Infectious diseases
–
–
–
–
Lyme disease
Pneumonia
Rabies
Staph and strep
infections
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39-19
Diseases and Disorders (cont.)
•
STDs
–
Acquired through
sexual contact with
an infected person
– Patient education
•
•
Prevention
Treatment
– Common types of
STDs
•
•
•
•
•
•
Candidiasis
Chlamydia
Genital herpes
Genital warts
Gonorrhea
Trichomoniasis
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39-20
Diseases and Disorders (cont.)
Condition
Description
Anemia
Deficiency of iron or vitamins; results from blood loss
Arthritis
Chronic inflammatory disease of tissues of joints
Gout
Metabolic disease caused by the overproduction or
retention of uric acid
Hypertension
Blood pressure greater than 140/90; usually
asymptomatic
Peptic ulcer
Lesion of mucous membrane of the esophagus,
stomach, or duodenum
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39-21
Apply Your Knowledge
What are the types of elder abuse, and what is the
medical assistant’s role in identification of elder
abuse?
ANSWER: Elder can be abused physically, sexually, or
psychologically. Neglect, abandonment, and exploitation are also
forms of elder abuse. The medical assistant should take a careful
history, observe interactions between caregiver and patient,
observe for signs of abuse, and report suspicions to the physician.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-22
Obstetrics and Gynecology
•
Specialization of the female reproductive
system
–
Obstetrician – focuses on caring for women
during pregnancy and childbirth
–
Gynecologist – focuses on
conditions of the female
reproductive system
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39-23
Gynecologic Physical Examination
• Purpose
– Overview of a woman’s health
– Opportunity for cancer-screening exams and tests
• Female assistant should be present during the
exam
– Assist a male doctor
– Provide legal protection
• Your role is similar to that of the general physical
examination
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39-24
Gynecologic Physical Examination (cont.)
• Physician’s interview
– Evaluation of total
health
– Review of factors that
may indicate cancer or
STDs
• Breast exam
– Check for abnormal
lumps
– Patient education
• Annual mammograms
starting at 40 years old
• Breast exam by
physician annually
• Monthly breast selfexamination
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39-25
Gynecologic Physical Examination (cont.)
• Pelvic examination
– External genitalia, cervix, vaginal wall, internal
reproductive organs, and rectum
– Speculum – expands the vaginal opening
– Medical assistant’s role
• Assist the patient into position
• Assist the doctor
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39-26
Life Cycle Changes
• Menstruation
– Normal cycle of
preparation for
conception
– Menarche –
• Onset of
menstruation
• 10–15 years of age
– Prompted by
hormonal changes
• Menopause
– Cessation of
menstrual cycle
– Stages
• Premenopause
• Perimenopause
– Hormonal changes
or surgical removal
of uterus and
ovaries
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39-27
Diagnostic Tests and Procedures
• Pregnancy test –
detect presence of
HCG
– Blood
– First voided urine
• Tests for STDs
– Cultures and blood
tests
– Examining lesions
– Patient’s history
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39-28
Diagnostic Tests and Procedures (cont.)
• Radiologic tests
– X-rays
• Avoid if pregnant
• Hysterosalpingography
• Mammograms
– Ultrasounds
– CT scan
– MRI
• Fetal screening
– Alpha fetoprotein
• Abnormal levels
can indicate neural
tube defect
– Ultrasound
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39-29
Diagnostic Tests and Procedures (cont.)
• Amniocentesis
– To determine if there
is a genetic or
metabolic problem
with the fetus
• Biopsy
– Surgical removal of
tissue
– Diagnose cancers
• Colposcopy
– Examination of vagina
and cervix
– To identify abnormal
cells
• D and C
– Dilation of the cervix
and scraping the
uterine lining
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39-30
Diagnostic Tests and Procedures (cont.)
• Fine-needle
aspiration
– Remove a sample of
tissue from a cyst,
lump, or tumor
• Pap smear
– Used to determine
presence of abnormal
or precancerous cells
• Hysterectomy
– Removal of the uterus
– Hysterosalpingectomy
• Removal of uterus and
fallopian tubes
– Hysterosalpingooophorectomy
• Removal of uterus,
fallopian tubes, and
ovaries
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39-31
Pregnancy
•
Stages
–
–
–
•
First trimester – conception to 12 weeks
Second trimester – 12 weeks to sixth month
Third trimester – sixth month until birth
Nägele’s rule – estimate of delivery date
–
Subtract 3 months from first day of last period
and add 7 days plus one year
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39-32
Pregnancy (cont.)
• Assisting with prenatal
care
– Patient education
– Assist with routine visit
•
•
•
•
Interview patient
Documentation
Specimen testing
Patient and physician
assistance
• Physician monitors
for
– Placenta previa
– Abrupt placenta
– Gestational diabetes
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39-33
Pregnancy (cont.)
• Labor – stages
– First – regular
contractions and
cervical dilation
– Second – complete
cervical dilation
and entrance of
head into vagina
– Third – expulsion of
the placenta
• Delivery
– Baby’s nose and
mouth suctioned
– Umbilical cord
clamped, tied, and
cut
– Vaginal vs.
cesarean section
– Apgar testing of
newborn
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39-34
Pregnancy (cont.)
• Breast-feeding
– Human milk – preferred form of nutrition
• Colostrum – rich in antibodies that provide
passive natural immunity to baby
– Economical and convenient
– Provide education
– Refer mother to community resources
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39-35
Contraception
Method
Description
Birth control pill
Daily oral contraceptive; inhibits ovulation
Birth control patch
Inhibits ovulation; replaced weekly for 3 weeks,
no patch 4th week
Injection
Synthetic hormone administered every 3 months;
inhibits ovulation
Condom
Worn on penis or inserted into vagina; barrier to
sperm
Diaphragm
Barrier device fits over patient’s cervix; used with
spermicide
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39-36
Contraception (cont.)
Method
Description
Spermicidal foam,
cream, jelly, vaginal
suppositories
Contain chemicals that kill sperm; inserted into
vagina
Vaginal contraceptive
ring
Inserted for 3 weeks; removed for 1 week
Cervical cap
Similar to diaphragm; covers smaller area of
cervix
IUD
Small piece of plastic or metal inserted into
uterus; inhibits fertilization or implantation
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39-37
Contraception (cont.)
Method
Description
Sterilization
Surgical procedure; males – vasectomy; female
– fallopian tubes cut or blocked
Periodic abstinence
Rhythm method; refraining from intercourse
when woman is fertile
Withdrawal
Withdrawing the penis before ejaculation
Postcoital pills
Prevent implantation
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39-38
Obstetrics and Gynecology (cont.)
• Contraception
information
– Planned
Parenthood
Federation
– National Library of
Medicine
– FDA
• Infertility
– Inability to conceive
– Patient education
• Tests
• Treatments
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39-39
Diseases and Disorders
Condition
Description
Cancer
Common occurrence in cervix, endometrium
(uterus), ovaries; cells divide uncontrollably,
eventually forming tumor or other growth of
abnormal tissue
Ectopic
pregnancy
Fertilized egg unable to move out of fallopian tube
into uterus for implantation
Endometriosis
Endometrial tissue present outside uterus, usually
in pelvic area; not life-threatening but may cause
sterility
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39-40
Diseases and Disorders (cont.)
Condition
Description
Fibroids, or
leiomyomas
Common, benign, smooth tumors of muscle cells
(not fibrous tissue) grouped in uterus
Fibrocystic
breast disease
Benign, fluid-filled cysts or nodules in breast
Menstrual
disturbances
Amenorrhea, dysmenorrhea, menorrhagia, or
metrorrhagia
Ovarian cysts
Sacs of fluid or semisolid material; usually benign
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39-41
Diseases and Disorders (cont.)
Condition
Description
Pelvic
inflammatory
disease (PID)
Acute or chronic infection of the reproductive tract;
causes include STDs or other organism
Pelvic support
problems
Abnormal weakening of vaginal tissue, unusual
increase in abdominal pressure, congenital
weakening
Polyps
Red, soft, and fragile growths, with slender stem
attachment on mucous membranes of cervix or
endometrium
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39-42
Diseases and Disorders (cont.)
Condition
Description
Premenstrual
dysphoric
disorder
(PMDD)
Severe premenstrual syndrome affecting 5% of
women; symptoms have disrupting effect on patient’s
life
Premenstrual
syndrome
(PMS)
Symptoms include swelling, bloating, weight
gain, breast tenderness, headaches, and mood
shifts 1 week to 10 days before menstruation
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39-43
Diseases and Disorders (cont.)
Condition
Description
Sexual
dysfunction
disorders
Interruption or lack of sexual response cycle
(excitement, plateau, orgasm, and resolution);
Vaginitis
Inflammation of vagina caused by bacteria,
viruses, yeasts, or chemicals in sprays, douches, or
tampons
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-44
Apply Your Knowledge
1.
A 38-year-old pregnant patient may be carrying
twins. What diagnostic tests may be performed
and why?
ANSWER: Tests will probably include:
Ultrasound to determine fetal size, position, and number of
fetuses
Amniocentesis to determine if there are possible genetic or
metabolic disorders of the fetus.
Alpha fetoprotein to determine if there is a possible neural
tube defect.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-45
Apply Your Knowledge
2.
A patient has just found out she is pregnant. Her
last period started on January 23rd. Using
Nägele’s rule, what day would be her estimated
date of delivery?
ANSWER: Nägele’s rule says count back three months
[1-December, 2-November, 3-October], then add seven days
plus 1 year, [23 + 7 = 30].
Her estimated date of delivery would be October 30th.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-46
Pediatrics
• Specialization in
the health care of
children
– Monitoring
development
– Diagnosing and
treating illnesses
– Pediatrician
• Medical assistant
responsibilities
– Parent or caregiver
education
– Immunization
schedule
– Detection of child
abuse
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39-47
Assisting with the Pediatric Physical
Examination
•
•
Ask about eating habits, sleep patterns, daily
activities, immunization schedules, and toilet
training
• Relieve fear
Adolescents
–
–
STDs, drugs, and alcohol
Awkward and self-conscious
–
–
•
Explain procedures
Allow child to examine
instruments
Speak in terms
appropriate to age
level
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39-48
Assisting with the Pediatric Physical
Examination (cont.)
•
Examining the well child
–
Infants need seven well-baby
examinations during their first year at
these intervals
•
•
•
•
2 weeks
1 month
2 months
4 months
6 months
 9 months
 1 year

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39-49
Assisting with the Pediatric Physical
Examination (cont.)
•
Examining the well child (cont.)
–
–
Children in the second year of life should
have checkups at 15 and 18 months
Annually after 2 years old
•
Prepare for exam as you would
for an adult
•
Follow Universal Precautions
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39-50
Detecting Child Abuse
•
Watch for problems
in relationship
between child and
parent/caregiver
• Signs of abuse
–
–
–
–
•
Observe for
unexplained injuries
–
–
–
Dirty diaper
Neglected appearance
Hunger
Extreme sadness or
fear
Inability to
communicate
Bruises or burns
Lesions on child’s
genitalia
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39-51
Detecting Child Abuse (cont.)
•
Risk factors for abuse
Stress
– Single parenthood
– Inadequate knowledge of developmental
expectations
– Lack of family support/family hostility
– Financial problems
– Mental health problems
–
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-52
Detecting Child Abuse (cont.)
•
Physician will examine for:
–
–
–
•
Internal injuries, tenderness when palpated or
auscultated
Malnutrition, tooth discoloration, unhealthy
gums
Lack of cognitive ability, dulled neurological
responses
You are legally responsible for reporting
suspected child abuse or neglect
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-53
Assisting with the Pediatric Physical
Examination (cont.)
• Examining for growth abnormalities
– Compare the child’s physical, intellectual, and
social signs to national averages
– Growth stages
•
•
•
•
One and Two – first and second years
Three – ages 3 to 5 years
Four – age 6 years to puberty
Five – adolescence
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39-54
Assisting with the Pediatric Physical
Examination (cont.)
• General eye exam
– Pediatrician examines
interior of the eye
– Visual acuity testing
• General ear exam
– Children more
susceptible to ear
infections
• Diagnostic testing
– Most are same as for
adults
– Rapid test for
presence of
streptococcal bacteria
– Throat cultures
– Urine specimens
– Blood specimens
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-55
Assisting with the Pediatric Physical
Examination (cont.)
• Immunizations
– Store vaccines properly
– Administer vaccines correctly
– Maintain careful immunization
records
– Educate parents
– Follow recommended schedule
for follow-up appointments
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-56
Diseases and Disorders
• Frequently seen in pediatric office
– Common childhood diseases (Table 39-2)
– Upper respiratory infections
• Do not make assumptions regarding
diagnosis or treatment
• Do not recommend aspirin for fever in
children
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-57
Diseases and Disorders (cont.)
Condition
Description
AIDS
Most transmitted from mother to infant; decreased
chance of infected infant if mother is being treated
Juvenile
rheumatoid
arthritis
Autoimmune disease of the joints; occurs in children 16
years or younger
ADHD
All conditions identified as hyperactivity, hyperkinesis,
and attention deficit
Learning
disabilities
Conditions that interfere with learning, including
dyslexia, dysgraphia, and dyscalculia
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-58
Diseases and Disorders (cont.)
Condition
Description
Cerebral
palsy
Birth-related disorder of nerves and muscles; caused by
brain damage occurring before, during, or after birth
Congenital
Cardiovascular malformations in the fetus before birth;
heart disease causes include genetic mutations, maternal infections,
maternal alcoholism, or maternal insulin-dependent
diabetes
Down
syndrome
Genetic disorder due to one extra chromosome in all
cells formed during fetal development; characteristic
facial features
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-59
Diseases and Disorders (cont.)
Condition
Description
Hepatitis B
Infection of liver; virus can be transmitted from the
mother before or during birth; immunization available
RSV
Major cause of lower respiratory infections; highly
contagious; difficult to treat; antibiotics only treat any
secondary infections
SIDS
Unexplained sudden death of an infant during sleep;
usually occurs before 6 months old; “Back to Sleep”
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39-60
Diseases and Disorders (cont.)
Condition
Description
Spina bifida
Defect of spinal development occurring during the
first trimester of pregnancy; spinal cord not fully
protected because tissues fail to close around it
Viral
gastroenteritis
Inflammation of stomach and intestines; can cause
dehydration and electrolyte imbalance due to fluid
loss
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-61
Patient and Caregiver Education
• Answer questions
appropriately
• American
Academy of
Pediatrics
– Brochures and
booklets
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-62
Apply Your Knowledge
What are the responsibilities of the medical
assistant relating to immunizations?
ANSWER: The medical assistant should be sure that
vaccines are stored properly, administer vaccines
correctly (if within scope of practice), maintain
careful immunization records, educate parents,
follow recommended immunization schedule for
follow-up appointments.
Supe
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-63
In Summary
39.1 Internal medicine practitioners diagnose and treat
diseases and disorders of the internal organs. An
obstetrician/ gynecologist (OB/GYN) specializes in the
female reproductive system, cares for pregnant
women and delivers babies. A pediatrician specializes
in the health care of children.
39.2 Examples of exams and diagnostic tests performed in
internal medicine, obstetrics and gynecology and
pediatrics include the basic physical exam, the
gynecological exam, the cervical biopsy, and the well
child exam.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-64
In Summary (cont.)
39.3 As a medical assistant in basic specialties, you might
perform or assist with testing such as urine, blood
tests, and bacterial cultures. You might educate
patients on diseases of aging, infectious diseases,
and STDs.
39.4 Some common diseases related to internal medicine
include hypertension, coronary artery disease, and
diabetes mellitus. Childhood diseases include
chickenpox, influenza, measles, mumps, rubella,
scarlet fever, and tetanus. Examples of diseases
related to obstetrics and gynecology include cancer,
endometriosis, and fibrocystic breast disease. Other
diseases are outlined in Tables 39-1, 39-3, and 39-5.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-65
In Summary (cont.)
39.5 Typical treatments for diseases related to internal
medicine, obstetrics and gynecology, and pediatrics
include such things such as local or oral medication,
including antibiotics, stress reduction, diet restrictions,
and surgery. Treatments are outlined in more detail in
Tables 39-1, 39-3, and 39-5.
39.6 Some common signs of domestic violence, elder
abuse, and child abuse include unusual bruising or
injuries that the patient tries to hide or excuse, foul
odor, poor skin color, soiled clothing, and malnutrition.
Recognizing the signs of these three problems is
essential to your role as a medical assistant.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-66
In Summary (cont.)
39.7 During a gynecological exam or procedure, you will
need to ensure patient comfort and safety as well as
assist the physician with patient positioning, draping,
equipment, and specimens obtained.
39.8 A pregnant woman will need to have her concerns
and questions answered. During late pregnancy, she
may not be able to move into certain positions and
will require assistance.
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.
39-67
End of Chapter 39
If pregnancy were a
book they would cut
the last two chapters.
~ Nora Ephron
© 2011 The McGraw-Hill Companies, Inc. All rights reserved.