The

Professional Medical Assistant

An Integrative, Teamwork-Based Approach

The

Professional Medical Assistant

An Integrative, Teamwork-Based Approach
Sharon Eagle, RN, MSN
Former Director, Medical Assisting Program Wenatchee Valley College Wenatchee, WA

Cindi Brassington, MS, CMA (AAMA)

Professor of Allied Health Quinebaug Valley Community College Danielson, CT

Candy Dailey, RN, MSN, CMA (AAMA)

Instructor, Medical Assistant Program Director, Health Occupations Instructor Nicolet Area Community College Rhinelander, WI

Cheri Goretti, MA, MT (ASCP), CMA (AAMA)

Professor and Medical Assisting Program Director Quinebaug Valley Community College Danielson, CT

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright 2009 by F. A. Davis Company Copyright 2009 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Senior Acquisitions Editor: Andy McPhee Manager of Content Development: George W. Lang Developmental Editor: Brenna H. Mayer Art and Design Manager: Carolyn OBrien As new scientic information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up-to-date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data The professional medical assistant: an integrative, teamwork-based approach / Sharon Eagle ... [et al.]. p. ; cm. Includes index. ISBN-13: 978-0-8036-1668-4 ISBN-10: 0-8036-1668-6 1. Physicians assistants. I. Eagle, Sharon. [DNLM: 1. Physician Assistants. 2. Clinical Competence. 3. Patient Care Team. W 21.5 P9635 2009] R697.P45P76 2009 610.7372069dc22 2009002947 Authorization to photocopy items for internal or personal use, or the internal or personal use of specic clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1668-6/09 0 $.25.

Dedication
Thanks to my children Brad, Brian, and Nicole for your love and encouragement; to my daughters-inlaw and son-in-law, Melissa, Sayo, and Adam for loving my children and for your patience with their mother; to my grandsons Gabe, Seth, and Isaac for enriching our family in such an amazing way; to my siblings, Rob, Steph, Rick, Roger, and Troy, though some of us are miles apart, we are always close in spirit; to my mother Durmma, for your unfailing love and support; and to my cowriters, Cindi, Cheri, and Candy, your support, commitment, work ethic, warmth, humor, and friendship have made this an awesome journey.SE Thanks to my husband Gary for your help with orthopedics, acupuncture, and does this sound right? Sadie and Hannah, my ever-understanding daughters for cooking, cleaning, doing laundry, and taking care of Mom through this project, I love you all.CB Thank you to my loving, supportive parents, Bill and Mary Jane Schultz, who taught me the importance of hard work and education; my husband, Bucky, who inspires me every day; my children, Bill, Deuce, Matthew, and Elizabeth, and siblings, Kirby, Brian, and Stephanie, for strength in family; my incredible repertoire of colleagues and friends who encourage and rejuvenate me with every conversationBecki, Dr. Nick, Ann, Connie, Shelly, Julie, Deb, Nancy, Holly, Tracey, the Wisconsin Medical Assistant Educators Group, the Dream Team, and my Lake Lucerne family.CD Thanks to Dean Huard and President Williams for the support you gave me throughout this project as well as all of the students who have touched my life and have, in their own way, contributed to this book. To the Dream Team, I enjoyed sharing this journey with a group of fabulous individuals and I value your friendship immensely. Lastly, to my family, John, Lynn, and Jill, for your understanding, patience, and help while I spent countless hours working on the book. This is for you, and I love you all!CG

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Preface
The profession of medical assisting has evolved dramatically since its inception more than 50 years ago. Expectations placed on medical assistants continue to increase. Individuals entering and working in this dynamic eld are challenged more than ever before to meet the demands of the profession and evolve with it. Developing a sound knowledge base is mandatory. Maintaining currency in knowledge and skills is crucial. Demonstrating exibility on the job is critical. Working effectively and efciently as team members is of the utmost importance. Those characteristics, so essential to the profession and so highly valued by employers, are the pervasive themes of this text. thats the way faculty teach, students learn, and medical assistants practice.

Teamwork
Health care employers highly prize medical assistants who demonstrate the ability to work well with others as effective members of the health care team. The importance of teamwork is emphasized throughout this book in the written text, sidebars, and activities. Special recurring sidebars clarify the connections between the front and back ofce by pointing out how team members from different areas of the medical ofce can work together in a cooperative, efcient manner. Activities in the text and workbook provide opportunities for students to practice and develop the skills necessary for good teamwork, especially communication and active problem-solving. These activities help students adopt and maintain a exible attitude, demonstrated by a willingness to help meet the needs of patients, coworkers, and supervisors. By emphasizing skill maintenance and exibility, this text encourages students to avoid restricting themselves to one narrow area of comfort. Rather, it urges them to become diverse and procient in all areas of knowledge and skill and carry this commitment beyond graduation into the workplace for the duration of their careers. By committing themselves to lifelong learning and skill maintenance, they will nd themselves among the most valued and respected members of the health care team, regardless of where they choose to work.

Our Approach
By integrating the content, focusing on building teamwork skills, and providing opportunities for students of all learning styles, The Professional Medical Assistant: An Integrative, Teamwork-Based Approach helps learners move from novice students to competent professionals.

Integrated Content
We have chosen to present this text as a unied whole to allow students to learn within the full context of medical assisting practice. Other comprehensive textbooks present sterile divisions between general, administrative, and clinical units. To divide the content in such a manner emphasizes the disconnect that already exists between the front and back ofce. In truth, neither can survive without the other, and both areas thrive when all individuals make the same commitment to work together as a team. Keeping the text unified has allowed us to present content the way most instructors present it in classby making full use of teachable moments, the times when an individual is particularly responsive to learning something new. Rather than presenting, say, medical coding content solely in the administrative section of the book, we also present it at opportune moments in the clinical section, listing pertinent ICD-9-CM codes, for instance, at the beginning of each discussion of a disease. Rather than covering patient education solely in the clinical section, we also present it at appropriate times in the administrative section. We chose this integrated approach because

Multiple Learning Styles

We have embedded within the textbook, workbook, and student and instructor ancillaries a wide variety of exercises and activities to help meet the learning needs of all students. The rst chapter introduces learning styles and helps students choose the most effective study techniques for them, such as study groups vs. solitary study or tape recording lectures. By addressing learning styles clearly and uniformly, we aim to enhance the entire learning experience for students and teaching experience for faculty.

Competency Development
This comprehensive text covers a wide range of topics in medical assisting theory and clinical competency, or skill. It supports competency acquisition by providing clear, thorough xi

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explanations within the text, detailed step-by-step procedures, and full-color photos and illustrations that show how to perform the necessary competencies. Procedures within this text are written in a student-friendly, step-by-step format so that students can easily refer to them as they learn and practice. Rationales are also included within the procedures to help students understand the reason for certain steps to help them become more than mere technicians and begin to function as knowledgeable professionals. The Instructors Resource Disk (IRD) contains in-depth procedure checklists, and the student disk offers fun animations and interactive activities, also available on the DavisPlus website (www.davisplus.fadavis.com). All activities support learning, review, repetition, and competency in all requirements. Demonstration of competency is an important part of the learning process and is the gold standard for verifying a students ability. It also provides critical data for program evaluation and maintenance of accreditation. To address the need for such verication, the text clearly identies competencies specically required by the Commission on Accreditation of Allied Health Programs (CAAHEP) and the Accrediting Bureau of Health Education Schools (ABHES). It also includes additional competencies common to the health care setting. Competencies are addressed in most of chapters of this text as appropriate to the subject matter. The instructor can easily locate each competency by referring to the Index of Competencies in Appendix C. In addition, the IRD contains information to help instructors evaluate student competence.

Reference Lists
Each chapter includes several reference lists that indicate the information addressed in the chapter, including:

clear learning objectives that indicate what the student should learn from reading the chapter key competencies addressed in the chapter for the Committee on Accreditation of Allied Health Programs (CAAHEP) and the Accrediting Bureau of Health Education Schools (ABHES) list of procedures included in the chapter chapter outline table of key terms from the chapter along with brief denitions with the corresponding term in the text set in boldface to emphasize its importance. bulleted chapter summary located at the end of each chapter for a quick review of the chapter highlights resource list at the end of each chapter that provides students with sources of current information, including books, journals, and Internet sites and encourages students to expand their learning by conducting their own information search.

Body Systems and Specialties

Several chapters in the clinical unit address body system and specialty information. Key features of these chapters include:

Gender References
We recognize and welcome the increasing number of men entering the profession of medical assisting. We desire to treat all individuals referenced in this text with the courtesy and respect they deserve but nd it awkward and cumbersome to consistently use gender-neutral references. Therefore, because the vast majority of individuals within this profession are female, this text refers to students and medical assistants as female. It refers to physicians alternately as male or female because recent data indicate that nearly one-half of those currently graduating from medical school are female. It also alternates references to patients as male or female, with preference shown only when discussing disorders or situations that overwhelmingly apply to one sex more than the other.

consistent organization of all body system chapters to clearly identify information on anatomy and physiology, medical terminology, and pathology, testing, and treatment information on structure and function for each body system to help students understand anatomy and physiology medical terminology related to body systems with an emphasis on relevant combining forms, abbreviations, and pathologic terms most common diseases and disorders seen by medical assistants for each body system along with the appropriate ICD-9-CM code used for each disorder discussion of the role of the medical assistant in each specialty, along with commentary about specialized diagnostic tests, procedures, and treatments.

Other Critical Information

In addition to comprehensive body system and specialty reviews, other chapters highlight critical information, including:

Features
Content within this text is organized according to general, administrative, and clinical subject areas. The user-friendly writing style engages the learner and explains the subject matter in a manner that is clear and simple, but sufciently detailed to inform without overwhelming. Numerous features of the text are designed to enhance student learning.

Chapter 1, Succeeding as a Student, sets the stage for success by helping students develop strategies for testtaking, anxiety reduction, and self-care. Chapter 3, Professionalism, stresses issues so important to prospective employers, including dependability, exibility, positive attitude, tact, appropriate appearance, and ability to function as a team player.

P R E FAC E

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Chapter 7, HIPAA and a Patients Rights, is devoted to information about a patients rights and the role and responsibilities of the medical assistant in maintaining protected health and personal information without unnecessarily preventing patients from access to their medical records. In addition, it reviews the responsibilities of a HIPAA compliance ofcer. Chapter 8, Bioethics, introduces students to ethical principles and philosophies and helps them better understand how they can identify and respond to ethical issues in the workplace. Chapter 14, Medical Records Management, discusses electronic medical records and how personnel in the medical ofce can transition from paper-based medical records to electronic medical records. Chapter 16, Coding and Insurance, introduces students to ICD-9-CM and CPT-4 coding. Examples and activities included help students gain competency. ICD-10 coding is also introduced. Chapter 23, Essentials of Medical Terminology, introduces students to basic medical terminology, including key categories of medical word elements and the steps to medical term translation. A comprehensive list of prexes and sufxes is provided. Organization of medical terminology content in this text introduces terminology to the novice or serves as a review for those who have already completed a medical terminology course. Chapter 34, Geriatrics, describes the physiological changes caused by the aging process in each body system as well as diseases and disorders associated with aging. It also explores special needs of the geriatric population related to communication, safety, mobility, pain management, and end-of-life care. Chapter 42, Hematology and Coagulation Procedures, Chapter 43, Clinical Chemistry and Serological Procedures, and Chapter 44, Urinalysis, include normal values for common laboratory tests. Chapter 46, Bioemergency Response and Preparedness, addresses the medical assistants role in responding to biological emergencies and pandemics.

informational sidebars that highlight specic information and provide additional detail recurring Front OfceBack Ofce Connection sidebars that emphasize the critical nature of teamwork that must occur on an ongoing basis between administrative and clinical medical assistants as well as other members of the health care team recurring Patient Education sidebars strategically placed throughout the text that capitalize on the teachable moments that occur in relation to specic topics and address patient education in a way that is more specic and, therefore, more useful than a list of generic teaching tips placed at the end of a chapter numerous tables and colorful illustrations located throughout the text that clarify and emphasize specic information

Learning Activities
Two groups of learning activities at the end of each chapter challenge students to think critically and apply the information they have learned from the chapter. These activities include:

team work exercises that allow students to work cooperatively as members of a group case studies that provide real-life scenarios, which require the student to problem-solve using the information supplied and the knowledge gleaned from the chapter.

Appendices
Also included are several key appendices that provide helpful information for using the book and enhancing student learning. Appendices include:

complete glossary of key terms from the text key abbreviations from the text listed in table format index of all competencies included in the chapters as well as an indication of work product requirements for those competencies outlines of the content on the CAAHEP and ABHES certication examinations list of over 200 of the most commonly prescribed drugs, including generic and trade names.

Sidebars, Tables, and Procedures

In addition to the individual chapter features, all chapters include numerous sidebars, tables, and procedures that highlight important information or provide additional information on an important subject. These elements include:

Support Materials
Several additional resources are available that will enhance the instructors and students use of the textbook.

procedures written in a clear, step-by-step format with rationales provided in a different color to help students quickly grasp and understand why a step should be performed charting examples included for procedures that require documentation to help students begin to learn how to document care

Instructors Resource Disk (IRD) helps instructors to administer examinations, design course content, provide student activities, and track student performance. Features include: test bank with more than 1,500 multiple-choice test questions that require critical thinking as well as memory

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recall, with each question categorized as general, administrative, or clinical function that enables the instructor to select questions from the test bank to create tests, including tests similar in format and subject matter to the certication examination chapter outlines to aid instructors in developing lecture notes sample syllabi for semester-based courses as well as module-based courses additional classroom activities not included in the text or student workbook detailed PowerPoint presentations for each chapter, including photos and illustrations from the text competency checklists in Microsoft Word format for each procedure included in the text so that instructors can print and use the checklists as they are designed or modify them as desired to meet individual program needs. Student workbook includes a variety of learning activities that incorporate various student learning styles. Activities include: key term review medical terminology review chapter review anatomy identication disease or condition identication competency checklists that correspond to each procedure within the text ofce projects that require students to apply knowledge and skills learned from a chapter to the performance of specic activities for those chapters that do not contain formal procedures, including creating educational or informational bulletin boards, sponsoring blood pressure clinics within the community, and hosting guest speakers for the benet of the class and entire student body critical thinking exercises that require students to use the reasoning process, to apply what they have learned, and to work cooperatively together to solve problems, including case studies, research activities, and team work exercises. Student Activity Disk includes interactive, fun learning activities, including: Match It Up Categorize This! Dont Tip the Scale! What Is It?

Label It Wheel of Terminology Flash Cards Multiple Choice Fill It In. DavisPlus website includes additional learning activities and colorful animations designed specically for medical assistant students as well as many others designed for all allied health students.

The complete Professional Medical Assistant package provides learners and educators with an exciting, comprehensive suite of information and activities. It provides learners with foundational information to launch their careers and guide them on their journey to becoming health care professionals. We have enjoyed the challenge and privilege of creating this comprehensive learning package. It is our hope that educators and students alike will nd it equally enjoyable to use. Sharon Eagle Cindi Brassington Candy Dailey Cheri Goretti

Contributors
The authors would like to acknowledge two individuals whose contributions to the text have ensured its quality and accuracy: Wilbert S. Ching, BSMT, CPT (NPA) Phlebotomy Instructor Quinebaug Valley Community College Program Coordinator and Instructor (Health Services) American Red Cross of Central Massachusetts Linda Howrey, EJD, CCS-P Managing Partner, Howrey and Associates Member, AHIMA Presidents Council in Physician Practice

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Reviewers
Darlene Kaye Acton, CMA (AAMA) Director Medical Assisting Department Alamance Community College Graham, NC Carole Berube, MA, MSN, BSN, RN Professor Emerita in Nursing, Instructor in Health Sciences Bristol Community College Health Sciences Fall River, MA Kay E. Biggs, BS, CMA (AAMA) Coordinator/Advisor Medical Assisting Columbus State Community College Medical Assisting Gahanna, OH Beth Anne Buchholz, CMA (AAMA) Medical Assistant Program Director Wichita Area Technical College Health Sciences Wichita, KS Carmen Carpenter, RN, MS, CMA (AAMA) Chair Allied Health and Medical Assisting South University West Palm Beach, FL Mary Ann Crandall, RN, BS, MS Instructor Extended Campus Programs Southern Oregon University Ashland, OR Michael Lewis Decker, RMA Instructor Vatterott College Medical Assistant Program Omaha, NE Linda Demain, LPN, BS in BQM & HRD Medical Externship Advisor Wichita Technique Institute Mulvane, KS Peter Doolin, MEd, MT (ASCP), RMA Instructor, Medical Program McFatter Technical Center Davie, FL Theresa Errante-Parrino, CMA (AAMA), EMTP,
BMO, MEd

Medical Assisting Program Director Indian River Community College Fort Pierce, FL Tracie Fuqua, B.S., CMA (AAMA) Program Director, Medical Assisting Wallace State Community College Athens, AL Anne D. Gailey, CMA (AAMA) Certied Medical Assistant Medical Assisting Instructor Ogeechee Technical College Medical Assisting Program Allied Health Department Statesboro, GA Marcie C. Jones, CMA (AAMA), CLC Medical Assisting Program Director Gwinnett Technical College Health Sciences and Personal Services Lawrenceville, GA V. Maloof, MD Phlebotomy Program Director, Educator Grifn Technical College Medical and Public Services Department Morrow, GA Maureen Elizabeth Russell Messier, AS, BA, RMA,
CMA (AAMA)

Instructor Branford Hall Career Institute Medical Assisting Department Unionville, CT

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REVIEWERS

Pat G. Moeck, PhD, MBA, BA, CMA (AAMA) Director, Medical Assisting Program El Centro College Health and Legal Studies Dallas, TX Lisa Nagle, CMA (AAMA), BSEd Program Director/Instructor, Medical Assisting Program Augusta Technical College Augusta, GA Tracy Thomas, RMA Instructor St. Louis College of Health Careers Medical Assistant Program St. Louis, MO Marilyn M. Turner, RN, CMA (AAMA) Director Medical Assisting Program Ogeechee Technical College Allied Health Department Statesboro, GA

Karon G. Walton, CMA (AAMA) Clinical Coordinator/Instructor Augusta Technical College Medical Assisting Program Augusta, GA Deborah L White, CMA (AAMA), MS Program Coordinator Trident Technical College Medical Assisting Program Charleston, SC Danielle Schortzmann Wilken, MS, MT (ASCP) Health Sciences Department Chair Goodwin College Avon, CT Kari Williams, BS, DC Program Director Medical Ofce Technology Front Range Community College Longmont, CO

Acknowledgments
The authors would like to thank the F.A. Davis editorial and production team for their contribution to this project:

Andy McPhee, Acquisitions Editor, who provided the perfect balance of guidance and support Margaret Biblis, Publisher, Health Professions and Medicine, whose behind-the-scenes support we have continually felt and appreciated Brenna Mayer, Developmental Editor, whose attention to detail, consistency, and quality have made this the highquality text that it is.

In addition, we wish to acknowledge and thank these dedicated individuals who also helped in this publication:

George W. Lang, Manager of Content Development Karen Carter, Developmental Editor Yvonne N. Gillam, Associate Developmental Editor Elizabeth Y. Stepchin, Developmental Associate Kimberly Harris, Administrative Assistant Stephanie A. Casey, Administrative Assistant Kirk Pedrick, Electronic Product Development Manager, Electronic Publishing Frank J. Musick, Developmental Editor, Electronic Publishing Carolyn OBrien, Design Manager Kate Margeson, Illustrations Coordinator Robert Butler, Production Manager David Orzechowski, Managing Editor Virgil Lloyd, Promotions Manager.

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Contents at a Glance
U N I T I General-Transdisciplinary CHAPTER 1 Succeeding as a Student CHAPTER 2 The Profession of Medical Assisting CHAPTER 3 Professionalism CHAPTER 4 Health Care Yesterday and Today CHAPTER 5 Therapeutic Communication CHAPTER 6 Legal Considerations CHAPTER 7 HIPAA and a Patients Rights CHAPTER 8 Bioethics CHAPTER 9 Patient Education UNIT II
CHAPTER CHAPTER CHAPTER CHAPTER

1
3 11 19 27 43 53 71 85 95

CHAPTER CHAPTER CHAPTER CHAPTER CHAPTER CHAPTER

26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49

CHAPTER CHAPTER CHAPTER CHAPTER

Administrative
The Ofce Environment Telephone Techniques Appointment Scheduling Written Ofce Communications and Mail Medical Records Management Ofce Management Coding and Insurance Billing and Collections Accounting and Banking

109
111 121 133 151 173 187 203 247 259

10 11 12 13 14 15 16 17 18

CHAPTER

CHAPTER CHAPTER CHAPTER

CHAPTER CHAPTER CHAPTER CHAPTER CHAPTER

CHAPTER

CHAPTER CHAPTER

CHAPTER

U N I T I I I Clinical C H A P T E R 19 Infection Control and Medical Asepsis C H A P T E R 20 The Patient Interview C H A P T E R 21 Vital Signs C H A P T E R 22 Physical Examination C H A P T E R 23 Essentials of Medical Terminology C H A P T E R 24 Surgical Asepsis and Assisting with Minor Surgery C H A P T E R 25 Dermatology

285
CHAPTER

285 307 319 345 367

CHAPTER CHAPTER

CHAPTER CHAPTER

CHAPTER

381 411

Neurology Cardiology and Lymphatics Pulmonology Endocrinology Gastroenterology Urology and the Male Reproductive System Obstetrics and Gynecology Pediatrics Geriatrics Orthopedics Ophthalmology and Otolaryngology Nutrition Introduction to Pharmacology Dosage Calculation and Medication Administration Introduction to the Clinical Laboratory Phlebotomy Hematology and Coagulation Procedures Clinical Chemistry and Serological Procedures Urinalysis Microbiology Bioemergency Response and Preparedness Ofce Emergencies Radiology and Diagnostic Imaging Externship and Career Strategies

435 461 495 519 537 567 599 641 683 707 745 777 805 825 849 867 889 903 919 935 959 967 991 1007

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C O N T E N T S AT A G L A N C E

APPENDICES APPENDIX A Glossary APPENDIX B Abbreviations APPENDIX C Index of Competencies

1023
1023 1037 1041

APPENDIX APPENDIX

D E

Commonly Prescribed Drugs Certication Examination Content Outlines Index

1047 1053 1059

Contents
U N I T I General-Transdisciplinary CHAPTER 1 Succeeding as a Student
The Journey Begins Learning Styles Solitary Learners Social Learners Auditory Learners Visual Learners Kinesthetic Learners Oral-Dependent Learners Writing-Dependent Learners Test-Taking Strategies Anxiety Reduction Preparing for the Examination Just Before the Examination During the Examination Practical Strategies Self-Care Body Mechanics Safe Lifting Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

1
3
4 4 4 4 5 5 5 5 5 5 5 7 7 7 7 8 8 8 10 10 10 10

CHAPTER

Professionalism
Characteristics of a Professional Accuracy Courteousness and Respectfulness Dependability Flexibility Commitment to Lifelong Learning Tactfulness Accountability Positive Attitude Professional Appearance Daily Hygiene Makeup Jewelry Tattoos Hair Attire Medical Assistant as a Role Model Qualities of a Good Role Model Barriers to Professionalism Bad Habits Reactive Versus Proactive Personal Problems at Work Rumors and Gossip Becoming a Team Player Chapter Summary Team Work Exercises Case Studies Resources

19
20 20 20 20 21 21 21 22 22 22 22 22 22 22 22 22 23 23 24 24 24 24 24 24 25 25 26 26

The Profession of Medical Assisting 11

Role Description Career Opportunities for Medical Assistants Credentialing Certied Medical Assistant Registered Medical Assistant Professional and Regulatory Organizations American Association of Medical Assistants American Medical Technologists Accrediting Organizations Chapter Summary Team Work Exercises Case Studies Resources 12 13 14 15 15 15 15 15 16 16 16 17 17

CHAPTER

Health Care Yesterday and Today

Brief History of Medicine Ancient Health Care Early Development of Medicine Current Medicine Future of Medicine Health Care Settings Hospitals Long-Term Care Subacute Care Home Care Ambulatory Care

27
29 29 30 31 32 33 33 33 33 33 33

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CONTENTS

Types of Medical Practices Sole Proprietorship Partnership Corporation Health Care Team Physicians Other Practitioners Nurses Physician Assistants Medical Technologists Therapists Physical Therapist Occupational Therapist Respiratory Therapist Speech Therapist Registered Dietitian Prehospital Care Specialists Emergency Medical Technicians Paramedics Technicians Phlebotomist Radiologic Technicians Medical Laboratory Technicians Administrative Specialists Medical Coding Specialist Medical Transcriptionist Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

33 33 34 34 34 34 35 37 38 38 39 39 39 39 39 39 39 39 40 40 40 40 40 40 40 41 41 42 42 42

Regression Repression Displacement Denial Projection Strategies for Dealing with Difcult People Focusing on the Patient Acknowledging the Patient Validating the Patients Feelings Using I Language Move to a Solution Setting Boundaries Cultural Variables Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

48 48 48 48 48 49 49 49 49 49 50 50 50 51 51 51 52

Legal Considerations
Legal Relationship of the Patient and Physician Medical Practice Act Licensure Revoking a License Scope of Practice Standard of Care Consent Implied Consent Informed Consent Malpractice The Lawsuit Process Subpoenas and Depositions Trial Malpractice Insurance Intentional Torts Criminal Versus Civil Law Patient Noncompliance Statute of Limitations Risk Management Documentation Condentiality Exceptions to Disclosure Rules Durable Power of Attorney and Living Wills Reporting Abuse Child Abuse Neglect Emotional Abuse Physical Abuse Sexual Abuse Elder Abuse Neglect Physical Abuse

53
55 55 55 56 56 56 56 56 57 57 57 57 58 58 58 59 60 61 61 62 63 63 63 63 64 64 65 65 65 67 67 67

Therapeutic Communication
First Impressions Communication Cycle Referent Message Sender and Receiver Channels Feedback Interpersonal Variables Environment Verbal Communication Nonverbal Communications Active Listening Giving Advice Communication Patterns Passive Passive-Aggressive Assertive Aggressive Communication Challenges Defense Mechanisms Rationalization Compensation

43
45 45 45 45 45 45 45 46 46 46 46 46 47 47 47 47 47 47 48 48 48 48

CONTENTS

xxv

Chapter Summary Team Work Exercises Case Studies Resources

CHAPTER

69 69 70 70

Case Studies Resources

CHAPTER

93 93

Patient Education
Medical Assistants Role in Patient Education Learning Styles Learning Domains Cognitive Domain Affective Domain Psychomotor Domain Assessing Learning Needs Identifying Learning Objectives Organizing the Teaching Session Motivation to Learn Locus of Control Self-Efcacy Barriers to Effective Patient Education Emotional Response to Illness and Disability Physical and Personal Barriers to Learning Age-Related Teaching Considerations Teaching Strategies Verbal Lecture Conversational Group Patient Education Literature Evaluation of Learning Legal Implications of Patient Education Chapter Summary Team Work Exercises Case Studies Resources

95
96 96 97 97 97 97 97 98 98 98 99 99 101 101 101 102 104 104 105 105 105 106 106 106 107 108 109

HIPAA and a Patients Rights

HIPAA Title I: Insurance Reform Title II: Administrative Simplication Reduced Cost Privacy Protection Patients Right to Access HIPAA Compliance HIPAA Compliance Ofcer Safeguards for PHI Administrative Technical Physical HIPAA Documents HIPAA Noncompliance Chapter Summary Team Work Exercises Case Studies Resources

71
72 74 74 74 75 77 79 79 79 79 80 80 80 82 84 84 84 84

CHAPTER

Bioethics
Ethics and Morals Law and Ethics Bioethics Ethical Principles Nonmalecence Benecence Autonomy Distributive Justice Paternalism Veracity Fidelity Ethical Philosophies Deontological Philosophies Teleological Philosophies Philosophical Divide Anatomy of an Ethical Dilemma Ethical Decision Making Ethics Committee Ethics and the Medical Professional Code of Ethics Ethical Behavior in the Medical Ofce Trust and Loyalty Condentiality Respect and Dignity Commitment to Professional Development Chapter Summary Team Work Exercises

85
86 86 87 87 87 87 88 88 88 88 88 88 89 89 89 89 89 90 90 90 90 91 91 91 92 92 93

UNIT II
CHAPTER

Administrative
The Ofce Environment
Welcoming New Patients Americans with Disabilities Act Ofce Design Privacy Workow Ergonomics Reception Area Managing Ofce Space Lighting Colors Reading Materials Music Cleanliness Educational Resources Marketing Materials Ofce Safety Other Precautions

109
111
112 112 112 112 113 113 114 114 115 116 116 117 117 118 118 118 118

10

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CONTENTS

Chapter Summary Team Work Exercises Case Studies Resources

CHAPTER

119 119 119 119

11

Telephone Techniques
Essential Tool Telephone Etiquette Answering Incoming Calls Hold Volume and Tone Clarity and Speed Multilingual Callers Making Outgoing Calls Ending Calls Time Zones Call Handling Taking Messages Triaging Calls Difcult Callers Automated Routing Units Documentation Answering Service or Machine Chapter Summary Team Work Exercises Case Studies Resources

121
122 122 123 123 123 123 123 124 124 124 124 128 128 130 130 130 130 131 132 132 132

Charging for Cancelled Visits or Denying Future Visits Triage for Setting Appointments Referral Procedures Termination of Services Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

140 140 145 147 147 148 148 149

13

Written Ofce Communications and Mail

Communications and the Medical Ofce Business Letters Four Styles for Letters Letters to Patients Letters to Physicians Letters to Attorneys Faxed Documents Preparing an Envelope Internal Marketing Reminder Notes Birthdays and Holidays Generating Referrals E-mail Guidelines Incoming Mail Transcription of Medical Documents Chapter Summary Team Work Exercises Case Studies Resources

151
152 152 154 155 156 156 160 162 164 164 164 164 166 166 169 171 171 171 171

CHAPTER

12

Appointment Scheduling
Challenges in Appointment Scheduling Types of Scheduling Systems Practice-Based Scheduling Stream Scheduling Cluster Booking Double Booking Wave Scheduling Open Hours Catch-up Time Patient Scheduling Scheduling Patients by Phone New Patient Established Patient Scheduling Patients During In-Ofce Checkout Appointment Matrix Computerized Appointment Systems Manual Appointment Book System Daily Worksheet Appointment Changes and Cancellations Computerized Changes and Cancellations

133
134 134 134 134 135 135 135 135 135 135 135 135 136 137 137 137 140 140 140 140

CHAPTER

14

Medical Records Management

Importance of Medical Records Management File Storage Vertical Files Open-Shelf Lateral Files Moveable Files File Folders Fasteners Tabs Units Filing Systems Alphabetical System Simple Alphabetical Filing Color-coded Alphabetical Filing Numeric Filing Consecutive Filing Nonconsecutive Filing Accession Log Filing Other Information on the File Folder

173
174 174 174 174 175 175 175 176 176 176 176 176 176 177 178 178 179 180

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Locating and Tracking Medical Records Tracking Medical Records Cross-Referencing Medical Records Electronic Health Record Increased Access Cost Reduction Reduced Medical Errors Barriers to EHR Conversion Medical Record Maintenance Medical Records Archives Medical Records Purging Release of Medical Records Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

181 181 181 182 182 183 183 183 183 184 184 185 185 185 186 186

15

Ofce Management
Qualities of Leadership Praising While Problem Solving Ofce Management Roles and Responsibilities Dealing with Employees Conducting an Interview New Employee Orientation Policies and Procedures Manual Conducting a Staff Meeting Conducting an Employee Evaluation Disciplinary Actions and Terminations Taking an Inventory and Ordering Supplies Maintaining Laboratory Equipment and Supplies Inventory Selecting Computer Hardware and Software Using Computers in the Medical Ofce Assisting with Physician Travel Arrangements Marketing in the Medical Ofce Internal Marketing External Marketing Tracking Marketing Chapter Summary Team Work Exercises Case Studies Resources

187
188 188 189 190 190 192 192 192 192 194 195 195 195 198 198 198 199 200 200 202 202 202 202

Diagnostic Coding ICD-9-CM Coding Multiple Diagnosis Codes Conventions Superbill Insurance in the Physicians Ofce Employer Insurance Programs Managed Care Health Maintenance Organization Independent Practice Association Preferred Provider Organization Traditional Insurance Consumer-Driven Health Plans Health Savings Account Health Reimbursement Account Flexible Spending Account Government Programs Medicare Medicaid CHAMPUS CHAMPVA Workers Compensation Multiple Insurance Policies COBRA Self-Pay Patients Insurance Claims HIPAA Life Cycle of an Insurance Claim Submitting a Claim Obtaining Referrals Payment Systems Usual, Customary, and Reasonable Fee-for-Service Resource-based Relative Value Scale Capitation Payment Processing Payment Denials and Appeals Process Fraud and Abuse Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

208 208 214 214 216 219 219 222 222 223 223 223 224 225 225 225 225 225 226 228 228 228 230 230 231 231 231 231 233 233 238 239 239 239 239 239 241 241 245 245 246 246

17

Billing and Collections

Patient Billing Determination of Fees Explaining Fees to the Patient Billing Procedures Aging of Accounts Computerized Billing and Account Transactions Monthly and Cycle Billing Monthly Billing Cycle Billing

247
248 248 248 249 249 250 251 251 251

CHAPTER

16

Coding and Insurance

Health Insurance and Payment Coding Procedural Coding CPT-4 Coding HCPCS

203
204 204 204 205 208

xxviii

CONTENTS

Credit and Collections Policies and Procedures Extending Credit Collections Collection Strategies Telephone Collections Collection Agency Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

252 252 253 253 253 254 257 257 257 257 257

18

Accounting and Banking

Financial Management Accounting Practices Fixed and Variable Costs Cost Ratio Income Statement Balance Sheet Bookkeeping Ledger Cards Adjustments NSF Checks Accounts Receivable Ratio Collection Ratio Accounts Payable Deliveries and Supplies Writing Checks Payroll Preparing Payroll Checks Banking Practices Reconciling Bank Statements Making Bank Deposits Petty Cash Chapter Summary Team Work Exercises Case Studies Resources

259
260 260 260 260 260 260 260 263 263 263 267 267 267 267 267 268 268 271 271 274 282 282 282 282 283

U N I T I I I Clinical C H A P T E R 19 Infection Control and Medical Asepsis

Infectious Disease Microorganisms and Pathogens Bacteria Rickettsia Virus Fungus Protozoa Chain of Infection Pathogen Reservoir Host Means of Exit Mode of Transmission

285
287
289 289 289 289 289 289 289 289 290 290 290 291

Means of Entry Susceptible Host Types of Infection Stages of Disease Incubation Stage Prodromal Stage Acute Stage Declining Stage Convalescent Stage The Bodys Defense Mechanisms Mechanical Defenses Chemical Defenses Cellular Defenses Inammatory Response Immunity Active Natural Immunity Active Articial Immunity Passive Natural Immunity Passive Articial Immunity Standard Precautions Personal Protective Equipment Disposal of Biohazardous Waste Sharps and Needlestick Safety Vaccinations Exposure Control Blood-borne Pathogen Exposure Biohazard Spill Asepsis Sanitization Hand Sanitization Sanitization of Equipment and the Environment Disinfection Sterilization Autoclave Chemical Sterilization Types of Asepsis Medical Asepsis Surgical Asepsis Chapter Summary Team Work Exercises Cases Studies Resources
CHAPTER

291 291 291 292 292 292 292 292 292 292 292 293 293 294 294 295 295 295 295 295 296 296 296 297 297 297 297 298 298 298 298 300 300 301 303 303 303 303 305 306 306 306

20

The Patient Interview

First Impressions Interviewing Techniques Talkative Patient Quiet Patient Obstacles to Effective Interviewing Offering Opinions and Advice Offering False Reassurance Using Technical Language

307
308 308 308 309 311 311 311 311

CONTENTS

xxix

Talking Too Much Asking Judgmental Questions Discussing Sensitive Topics Age-Appropriate Communication Medical History Documentation Documentation Types Source-oriented Problem-oriented Subjective Objective Assessment Plan of Care Evaluation Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

311 311 311 312 313 314 314 315 315 316 316 316 316 316 316 317 317 317
CHAPTER

Team Work Exercises Case studies Resources

342 342 343

22

Physical Examination
Purpose of the Physical Examination Physical Examination Techniques Inspection Palpation Percussion Auscultation Mensuration Manipulation Components of a Physical Examination Preparing for the Physical Examination Preparing the Examination Room Preparing the Patient Physical Examination Supplies and Equipment Assisting with the Physical Examination Positioning and Draping Measurement of Weight and Height Measuring Weight Measuring Height Chapter Summary Team Work Exercises Case Studies Resources

345
346 346 346 347 347 347 348 348 348 348 348 352 352 352 353 359 359 362 364 364 364 365

21

Vital Signs
Vital Signs Prociency Temperature Fever Thermometer Types and Uses Glass Thermometer Digital Thermometer Tympanic Thermometer Chemical Thermometers Temporal Thermometer Disinfecting Thermometers Celsius Versus Fahrenheit Pulse Pulse Sites Temporal Carotid Brachial Radial Apical Femoral Popliteal Dorsalis Pedis Posterior Tibialis Respiration Characteristics of Respiration Rate Rhythm Depth Blood Pressure Evaluating Blood Pressure Korotkoff Sounds Postural Vital Signs Oxygen Saturation Chapter Summary

319
320 320 321 321 321 321 323 323 323 328 329 329 330 330 330 331 331 331 334 334 334 334 334 335 335 335 335 336 337 337 339 339 341

CHAPTER

23

Essentials of Medical Terminology

Origins of Medical Language Medical Word Elements Combining Forms Prexes Sufxes Abbreviations Pathological Terms Translating Terms Pronunciation and Plural Forms Directional Terms Memorize and Practice Chapter Summary Team Work Exercises Case Studies Resources

367
368 368 369 369 370 374 374 376 377 377 378 379 380 380 380

CHAPTER

24

Surgical Asepsis and Assisting with Minor Surgery

Surgical Role of a Medical Assistant Surgical Instruments

381
382 382

xxx

CONTENTS

Cutting Instruments Scissors Scalpels Grasping-Clamping Instruments Probing and Dilating Instruments Specula Scopes Probes, Retractors, and Dilators Specialty Instruments Biopsy Equipment Principles of Surgical Asepsis Sterile Technique Surgical Scrub Sterile Field Sterile Gloving Minor Surgical Procedures Cryosurgery Microsurgery Laser Surgery Electrosurgery Endoscopy The Medical Assistants Role in Minor Surgery Patient Preparation and Postoperative Care Wound Care Sutures Staples Wound Care Supplies Dressings Bandages Creams, Ointments, and Solutions Anesthetics Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

383 383 384 384 384 384 384 384 386 386 386 387 388 388 394 394 397 397 398 398 398 398 399 403 403 403 403 403 405 407 407 408 409 409 410

25

Dermatology
Structures and Functions of the Integumentary System Structures of the Skin Functions of the Skin Protection Temperature Regulation Medical Terminology Related to the Integumentary System Common Integumentary System Diseases and Disorders Bacterial Skin Infections Impetigo Acne Cellulitis Folliculitis

411
CHAPTER

Viral Skin Infections Warts Herpes Viruses Herpes zoster Fungal Skin Disorders Tinea Candidiasis Parasitic Infestations Pediculosis Scabies Hypersensitivity and Inammatory Reactions Eczema Psoriasis Systemic Lupus Erythematosus Neoplasms Basal Cell Carcinoma Squamous Cell Carcinoma Malignant Melanoma Dermatology Procedures Assisting with Examination Allergy Skin Testing Scratch Test Intradermal Test Patch Test Radioallergosorbent Test Culture and Sensitivity Testing Image Enhancement Procedures Dermabrasion and Dermaplaning Microdermabrasion Chemical Peel Laser Resurfacing Botox Chapter Summary Team Work Exercises Case Studies Resources

422 422 422 423 423 424 424 424 425 425 425 426 426 426 427 428 428 428 428 428 429 429 429 429 432 432 432 432 432 432 433 433 434 434 434 434

26

Neurology
Structures and Functions of the Nervous System Structures of the Nervous System Neuron Central Nervous System Peripheral Nervous System Functions of the Nervous System Neuron Central Nervous System Peripheral Nervous System Medical Terminology Related to the Neurological System Common Nervous System Diseases and Disorders

435
436 436 436 437 437 439 439 439 439 441 441

412 412 412 412 414 414 417 417 417 420 421 421

CONTENTS

xxxi

Disorders of the Central Nervous System Stroke Transient Ischemic Attack Migraine Headache Epilepsy Encephalitis Meningitis Traumatic Brain Injury Spinal Cord Injury Parkinson Disease Multiple Sclerosis Brain Tumor Disorders of the Peripherall Nervous System Amyotrophic Lateral Sclerosis Bell Palsy Peripheral Neuropathy Carpal Tunnel Syndrome Spinal Stenosis Neurology Procedures Assisting with Examination Nervous System Tests Electroencephalography Lumbar Puncture Computed Tomography Magnetic Resonance Imaging Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

444 444 445 445 446 447 447 448 449 449 450 451 451 451 452 452 453 454 455 455 455 455 456 457 457 459 459 460 460

27

Cardiology and Lymphatics

Structures and Functions of the Cardiovascular System Structures of the Cardiovascular System Heart Circulatory System Functions of the Cardiovascular System Heart Circulatory System Structures and Functions of the Lymphatic System Structures of the Lymphatic System Thymus Spleen Functions of the Lymphatic System Thymus Spleen Medical Terminology Related to the Cardiovascular and Lymphatic Systems

461
462 462 462 462 463 463 465 466 466 467 467 467 467 467

Common Cardiovascular and Lymphatic System Diseases and Disorders Cardiovascular System Hypertension Coronary Artery Disease Myocardial Infarction Heart Failure Aneurysm Atrial Fibrillation Varicose Veins Deep Vein Thrombosis Shock Anemia Leukemia Hodgkin Disease Non-Hodgkin Lymphoma Acquired Immune Deciency Syndrome Cardiology and Lymphatics Procedures Assisting with Examination Electrocardiography Preparing the Electrocardiograph Machine Electrocardiograph Paper Standardization Leads and Electrodes Preparing the Patient Recording the ECG Rhythm Interpretation Artifacts Articial Cardiac Pacemaker Implantable Cardioverter Debrillator Cardiac Stress Test Holter Monitoring Event Recorder Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

472 472 472 473 473 474 476 477 477 478 478 478 479 479 480 480 481 481 481 481 482 482 482 483 484 484 486 486 486 486 486 491 493 494 494 494

28

Pulmonology
Structures and Functions of the Pulmonary System Structures of the Pulmonary System Upper Airway Lower Airway Lungs Functions of the Pulmonary System Upper Airway Lower Airway Lungs Medical Terminology Related to the Pulmonary System

495
497 497 497 497 497 497 497 498 498 498

468

xxxii

CONTENTS

Common Pulmonary System Diseases and Disorders Common Upper Respiratory System Diseases and Disorders Allergic Rhinitis Upper Respiratory Infection Sinusitis Pharyngitis Common Lower Respiratory System Diseases and Disorders Pneumonia Inuenza Chronic Obstructive Pulmonary Disease Bronchitis Asthma Emphysema Pulmonary Tuberculosis Epstein-Barr Virus Lung Cancer Pulmonology Procedures Assisting with Examination Diagnostic Testing Pulmonary Function Tests Bronchoscopy Mantoux Test Peak-ow Measurement Treatments Metered-dose Inhaler Nebulizer Treatments Incentive Spirometry Oxygen Therapy Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

502 502 502 502 502 503 503 503 503 504 505 505 506 507 508 508 509 509 509 509 511 511 512 512 513 513 513 514 517 517 517 518

Common Endocrine System Diseases and Disorders Types of Diabetes Type I Diabetes Type II Diabetes Gestational Diabetes Thyroid Disorders Hypothyroidism Hyperthyroidism Endocrinology Procedures Assisting with Examination Endocrine System Tests Fasting Blood Glucose Glucose Tolerance Test Glycosylated Hemoglobin Urine Glucose Test Glucometer Testing Thyroid Tests Thyroid Scan Radioactive Iodine Uptake Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

528 528 528 528 529 530 530 531 532 532 534 534 534 535 535 535 535 535 535 536 536 536 536

30

Gastroenterology
Structures and Functions of the Gastrointestinal System Structures of the GI System Alimentary Canal Accessory Organs of Digestion Functions of the GI System Alimentary Canal Accessory Organs of Digestion Medical Terminology Related to the GI System Common GI System Diseases and Disorders Disorders of the Upper GI Tract Gastroesophageal Reux Disease Hiatal Hernia Peptic Ulcer Disease Gastritis Pyloric Stenosis Disorders of the Lower GI Tract Abdominal Hernia Appendicitis Diverticular Disease Hemorrhoids Inammatory Bowel Disease Disorders of the Accessory Organs of0Digestion Vir0l Hepatitis

537
537 537 537 539 539 539 541 544 544 544 545 545 545 546 548 548 548 549 549 550 550 551 551

29

Endocrinology
Structures and Functions of the Endocrine System Structures of the Endocrine System Functions of the Endocrine System Pineal Gland Pituitary Gland Thyroid Gland Adrenal Glands Pancreas Thymus Gland Ovaries Testes Negative Feedback System Medical Terminology Related to the Endocrine System

519
520 520 520 521 521 522 522 522 522 522 522 522 524

C O N T E N T S xxxiii

Cholelithiasis and Cholecystitis Acute Pancreatitis Disorders of Nutrition Celiac Disease Anorexia Nervosa Bulimia Disorders That Commonly Cause Diarrhea Food Poisoning Escherichia Coli Infection Campylobacter Infection Salmonella Infection Cancers of the GI System Oral Cancer Esophageal Cancer Gastric Cancer Colorectal Cancer Liver Cancer Pancreatic Cancer Gastroenterology Procedures Assisting with Examination Stool Specimen Collection Fecal Occult Blood Test Flexible Sigmoidoscopy Cleansing Enema GI System Tests Helicobactor Pylori Liver Function Test Upper GI X-ray Lower GI X-ray Gallbladder Ultrasound Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

552 553 553 554 554 554 555 555 555 555 556 556 556 557 557 557 557 558 558 558 559 559 560 560 561 561 561 561 561 564 564 565 565 565

31

Urology and the Male Reproductive System

Structures and Functions of the Urinary and Male Reproductive Systems Structures of the Urinary System Kidneys Nephrons Ureters, Urinary Bladder, and Urethra Functions of the Urinary System Kidneys Nephrons Ureters, Urinary Bladder, and Urethra Structures of the Male Reproductive System Functions of the Male Reproductive System

567
568 568 568 568 568 569 569 569 569 570 570
CHAPTER

Medical Terminology Related to the Urinary and Male Reproductive Systems Common Urological and Male Reproductive Diseases and Disorders Urinary System Diseases and Disorders Bacterial Cystitis and Urethritis Pyelonephritis Glomerulonephritis Bladder Cancer Renal Cancer Wilms Tumor Hydronephrosis Polycystic Kidney Disease Renal Calculi Acute Renal Failure Chronic Renal Failure Male Reproductive System Diseases and Disorders Benign Prostatic Hypertrophy Prostate Cancer Testicular Cancer Epididymitis Balanoposthitis Prostatitis Sexually Transmitted Diseases Erectile Dysfunction Urology and Male Reproductive Procedures Assisting with Examination Catheterization Renal Computed Tomography Scan Intravenous Pyelography Cystoscopy Voiding Cystourethrography Creatinine Blood Urea Nitrogen Renal Angiography Vasectomy Chapter Summary Team Work Exercises Case Studies Resources

571

576 576 576 577 577 578 578 579 579 580 580 580 582 582 582 583 584 586 586 586 586 587 587 588 588 589 593 594 594 594 595 595 595 596 596 596 597

32

Obstetrics and Gynecology

Structures and Functions of the Female Reproductive System Structures of the Female Reproductive System Internal Structures External Structures Breasts Functions of the Female Reproductive System

599
601 601 601 601 602 602

xxxiv

CONTENTS

Internal Structures External Structures Breasts Female Reproduction Cycle Menstruation Follicular Phase Luteal Phase Menstrual Phase Pregnancy Birth Process Menopause Medical Terminology Related to the Female Reproductive System Common Obstetric and Gynecological Diseases and Disorders Vaginal Infections Candidiasis Chlamydia Genital Herpes Genital Warts Gonorrhea Syphilis AIDS Trichomoniasis Bartholin Gland Cyst Menstrual Disorders Dysmenorrhea Amenorrhea Ovarian Cysts Premenstrual Syndrome Toxic Shock Syndrome Uterine Disorders Endometriosis Pelvic Inammatory Disease Uterine Fibroids Uterine Prolapse Complications of Pregnancy Ectopic Pregnancy Abortion Gestational Diabetes Placenta Previa Abruptio Placentae Eclampsia Cancers of the Female Reproductive System Breast Ccancer Cervical Cancer Uterine Cancer Ovarian Cancer Other Disorders of the Female Reproductive System Infertility Fibrocystic Breast Disease

602 603 603 604 604 604 604 604 604 606 607 607 610 610 610 611 611 612 612 612 613 613 613 614 614 614 614 615 615 615 615 616 616 617 618 618 618 618 619 620 621 621 621 623 623 623 624 624 625

Obstetric and Gynecological Procedures Prenatal Care Initial Visit Routine Prenatal Visits Assessment of the Neonate Postpartum Visit Assisting with the Gynecological Examination Breast Examination Pelvic examination Pap Test, KOH Preparation, and Wet Preparation Common Gynecological Surgical Procedures Cryosurgery Laparoscopy Dilatation and Curettage Uterine Ablation Hysterectomy Diagnostic Testing in Pregnancy Fetal Ultrasound Amniocentesis Chorionic Villus Sampling Common Gynecological Diagnostic Tests Amplied DNA Probe Test Colposcopy with Biopsy Endometrial Biopsy Mammography Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

625 625 625 627 629 629 629 632 632 633 633 634 635 635 636 636 636 637 637 637 637 637 638 638 639 639 639 640 640

33

Pediatrics
Pediatric Patients Growth and Development Medical Terminology Related2 to Pediatrics Common Pediatric Diseases and Disorders Communicable Pediatric Diseases and Disorders Common Cold Conjunctivitis Croup Diarrhea Impetigo Inuenza Virus Otitis Media Respiratory Syncytial Virus Strep Throat Oral Thrush

641
642 642 642 645 645 645 646 646 647 648 649 649 651 651 652

CONTENTS

xxxv

Chickenpox Warts Noncommunicable Pediatric Diseases and Disorders Allergies Eating Disorders Asthma Behavioral Disorders Autism Down Syndrome Constipation Failure to Thrive Cerebral Palsy Eczema Scoliosis Obesity Lead Poisoning Phenylketonuria Pediatric Procedures Assisting with Examination Vital Signs Vision Screening Hearing Screening Well-child Examination Sick-child Examination Reporting Abuse Physical Abuse Sexual Abuse Neglect Immunizations Vaccine Registry Objections to Vaccination Pediatric Laboratory Tests Urinalysis Hemoglobin and Hematocrit Rapid Strep Test Nutritional Counseling Birth to 6 Months 6 Months to 1 Year Age 1 Ages 2 to 5 School-age Children Adolescents Vitamin and Mineral Supplements Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

652 653 653 653 655 655 656 656 657 657 657 658 658 660 660 660 661 662 662 662 668 668 668 672 673 674 674 674 674 674 676 677 677 679 679 679 679 679 679 679 679 680 680 682 682 682 682

Integumentary System Nervous System Cardiovascular System Respiratory System Digestive System Urinary System Reproductive System Endocrine System Musculoskeletal System Sensory System Medical Terminology Related to Geriatrics Common Geriatric Diseases and Disorders Dementia Alzheimer Disease Bone Disorders Osteoporosis Osteoarthritis Sensory Disorders Presbyopia Cataracts Glaucoma Macular Degeneration Presbycusis Special Needs of the Geriatric Patient Communication Strategies Safety Promotion Mobility Aids Home Safety Pain Management Extended Care and End-of-Life Issues In-home and Home Health Care Assisted Living Nursing Center Extended Care Campus End-of-life Issues Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

685 686 686 686 686 687 687 687 687 688 688 690 690 690 692 693 693 694 694 694 695 696 696 697 697 697 698 698 700 700 700 700 703 703 703 705 705 706 706

35

Orthopedics
Structures and Functions of the Musculoskeletal System Structures of the Musculoskeletal System Bone Muscle Tendons and Ligaments Functions of the Musculoskeletal System Bone Muscle Tendons and Ligaments

707
709 709 709 709 709 709 710 710 712

34

Geriatrics
The Aging Population Ageism Physiological Changes of Aging

683
684 684 685

xxxvi

CONTENTS

Medical Terminology Related to the Musculoskeletal System Common Musculoskeletal System Diseases and Disorders Injuries to Bones Dislocation Scoliosis Kyphosis Lordosis Gout Osteoarthritis Osteoporosis Rheumatoid Arthritis Juvenile Rheumatoid Arthritis Muscle Disorders Fibromyalgia Strain Myasthenia Gravis Rotator Cuff Tear Herniated Disk Injuries to Tendons and Ligaments Anterior Cruciate Ligament Tear Epicondylitis, Medial and Laterial Tendinitis Sprain Orthopedic Procedures Assisting with Examination Evaluating Muscle Strength and Range of Motion Goniometry Range of Motion Fitting a Patient with a Walker, Cane, and Crutches Fitting a Patient with a Walker Fitting a Patient with a Cane Fitting a Patient with Crutches Casting Thermotherapy Moist Heat Dry Heat Cryotherapy Ultrasound Transcutaneous Electrical Nerve Stimulation Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

712 716 717 717 717 717 718 718 718 718 718 719 719 719 719 720 720 721 721 721 721 722 722 722 722 725 725 727 727 727 727 730 730 735 735 738 740 741 741 743 743 743 743

36

Ophthalmology and Otolaryngology

Structures and Functions of the Eyes, Ears, Mouth, Nose, and Throat

745
746

Structures of the Eyes, Ears, Mouth, Nose, and Throat Eyes Sclear and Cornea Choroid Retina Other Structures Ears External Ear Middle Ear Inner Ear Mouth Nose and Throat Functions of the Eyes, Ears, Mouth, Nose, and Throat Eyes Sclear and Cornea Choroid Retina Other Structures Ears External Ear Middle Ear Inner Ear Mouth Nose and Throat Medical Terminology Related to the Eyes, Ears, Mouth, Nose, and Throat Common Diseases and Disorders of the Eyes, Ears, Mouth, Nose, and Throat Eyes Astigmatism Blepharitis Conjunctivitis Diabetic Retinopathy Hypertensive Retinopathy Exophthalmos Myopia Hyperopia Presbyopia Photophobia Cataracts Glaucoma Macular Degeneration Ears Mnire Disease Otitis Externa Otitis Media Labyrinthitis Tinnitus Vertigo

746 746 746 746 746 747 747 747 747 748 748 748 749 749 749 750 750 751 751 751 751 751 751 752

752

755 755 755 755 755 755 755 756 756 757 757 757 758 758 758 758 758 758 759 759 759 760

CONTENTS

xxxvii

Mouth Oral Herpes Oral Thrush Cleft Lip Cleft Palate Nose and Throat Rhinitis Tonsillitis Ophthalmology and Otolaryngology Procedures Assisting with Ophthalmic Examination Assisting with Ophthalmic Irrigation and Instillation Assisting with Otic Examination Tuning Fork Test Weber Test Rinne Test Audiometric Testing Assisting with Otic Irrigation and Instillation Assisting with Examination of the Mouth, Nose, and Throat Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

760 760 760 760 761 761 761 761 761 761 762 762 770 770 770 770 772 772 775 775 775 775

37

Nutrition
Understanding Nutrition Macronutrients Carbohydrate Simple Carbohydrates Monosaccharides Disaccharides Complex Carbohydrates Carbohydrate Digestion Regulation of Blood Glucose Proteins Essential and Nonessential Protein Digestion Body Protein Manufacturing Fats Fatty Acids Triglycerides Phospholipids Sterols Digestion of Fat Micronutrients Vitamins Minerals Water Planning for Good Nutrition Nutrition for Special Populations

777
778 778 778 779 779 779 779 781 781 781 782 783 785 786 786 787 787 788 788 788 789 789 790 792 794

Pregnancy Children Infancy to Age 2 Ages 2 to 12 Adolescence Older Adults Medical Conditions HIV and AIDS Cancer Diabetes Soft Diet Bland Diet Sodium-Restricted Diet Weight-Loss Diets Common Nutritional Diseases and Disorders Macronutrient Disorders Kwashiorkor Marasmus Morbid Obesity Syndrome X Micronutrient Disorders Rickets Scurvy Pellagra Beriberi Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

794 794 794 795 795 795 795 795 796 796 796 796 796 796 796 796 797 797 798 798 800 800 800 801 801 802 802 802 802

38

Introduction to Pharmacology
Pharmacology and the Medical Assistant Drug Forms Drug Categories Prescription Over-the-Counter Natural Drug Sources Plants Animals Minerals Laboratories Drug Action and Uses Pharmacokinetics Absorption Distribution Metabolism Excretion Pharmacodynamics Pharmacotherapeutics Cure

805
807 807 807 807 807 807 807 807 807 807 808 808 808 808 808 808 808 808 809 809

xxxviii

CONTENTS

Treatment Diagnosis Prevention Replacement Drug Names Chemical Name Generic Name Trade Name Drug Classications Drug Effects Therapeutic Effect Adverse Effects and Reactions Allergic Reaction Idiosyncratic Effect Cumulative Effect Toxic Effect Tolerance Drug Interactions Synergism Antagonism Potentiation Contraindications Drug Regulation Drug Enforcement Agency DEA Registration Controlled Substances Record Keeping Food and Drug Administration OTC Drugs Drug Safety Drug Disposal Drug References United States Pharmacopeia National Formulary Physicians Desk Reference Drug Handbooks Package Inserts Patient Prescription Information Teaching Patients about Drugs Special Considerations Geriatrics Pediatrics Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

809 809 810 810 810 810 810 810 811 811 814 814 814 814 814 815 815 815 815 815 816 817 817 817 817 817 818 819 819 819 820 820 820 820 820 820 820 820 822 823 823 823 823 823 823

Apothecary and Household Systems Calculation Methods Dose on Hand Ratio and Proportion Fractional Equation Using Conversions Calculating Infant and Child Dosages Medication Administration Parts of a Prescription Routes of Medication Administration Oral Parenteral Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

826 827 827 827 827 828 828 829 829 829 830 832 847 847 847 847

40

Introduction to the Clinical Laboratory

Purpose of the Clinical Laboratory Laboratory Tests Panel Manual or Automated Purpose of Laboratory Tests Quantitative or Qualitative Results Laboratory Profession CLIA 1988 Laboratory Testing Categories Waived Tests Moderate-complexity Tests High-complexity Tests Provider-performed Microscopy Procedures Quality Control Physicians Ofce Laboratory Laboratory Requisitions and Reports Laboratory Requisition Slip Laboratory Report Patient Preparation Fasting Medication Restrictions Specimen Collection, Handling, and Transport Guidelines for Specimen Collection Laboratory Equipment Proper Equipment Maintenance Chapter Summary Team Work Exercises Case Studies Resources

849
850 850 850 851 851 852 852 852 854 854 854 854 854 855 856 856 856 856 859 859 859 859 861 862 863 865 865 865 876

39

Dosage Calculation and Medication Administration

Dosage Calculation Systems of Measurement Metric system

825
826 826 826

CONTENTS

xxxix

CHAPTER

41

Phlebotomy
Types of Phlebotomy Procedures Venipuncture Composition of Blood Venipuncture Equipment Tubes Plastic Adapters Needles Syringes Winged Infusion Sets Tourniquet Gloves Proper Site Selection for Venipuncture Patient Preparation for Venipuncture Venipuncture Procedure Capillary Puncture Composition of Capillary Blood Capillary Puncture Equipment Capillary Puncture Devices Capillary Puncture Collection Containers Proper Site Selection for Capillary Puncture Patient Preparation for Capillary Puncture Capillary Puncture Procedure Special Phlebotomy Considerations Fainting Failing to Obtain Blood Dealing with Problem Specimans Chapter Summary Team Work Exercises Case Studies Resources

867
868 868 868 868 868 872 872 874 874 875 875 876 877 877 877 882 884 884 884 884 885 885 886 886 887 887 887 887 887 888

Other Hematology Department Tests Diseases Associated with Hematology Tests Tests and Procedures Associated with Coagulation Other Coagulation Department Tests Diseases Associated with Coagulation Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

898 898 899 899 900 901 901 901 901

43

Clinical Chemistry and Serological Procedures

Testing in the POL Clinical Chemistry Chemistry Analyzers Specimen Types Common POL Chemistry Tests Blood Glucose Testing Fasting Blood Glucose Two-hour Postprandial Glucose Tolerance Test Glucose Monitors Lipids Cholesterol Other Chemistry Department Tests Diseases Associated with Chemistry Tests Serology Antibody-Antigen Reactions Agglutination ELISA Blood Groups and Typing Common POL Serological Tests Mononucleosis Testing Rheumatoid Factor HIV Testing Chapter Summary Team Work Exercises Case Studies Resources

903
904 904 904 905 906 906 906 906 906 907 908 910 911 912 913 913 913 913 914 914 915 915 915 918 918 918 918

CHAPTER

42

Hematology and Coagulation Procedures

Hematology and Coagulation Overview Whole Blood, Plasma, and Serum Whole Blood Plasma Serum Blood Cells and Their Functions RBCs WBCs Granulocytes Agranulocytes Platelets Tests and Procedures Associated with Hematology Hemoglobin and Hematocrit Complete Blood Count CLIA-Waived Hematological Tests

889
890 890 890 890 891 891 892 892 892 892 892 893 892 892 894

CHAPTER

44

Urinalysis
Urinalysis in the POL Urinary System Overview Characteristics of Urine Collecting a Urine Specimen Urine Specimen Types Collection Procedure Preparation for Urinalysis Reagent Strip Urine Analyzer Quality Control

919
920 920 920 921 921 921 924 924 924 925

xl

CONTENTS

Urinalysis Components Evaluating the Physical Components of Urine Color Clarity Odor Specic Gravity Evaluating the Chemical Components of Urine pH Glucose Protein Ketones Bilirubin Urobilinogen Blood Nitrite Leukocytes Evaluating the Microscopic Components of Urine Urine Pregnancy Testing Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

925 925 925 925 926 926 926 926 926 927 927 927 927 927 927 927 927 928 933 934 934 934

CHAPTER

46

Bioemergency Response and Preparedness

Emergency Preparedness Bioterrorism Agents Used in Bioterrorism Categories of Bioterrorism Agents Laboratory Response Network Federal Laboratory Reference Laboratory Hospital Clinical Laboratories Bioterrorism Response and the Medical Assistant Pandemic Inuenza Pandemic Response Plan Chapter Summary Team Work Exercises Case Studies Resources

959
960 960 960 961 962 962 963 963 963 964 964 965 966 966 966

CHAPTER

47

Ofce Emergencies
Emergency Preparedness Emergency Planning Common Emergency Equipment Triage Responding to Common Ofce Emergencies Common Signs and Symptoms in Ofce Emergencies Dyspnea Chest Pain Altered Consciousness Acute Abdominal Pain Common Ofce Emergencies Hemorrhage Poisoning Environmental Injuries Musculoskeletal Injury Eye Injury Chapter Summary Team Work Exercises Case Studies Resources

967
968 968 970 971 972 972 972 974 974 978 978 978 981 981 985 986 986 987 988 988

45

Microbiology
History of Microbiology Infection and Disease Normal Flora Types of Microorganisms Bacteria Cocci Bacilli Spiral Viruses and Prions Fungus Protozoa and Parasitic Worms Microbiological Testing Bacterial Culture Antimicrobial Susceptibility Testing Microbiology Procedures Specimen Collection for Microbiological Analysis Microbiological Testing Performed in the POL Rapid Streptococcal Test Throat Culture Test Chapter Summary Team Work Exercises Case Studies Resources

935
936 936 936 938 939 939 939 941 941 942 942 945 945 947 949 949 951 953 953 957 958 958 958

CHAPTER

48

Radiology and Diagnostic Imaging

Radiography and the Medical Assistant X-Ray X-Ray Film X-Ray Views Patient Preparation for X-Ray Mammography Patient Preparation for Mammography Fluoroscopy

991
993 993 995 995 995 998 998 999

CONTENTS

xli

Computer Imaging Ultrasound Patient Preparation Magnetic Resonance Imaging Patient Preparation Computed Tomography Nuclear Medicine Radiation Therapy External Radiation Therapy Internal Radiation Therapy Patient Preparation Positron Emission Tomography Patient Preparation Radiation Safety Scheduling Diagnostic Imaging Procedures Chapter Summary Team Work Exercises Case Studies Resources
CHAPTER

1000 1000 1000 1002 1002 1002 1003 1003 1003 1003 1004 1004 1004 1004 1005 1006 1006 1006 1006

The Cover Letter The Interview After the Interview Career Advancement Performance Evaluation Credentialing Certied Medical Assistant Registered Medical Assistant Preparing for the Credentialing Examination Recertication Chapter Summary Team Work Exercises Case Studies Resources

1011 1011 1012 1013 1014 1016 1016 1018 1018 1019 1020 1021 1022 1022

49

Externship and Career Strategies

Bridging the Gap Key Benets of an Externship Externship Placement Making a Good Impression The Job Search Applying for a Position The Resum Resum Types

1007
1008 1008 1008 1009 1010 1010 1010 1011

APPENDICES APPENDIX A Glossary APPENDIX B Abbreviations APPENDIX C Index of Competencies A P P E N D I X D Commonly Prescribed Drugs APPENDIX E Certication Examination Content Outlines

1023
1023 1037 1041 1047 1053

Index

1059

UNIT I
GeneralTransdisciplinary

CHAPTER

1 2 3 4 5 6 7 8 9

Succeeding as a Student 3
CHAPTER

The Profession of Medical Assisting 11

CHAPTER

Professionalism 19
CHAPTER

Health Care Yesterday and Today 27

CHAPTER

Therapeutic Communication 43
CHAPTER

Legal Considerations 53
CHAPTER

HIPAA and a Patients Rights 71

CHAPTER

Bioethics 85
CHAPTER

Patient Education 95

CHAPTER

Succeeding as a Student
Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms identify their learning style describe study strategies relevant to their learning style differentiate between visual, auditory, kinesthetic, solitary, and social learners describe symptoms of burnout discuss factors that contribute to burnout design and describe a self-care plan that will help prevent burnout.

1
Test-Taking Strategies
Anxiety Reduction Preparing for the examination Just before the examination During the examination Practical Strategies

CAAHEP Competencies
General Competencies Patient Instruction
Instruct individuals according to their needs

ABHES Competencies
Instruction
Instruct patients with special needs Teach patients methods of health promotion and disease prevention

Self-Care
Body Mechanics Safe Lifting

Chapter Outline
The Journey Begins Learning Styles
Solitary Learners Social Learners Auditory Learners Visual Learners Kinesthetic Learners Oral-Dependent Learners Writing-Dependent Learners

Chapter Summary Team Work Exercises Case Studies Resources

Key Terms
body mechanics

The Journey Begins

Medical assisting is an exciting and rewarding career. However, the journey for each individual really begins when she steps into the role of the student. Programs of medical assisting are designed to provide students with foundational knowledge in two general ways. The rst building block of this foundation is through theory (lecture) classes, which provide information about everything from medical terminology, body structure and function, and pharmacology to medical ofce procedures, coding, and many other content areas. The second building block is through laboratory and clinical courses, which provide students with the opportunity to acquire skills though hands-on practice. Both areas provide students with a sound knowledge base and the administrative and clinical skills necessary for a successful career as a medical assistant.

The conscious coordination of the nervous and musculoskeletal systems to preserve and protect posture, balance, and body alignment while bending, lifting, and performing activities of daily living (ADLs)
burnout

Decreased physical, emotional, or mental energy secondary to ongoing intensive demands without sufcient physical or emotional rest
learning style

Manner in which a person most effectively learns

mnemonic

Technique used to enhance memory, such as creating a word from the rst letters of a series of words
self-care

Activity that supports and nurtures an individuals physical, mental, spiritual, or emotional health and well-being

Learning Styles
Embarking on this program of study requires a serious commitment of time, money, energy, and other resources. Therefore, students naturally wish to be as successful as possible in their endeavors. An important way a student can ensure her chance of success is by taking the time to determine her learning style. This information will then help her identify learning activities that will be most effective. All people have learning styles, but no two people are exactly alike. Understanding more about learning styles will aid students in choosing the most effective study techniques for them, such as study groups versus solitary study or tape recording lectures versus creating mnemonics, which are words created from the rst letters of a series of words to help remember a concept. Most people are actually a combination of styles, but one tends to be dominant. The most common learning styles are:

solitary social auditory visual kinesthetic. (See Learning in practice.)

Solitary Learners
Solitary learners usually prefer to study alone because they nd the conversation of others to be distracting rather than helpful. They should spend the majority of their study time alone in a quiet place and may wish to avoid study groups.

Social Learners
Social learners are the opposite of solitary learners. They are easily distracted when trying to study alone and prefer to

CHAP TER 1

Succeeding as a Student

Patient Education

Oral-Dependent Learners
Oral-dependent learners can enhance their learning by verbalizing concepts and thinking aloud even if they are talking only to themselves. Describing and explaining concepts to a partner who can ask questions and give feedback is especially helpful.

Learning in Practice
As a student moves on to become a professional medical assistant, she must remember that her patients will each have their own learning styles, too. As she teaches them about medications, lifestyle modifications, or other health practices, she must utilize strategies that best help them learn, understand, and remember what she has taught. Because she will likely not have time to conduct an intensive evaluation of each patients learning style, she must develop a teaching routine that appeals to as many styles as possible.

Writing-Dependent Learners
Writing-dependent learners can enhance their learning by taking notes during lecture, writing out challenging concepts, or creating tables and diagrams or other written illustrations. These people may nd that recopying their lecture notes is immensely helpful. (See Suggested study strategies, page 6.)

have company when studying. They nd that discussion with others helps them to think out loud, or process information to gain a deeper understanding. The exchange of ideas and hearing others verbalize concepts is very helpful to them.

Test-Taking Strategies
Throughout their course of study, all students take many written examinations. Once they have completed their programs, most will take the CMA or RMA certication examination. Needless to say, test taking is commonly an anxiety-producing event for many people. For some students, anxiety may be so severe that it hinders their ability to be successful. It is a frustrating experience for students to study hard, feel prepared, and then test poorly because of severe anxiety. Many test-taking strategies, then, address reducing anxiety levels before and during the examination. Other strategies address more practical actions to take during the examination to aid memory and avoid common pitfalls.

Auditory Learners
Auditory learners need to hear the spoken word. When they try to read or study silently, their minds wander. Auditory input, even by means of talking to themselves, helps them process information and gain deeper understanding. Few people are strong auditory learners, yet nearly everyone has an auditory component to their learning style. Therefore, most individuals benet from combining auditory activities with their other study strategies.

Visual Learners
Visual learners may nd their minds wandering when listening to a speaker without the benet of interesting visual aids. They may often wonder why they have such a hard time paying attention and why they struggle so hard to remember what was said. Individuals with this learning style must see the information with their own eyes. Doing so helps them take in new information, process it, and understand it. They will sometimes say that after being exposed to information in a strongly visual manner, they can later see it in their minds eye and remember it long after.

Anxiety Reduction
A mild level of anxiety can be useful if students learn to channel their nervous energy in positive ways, such as devoting time to study and prepare for tests. During the test, a mild level of anxiety can actually help students stay awake and alert. However, excessive anxiety becomes a hindrance and can impair a students ability to focus and problem solve. Therefore, students serve themselves well to identify, learn, and practice strategies that help keep their anxiety under control before and during a test. There are many techniques that can be employed to reduce feelings of anxiety and help students focus on the task at hand. Not all techniques work equally well for everyone. Therefore, students should take time to try different strategies to nd what best suits their individual needs. Some strategies address actions to take just before the examination or during the examination. Others address actions to take in preparing for the examination and require more time or practice to be effective. Students who suffer extreme anxiety should meet with a counselor. Most colleges have counselors on campus who

Kinesthetic Learners
Kinesthetic learners need hands-on interaction to learn. Sitting still for long periods of time is difcult for these people. They benet far more from hands-on activities than from observation. While most adults are predominantly visualkinesthetic learners, most people possess some of the traits of all of the styles described. Therefore, any of the suggested strategies may help students learn.

UNIT 1

General-Transdisciplinary

Suggested study strategies

The table below contains suggested study strategies for individual learning styles. Most people have more than one style, so students should try out a variety of strategies.

Learning Style
Solitary

Suggested Study Strategies

Study in a quiet, isolated place. Read the chapters of this book as assigned and work through the exercises in the corresponding chapter of the student workbook. Be sure to use the answer key to get immediate correction and feedback. Complete the exercises on the student CD that correspond to the assigned chapter. Make and use ash cards to aid in memorizing key terms or concepts.

Social

Identify other social learners in your class with the same needs and make arrangements to study with a partner or in a group. Take turns quizzing each other with ash cards and terms from the textbook or the student workbook. Take turns looking terms up in this book or in a medical dictionary. Then read and discuss the meanings. Persuade family members or roommates to help by doing some of the same activities described above. Attend class to take advantage of the social interaction. Ask questions and participate in discussions.

Auditory

Study with others (see suggestions for social learners). Listen to others pronounce terms. Participate in discussions. Repeat key terms and denitions aloud after reading or hearing them. Read key passages aloud. Tape-record lectures, passages from the text, or even discussions. Speak aloud when reviewing ash cards. Be sure to attend class so you can hear the lecture, questions asked by others, and general discussion.

Visual

Read this textbook and utilize the student workbook. Pay close attention to illustrations, sidebars, and tables. Use colored highlighters on key terms and passages while reading or to color-code different categories of information. Draw pictures, arrows, diagrams, or other visual cues on a card or in the book to help make connections and understand concepts. Make ash cards with key terms on one side and a brief explanation or denition on the back. Keep them with you to review as time allows. To make ash cards more effective, consider adding visual cues. These may include diagrams or illustrations copied from the book or any other drawings. Also consider using mnemonics.

Kinesthetic

Conduct hands-on, or interactive learning. Utilize as many senses as possible (such as vision, hearing, and touch). Draw pictures or diagrams. Use colored highlighters to emphasize important information. Try strategies suggested for social and auditory learners. Complete learning activities in the text, student workbook, and CD. Incorporate body movement whenever possible, such as walking or using a stationary bike or treadmill. Attend class and participate in all discussions and learning activities.

Oral-Dependent

Speak out loud to verbalize complex concepts or to memorize terms. Explain concepts to someone else. When given the option, choose to do an oral presentation rather than a written project.

Writing-Dependent

Rewrite lecture notes. Write out challenging concepts. Write terms and denitions. Draw illustrations, diagrams, or other written clues to help explain concepts or cause-effect relationships.

CHAP TER 1

Succeeding as a Student

provide free services to students. They have expertise in such areas and can provide specic guidance and instruction. They can also provide referrals to a private therapist if appropriate.

natural morphine-like substance produced in the body). These techniques are most effective when practiced regularly. Conditions that respond to meditation include anxiety, headache, hypertension, insomnia, and backache.

Preparing for the Examination

Examples of anxiety management strategies that students can learn to use in preparing to take an examination include biofeedback and meditation and relaxation.

Just Before the Examination

For most students, keeping test anxiety at bay begins before the examination. Taking care to avoid other highly anxious students just before the examination and relaxing in a quiet, calm environment can be helpful. Some possibilities include quiet study in the library, listening to soothing music with headphones, or performing relaxation exercises while sitting in the car. Other test preparation activities include getting enough sleep the night before and eating a nutritious meal before the examination so that energy levels do not drop during the examination. Some students benefit by drinking a cup of coffee or tea prior to the test, because a small amount of caffeine helps them remain awake and alert. However, drinking too many caffeinated beverages will lead to increased anxiety. Caffeine also has a diuretic effect, so too much may result in the need for frequent bathroom breaks. In addition, adequate hydration helps students feel and think their best. However, consuming large volumes of liquids should be avoided because doing so will also increase the need for trips to the bathroom.

Biofeedback
Biofeedback is a type of therapy that teaches a person to control her autonomic (involuntary) nervous system. Techniques include the use of a variety of technologies that provide feedback about physiologic functions. Such technologies include:

electromyography (EMG), which provides feedback about muscle tension skin sensors, which provide feedback about skin temperature electroencephalography (EEG), which provides feedback about brain wave activity electrodermal response (EDR), which provides feedback about sweat gland activity.

The person undergoing biofeedback receives feedback by way of sounds through headphones or blinking lights when changes in her pulse, blood pressure, brain waves, or muscle contractions occur. This biological feedback helps her develop increased awareness of her body. With this increased awareness, she learns to recognize relationships between sensations and actual levels of function. Once her skills are developed, she can then use learned techniques, such as muscle relaxation and breathing, to create the changes she desires without the assistance of technology. Through this process, a person can learn how to exercise voluntary control over bodily functions that were previously involuntary or unconscious. People usually master the skill after 10 to 12 sessions and are able to use it when needed. Many people with a number of conditions, including anxiety, hypertension, migraine and tension headaches, attention deficit hyperactivity disorder (ADHD), and attention decit disorder (ADD), have found biofeedback useful.

During the Examination

Students can employ specic strategies during the examination to keep their anxiety levels low. For example, those who nd themselves distracted by others should try to sit near the front of the room or in a corner where they are less likely to notice what others are doing. They can ask permission to wear ear plugs or headphones to reduce distractions from room noise.

Practical Strategies
As soon as the examinations are distributed, the student should do an information dump by writing memorized facts in the margins of the examination. Doing so will avoid the danger of forgetting such information and will free the student to concentrate on the examination. Examples of such data include formulas, laboratory values, and normal vital signs for various age groups. Other strategies can help students effectively read questions on the examination and select answers. Some suggestions include:

Meditation and Relaxation

Many kinds of meditative and relaxation techniques are useful in relieving anxiety, easing depression, reducing pain, and promoting healing. Many forms exist and all work by inducing a deep state of relaxation. Some of the most common techniques include slow, rhythmic breathing; progressive relaxation of muscle groups; calming of the mind; and imagery or visualization. When using imagery, the person usually imagines himself in an environment that is safe, pleasant, soothing, and relaxing. These techniques promote physical and emotional relaxation and promote the production of endorphins and enkephalins (a

covering potential answers until the questions have been read twice carefully reading potential answers one at a time (while keeping others covered) going back and reading the question one more time before selecting the answer

UNIT 1

General-Transdisciplinary

avoiding overanalyzing questions by selecting the best answer from the choices available based on the data at hand and then moving on resisting the temptation to go back and change answers without an extremely good reason for doing so double-checking to make sure all questions have been answered before turning in the examination.

Self-Care
Most people are drawn to the health care professions because of a combined interest in medicine and a desire to help others and to make a difference in the world. This desire will serve them well in their careers but can also be their undoing because caregivers sometimes have a tendency to take good care of everyone but themselves. Ignoring their needs can eventually put them at great risk of burnout, a syndrome in which an individual feels physical, emotional, or mental exhaustion caused by ongoing intensive demands without sufcient physical or emotional rest. New medical assistants are usually so enthusiastic about their careers that they nd it difcult to imagine themselves ever feeling burned out. However, no one is immune. Furthermore, burnout rarely occurs suddenly. Rather, it usually develops slowly over a period of time and may become profound before an individual is fully aware. Therefore, all new medical assistants should develop a plan now to avoid burnout later. (See Symptoms of burnout.) Many factors contribute to burnout but a key factor is the neglect of self-care. Self-care is any activity that supports and nurtures an individuals physical, mental, spiritual, or emotional health and well-being. Providing effective selfcare entails taking full responsibility for nurturing and keeping oneself physically, emotionally, and mentally healthy. Some people have a hard time doing this and feel guilty when they spend time on themselves. Yet they may nd themselves feeling needy and resentful when their needs go

unmet and may even begin to feel resentful of others for failing to meet their needs. This has a negative impact on their relationships. Such individuals are at high risk for eventual burnout. To avoid this risk, they must learn to grant themselves permission to provide self-care, understanding that caring for oneself is a critical rst step in being able to effectively care for others. A key principle in self-care is nding ways to create balance among work, play, rest, family obligations, and self-care needs. Medical assistants who develop and consistently use a plan of self-care nd their effectiveness in their professional and personal lives is enhanced. (See Self-care strategies to avoid burnout.)

Body Mechanics
Body mechanics can be dened as the conscious coordination of the nervous and musculoskeletal systems to preserve and protect posture, balance, and body alignment while bending, lifting, and performing activities of daily living (ADLs). An important part of self-care involves the practice of good body mechanics, which protects the medical assistant and others with whom she works from injury. Making the effort to learn and develop good body mechanics should be viewed as an investment that produces real rewards. Preventing injury saves the medical assistant untold pain, suffering, lost work, and lost income and may even prevent permanent disability. In addition, it saves the employer costs in terms of insurance and stafng issues. Furthermore, it might save patients from injury as well, which benets everyone. In fact, it really takes no more time to develop good habits and to do things correctly than to develop bad habits and do things improperly. Back injuries are among the most common type of workplace injury and usually occur as a result of improper lifting. Typical injury involves the strain of lumbar muscles. More severe injuries involve intervertebral disk herniation or rupture. Such injuries can put the medical assistant out of work for weeks or even months. Surprisingly, not all back injuries occur while moving or lifting heavy objects. Many individuals suffering from back pain recite stories of feeling a pop, twinge, or some other sensation followed by severe pain when doing something as seemingly innocent as bending over to retrieve a dropped pen. Therefore, good body mechanics and a safe lifting technique should be employed for any lifting or transferring demands, regardless of the weight involved.

Symptoms of burnout
A practicing medical assistant should watch out for these common symptoms of caregiver burnout: fatigue depression loss of interest in or enthusiasm for the job insomnia excessive need for sleep loss of empathy for clients feelings of anger or frustration.

Safe Lifting
Before lifting any item, the medical assistant should evaluate the size and weight of the object to determine whether help is needed. The extra few minutes required to get help is well worth the benet of avoiding injury and lost work time. If the item is too heavy to be safely lifted by one person, the

CHAP TER 1

Succeeding as a Student

Self-care strategies to avoid burnout

The table below lists some of the most common factors that contribute to burnout as well as self-care strategies that can help avoid them.

Burnout Factor
Stressful work environment Feeling unsupported by boss/manager Conict among coworkers Long work hours; inability or unwillingness to take time off Insufcient or poor quality sleep Substance abuse (self or family members); dysfunctional or stressful relationships; pent-up anger or frustration over unresolved issues Poor nutrition Lack of quality physical exercise Medical illness Financial stress

Self-Care Strategy
Utilize stress reduction strategies (meditation, exercise, relaxation, etc.) Set and adhere to healthy, effective boundaries in work and personal relationships Create positive, nurturing relationships; participate in meaningful spiritual activities Make time for fun and recreational activities Get an adequate amount of quality sleep each night (7 to 8 hours for most adults) Seek professional counseling for major unresolved issues or dysfunctional relationships Follow a commonsense balanced nutritional plan (avoid fad diets) Participate in regular physical exercise (minimum of 3 days/week) Practice good body mechanics; achieve and maintain optimal body weight Develop and follow a budget; get advice from a credit counselor if necessary

medical assistant should get the help of a second person or use an approved lifting device. When lifting and moving numerous items, it is always better to make more frequent trips carrying fewer items than try to save time by carrying too much. (See Chapter 35, Orthopedics, for more information on safely assisting and transferring patients.) When lifting an object, the medical assistant should adhere to the following guidelines:

Stand as close to the item as possible. Tighten the stomach muscles and tuck the pelvis. Bend the knees rather than the back, keeping feet shoulder-width apart. Firmly grasp the item and hug it as close to the body as possible. Keeping the back as straight as possible, lift by straightening the knees. Consciously use the leg muscles, rather than back muscles, to do the work of lifting. Move the feet in the direction of the lift but do not twist. (See Figure 1-1.)

For most busy professionals, nding time for self-care activities is challenging. Yet, when one weighs the many benets of self-care against the risks of burnout or injury, the choice becomes easier. For most individuals, it is helpful to view the time spent in self-care activities as an investment in their career and relationships that will reap benets for years to come.

FIG 1-1 Proper lifting technique.

10

UNIT 1

General-Transdisciplinary

Chapter Summary

All people have learning styles, but no two people are exactly alike. Most people are a combination of solitary, social, auditory, visual, kinesthetic, oral-dependent, and writing-dependent learners, with one or two areas being dominant. Different study strategies are effective for different types of learners. Students should try out a variety of test-taking strategies to nd what works for them. Many such strategies can reduce anxiety prior to and during an examination, help with concentration and focus, and help the student be more successful. Numerous factors, such as long work hours and a stressful work environment, contribute to feelings of burnout. The development of good self-care habits is important to help prevent burnout and keep job satisfaction high. Each person should develop a good self-care plan that addresses such issues as exercise, rest, and nutrition. Development of good body mechanics is critical to workplace safety and self-care. An important example is learning to lift safely to avoid injury to the back.

information to the class. Design your presentation with the learning needs of all styles in mind. Your presentation should include descriptive information about the learning style and study strategies that might work for individuals with this style. a. Visual b. Auditory c. Kinesthetic d. Social e. Solitary

Case Studies
1. Mary Franklin is a coworker who comes to you for advice. She is a CMA who has worked in the family medical clinic for the past 5 years. She states that she is feeling unhappy and just isnt enjoying her work like she used to. She notices that she has less patience with clients and nds herself feeling overwhelmed and exhausted most of the time. She states that she would like to quit work for a while, but being a single mother of two teenagers she cannot afford to do this. You suspect that Mary may be experiencing burnout. a. What potential symptoms of burnout is Mary exhibiting? b. What questions might you ask her to further determine whether she might be experiencing burnout? c. Since Mary cannot afford to quit working, what advice might you offer to help her experience more job satisfaction? 2. Hilda Velasquez has just graduated from an accredited program of medical assisting and will be starting her new job soon. She is very excited about her new career and the work that she will be doing to help people with their health care needs. She has heard that some medical assistants burn out after a few years on the job and doesnt want that to happen to her. Describe a plan of self-care that Hilda might follow that will help her continue to enjoy her job for many years to come.

Team Work Exercises

1. Divide into groups of three to ve students per group. Within your team take turns sharing the following information: a. why you chose a career in medical assisting b. where you see yourself in 5, 10, and 20 years (professionally) c. what type of learning style you believe you have and what type of study strategies you want to explore d. what activities you enjoy in your nonwork time that reduce your feelings of stress and make you feel nurtured, rested, or energized e. at least two different activities that you will do at least once per week for the remainder of the school term that will contribute to your physical, emotional, psychological, or spiritual well-being. 2. Divide into teams of three to ve members each. Each team will select one of the learning styles listed below. Over the next week (or time frame indicated by your instructor), your team will gather information about your assigned learning style and then return to present your

Resources

Applied Psychophysiology and Biofeedback: www.aapb.org Free learning styles inventory test: www.learningstyles-online.com Help Guide: www.helpguide.org/mental/burnout_signs_ symptoms.htm

CHAPTER

The Profession of Medical Assisting

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms describe the role of the medical assistant list the duties commonly performed by medical assistants describe the value of certication to the medical assistant and the employer compare national organizations that grant credentials to medical assistants identify national organizations that grant accreditation to programs of medical assisting list at least 10 different health care specialties that may employ medical assistants.

Chapter Outline
Role Description Career Opportunities for Medical Assistants Credentialing
Certied Medical Assistant Registered Medical Assistant

Professional and Regulatory Organizations

American Association of Medical Assistants American Medical Technologists Accrediting Organizations

Chapter Summary Team Work Exercises Case Studies Resources

11

Key Terms
accredit

Role Description
Medical assistants can work in various settings within health care; however, most medical assistants work in ambulatory settings, such as clinics and medical ofces. Medical assistants work as part of the health care team performing clinical and administrative procedures. Because they are multiskilled professionals, they are commonly described as the most versatile members of the health care team. On any given day, a medical assistant might aid a physician in the examination of elderly patients, assist in the care of prenatal clients, give immunization injections to infants, administer medications, perform electrocardiograms (ECGs), draw blood for laboratory tests, le medical records, schedule appointments, enter data into a computer, and any number of other duties. Some medical assistants work primarily as clinical medical assistants, sometimes called back ofce medical assistants, helping with such hands-on duties as examinations and treatments. Others work primarily as administrative medical assistants, sometimes called front ofce medical assistants, where they perform a variety of clerical duties, such as reception, scheduling, billing, and coding. Others work in ofces where they serve in both areas. Because of their versatility, medical assistants are sometimes oated, which means they are temporarily moved from one area to another within a facility in order to help where they are most needed. (See Maintaining versatility.) Medical assistants perform clinical and administrative tasks as delegated, or assigned, by the physician, supervisor,

To certify as having met specic standards set by regional or national organizations

administrative medical assistant

Person who works in a medical ofce primarily in the front ofce areas, performing clerical, reception, or medical records duties
certication

Issuance of a certicate by a professional organization to an individual who has met a specied standard of education or training and has, therefore, earned the right to exercise certain skills
clinical medical assistant

Person who works in a medical ofce primarily in the back ofce areas, assisting the physician with patient care, procedures, and diagnostic testing
delegation

Act of assigning tasks to another person who then legally acts as the assigners representative
oat

Ability to fulll a temporary assignment to work in a different area from the one in which an individual usually works
scope of practice

Legal description of professional responsibilities and duties that may be performed by a licensed or certied individual

Front ofceBack ofce connection

Maintaining Versatility
Medical assistants are educated and trained to work in virtually any area of the medical ofce. This versatility is a key reason they are so highly valued by employers. Yet, after beginning their careers, most medical assistants nd jobs working in areas of preference. Over time, these medical assistants feel more and more reluctant to venture out of the area that has become their comfort zone. Sadly, this results in a loss of the very exibility and versatility that initially made them so attractive to their employers. Medical assistants should remember that maintaining versatility not only enhances their value to their employers but also opens more doors of opportunity for future role enhancement and promotion. With this in mind, medical assistant students are encouraged to develop a career plan that will help them maintain and further develop their knowledge and skills in all areas. Such a plan might include these strategies: attending continuing education conferences and workshops that offer administrative and clinical content

CHAP TER 2

The Profession of Medical Assisting

13

Front ofceBack ofce connectioncontd

reading current professional literature on medical assisting and health care at least one day each month, volunteering to work in areas of the ofce other than where you usually work asking to be oriented or cross-trained to work in other areas of the clinic that are of interest to you volunteering to ll in for other members of the team when they are out of the ofce at lunch or away due to illness or vacation asking your manager about designing a job-swap experience with another medical assistant in the clinic who works in an area different from yours.

or nurse. Duties that can be delegated include those within the medical assistants legal scope and for which she has received appropriate training. Such tasks must also be within the delegators scope of practice, which is the legal description of professional responsibilities and duties that may be performed by a licensed or certied individual. Scope of practice is determined primarily by a state practice act. Tasks must also be within the bounds of the medical assistants education, training, and experience. The scope of practice for medical assistants varies from state to state, but in most states medical assistants work as agents of the physician and are under his or her supervision. (See Common skills of the medical assistant.)

Historically, most medical assistants were trained on the job. Many such individuals have attained a commendable level of knowledge and skills in this manner. However, there is little consistency in the training that occurs on the job, and employers bear the burden of such training. Therefore, employers appreciate the opportunity to hire individuals who are already fully trained and qualied. Therefore, it is best for medical assistants to attend and graduate from accredited programs of medical assisting. These programs have been certied as having met specic standards set by regional or national organizations. Students who enroll in accredited programs can rest assured that they will receive excellent education and training that meets the standards and expectations of future employers. They will be prepared to enter the profession and work in virtually any ambulatory health care setting. Furthermore, as graduates of accredited programs, they will be eligible to take an examination to earn their certication credentials, which are an indication that they have met specic requirements and earned the right to exercise certain skills.

Career Opportunities for Medical Assistants

Medical assistants are commonly employed in primary care settings, such as family practice clinics where patients of all ages are seen for wellness checks as well as nonemergency care of injury and illness. Specialty ofces also employ medical assistants in administrative and clinical roles, making it

Common skills of the medical assistant

A versatile medical assistant will maintain her skills in administrative and clinical areas of the medical ofce or facility in which she works. Below are some of the administrative and clinical skills a medical assistant will put to use in her practice. Perform manual or electronic bookkeeping Answer telephones Schedule appointments Update medical records

Administrative
Prepare and maintain the reception and waiting areas Greet patients Gather insurance data Determine insurance coverage Complete insurance claim forms Enter data into the computer Compile patients charts Identify and record codes related to diagnoses and procedures

Handle mail and correspondence Coordinate consultations Perform inventory and order supplies

Clinical
Assist the physician with patient examinations Prepare patients and equipment for examinations and procedures Assist with testing Perform phlebotomy (draw blood)
Continued

14

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General-Transdisciplinary

Common skills of the medical assistantcontd

Assist as appropriate in rst aid or cardiopulmonary resuscitation (CPR) Collect and prepare specimens for testing Perform basic laboratory testing Administer medications (in most states) under the supervision of the physician Authorize drug rells as directed Phone prescriptions to the pharmacy Obtain an electrocardiogram (ECG) Prepare and assist with x-rays Assist in minor surgical procedures Prepare sterile trays and equipment Sanitize equipment and supplies Sterilize equipment using autoclave, steam, or chemical methods Gather patients medical histories Provide patient education Obtain and record vital signs Remove sutures Apply and change dressings Prepare examination rooms

possible for medical assistants to specialize in an area of interest. Other, less traditional sites known to employ medical assistants include laboratories and research clinics. (See Health care specialties.)

Credentialing
A medical assistant can earn one of two credentials. She can become a certified medical assistant (CMA) or a

registered medical assistant (RMA). These credentials are not legally required for employment as a medical assistant. However, individuals with these credentials are highly sought after by employers who understand that such individuals have demonstrated a specific level of competence in educational knowledge as well as clinical and administrative skills in order to have earned the credential. The CMA and RMA credentials are sometimes confused with certicates of attendance awarded for completion of

Health care specialties

The list below indicates many of the health care specialties that employ administrative and clinical medical assistants. Family practice Pediatrics Geriatrics Cardiology Neurology Pulmonology Obstetrics Gynecology and womens health Urology and mens health Orthopedics Endocrinology Gastroenterology Podiatry Dermatology Nephrology Eyes, ears, nose, and throat Urgent care Psychiatricmental health Oncologyhematology Internal medicine Minor surgery Community health Public health Rehabilitation Rheumatology Infectious disease Occupational medicine Laboratory Diagnostic imaging and radiology Sports medicine Physical therapy Chiropractic Naturopathy Work injury Pain management

CHAP TER 2

The Profession of Medical Assisting

15

individual classes or workshops. However, they are not the same thing. They represent a much more comprehensive level of education and skill than what might be provided by any single class or workshop. Only individuals who have earned the CMA and RMA certication credential are entitled to use the letters CMA or RMA (in capitals) after their names to designate their level of educational achievement. (See Teaching patients about the medical assistants role.) Whether a medical assistant elects to earn the CMA or RMA credential is a matter of personal preference. There is very little difference between the two as far as knowledge, skills, or scope of practice. Students interested in becoming credentialed should visit the websites listed at the end of this chapter, gather information about each, and make an informed choice.

Upon successful completion of the examination, medical assistants earn the privilege of using the CMA (AAMA) title after their name on their name badge and on all official documents. Recertification occurs every 5 years by continuing education or by reexamination.

Registered Medical Assistant

Medical assistants earn the RMA credential by passing an examination offered by the American Medical Technologists (AMT), a national certifying organization for laboratory professionals. There are three ways that individuals may qualify for the examination. They must have: 1. Graduated from a medical assisting program accredited by the ABHES or an organization approved by the U.S. Department of Education 2. Graduated from a formal medical services program of the U.S. Armed Forces 3. Been employed in the profession of medical assisting for at least 5 years. RMA examinations are offered at testing center locations throughout the country every week. Upon successful completion of the examination, medical assistants earn the privilege of using the RMA credential after their name on their name badge and on all official documents. (See Figure 2-1.)

Certied Medical Assistant

Medical assistants earn the CMA credential by passing an examination offered by the American Association of Medical Assistants. To be eligible to take the examination, a person must have graduated from a program of medical assisting that is accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) or by the Accreditation Bureau of Health Education Schools (ABHES). Students wishing to sit for the certication examination offered by the AAMA can take their exam within a 3-month period after applying for the examination.

Teaching patients about the medical assistants role

Many people do not understand the professional role of medical assistants and commonly confuse them with nurses, nurses aides, or physician assistants. Therefore, medical assistants should take advantage of opportunities to educate patients about their role. They can easily do this when they introduce themselves to patients by offering a brief explanation of their role and their educational training. Some points of clarication they might share include: Medical assistants are not the same as nurses, nurses aides, or physician assistants. Medical assistants are not licensed but commonly do earn certication. Medical assistants are educated, trained, skilled professionals whose jobs usually involve helping the physician with patient care in the medical ofce. Medical assistants may be graduates of 1- or 2-year programs of medical assisting.

Professional and Regulatory Organizations

There are several organizations that set the standards for the profession of medical assisting. These organizations and their role in the profession of medical assisting are described in the following sections.

American Association of Medical Assistants

The American Association of Medical Assistants (AAMA) was founded in 1956 to promote the profession of medical assisting. The AAMA has since promoted the CMA credential as the minimum standard for entry to practice and established the national CMA certification program. They administer the CMA examination to graduates of accredited programs and also publish the journal CMA Today.

American Medical Technologists

The American Medical Technologists (AMT) organization formed the RMA program and offers national RMA certication to eligible candidates who successfully pass the RMA examination. The AMT offers credentialing examinations for other health-care-related elds as well, including certied

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Chapter Summary

FIG 2-1 Certication pins. (A) RMA pin. (B) CMA pin.

ofce laboratory technicians (COLT), phlebotomy technicians (RPT), medical technologists (RMT), and medical laboratory technicians (RMLT). The AMT also publishes the journal AMT Events.

Accrediting Organizations
Students who are interested in attending a school of medical assisting should carefully consider their options. Consideration should be given to attending accredited programs that have met the accrediting organizations high standards for faculty qualications, facilities, curriculum, clinical experience, and other factors. Students who attend accredited programs can feel assured that they will receive a good education. The two organizations that confer accreditation to medical assistant programs include the CAAHEP and the ABHES. Over 700 programs are currently accredited by these two organizations in the United States.

Medical assistants work primarily in ambulatory settings, such as clinics and medical ofces. Because they are multiskilled professionals, they are commonly described as the most versatile members of the health care team. Some medical assistants work primarily as clinical, or back ofce, medical assistants helping with such handson duties as examinations and treatments. Others work primarily as administrative, or front ofce, medical assistants, where they perform a variety of clerical duties, such as reception, scheduling, billing, and coding. Medical assistants perform clinical and administrative tasks as delegated by the physician, supervisor, or nurse. Students who enroll in accredited programs can rest assured that they will receive excellent education and training that meets the standards and expectations of future employers. Medical assistants are commonly employed in primary care settings, such as family practice clinics, but also may work in specialty areas. Individuals with the CMA or RMA credential are highly sought after by employers who value hiring well-educated and trained individuals. Medical assistants earn the CMA credential by passing an examination offered by the American Association of Medical Assistants (AAMA). Medical assistants earn the RMA credential by passing an examination offered by the American Medical Technologists (AMT), a national certifying organization for laboratory professionals. The AAMA was founded in 1956 to promote the profession of medical assisting and has since promoted the CMA credential as the minimum standard for entry to practice. The AMT organization formed the RMA program and offers national RMA certication to eligible candidates who successfully pass the RMA examination. Students who attend accredited programs of medical assisting can feel assured that they will receive a good education.

Team Work Exercises

1. Divide into four teams and complete these assignments as indicated by your instructor: a. Two teams will visit and review information available on the AAMA and AMT websites (see website addresses below). Each team will create a poster that summarizes the information available at their website and present it to the rest of the class.

CHAP TER 2

The Profession of Medical Assisting

17

b. One team will create a poster or multimedia presentation that illustrates the various pathways an individual might take to pursue a career in medical assisting. The presentation should include information about on-the-job training versus formal education and credentialing issues (such as national certication in the form of the CMA and RMA and certication by the state). The team must present the posters to the rest of the class. c. One team will collect examples of professional medical assisting journals and create poster presentations that describe typical content in each of these journals. 2. Divide into two teams. Each team will research and present to the rest of the class how one earns: a. RMA credential b. CMA certication. Include the steps involved and information about applying for and taking the national examinations.

as it can in this area. Furthermore, he confesses that his interest in urology is lessening and he would like to try working in a different area. However, he is reluctant to venture out of his comfort zone. Help Jon develop a plan for making a change in his medical assistant career. 2. Isabella Rousseau is a newly graduated medical assistant working in a family practice clinic. She has noticed that many of her patients seem confused about her role. Sometimes they call her the nurse or the physician assistant, which makes her feel uncomfortable. She does not wish to misrepresent herself, yet she does not want to embarrass her patients by correcting them. Describe some strategies she might employ to appropriately respond to her patients and clarify her role.

Resources

Case Studies
1. Jon Alexander is a medical assistant who has worked in the urology department for the past 10 years since he graduated from a medical assisting program. He is good at his job and feels comfortable in this department. However, he is beginning to feel like his career has gone as far

Information regarding accredited programs of medical assisting or CMA examination: AAMA, 20 North Wacker Drive; Suite 1565; Chicago, IL 60606-2903 or www.aama-ntl.org Applications and further information about the RMA credential: Registrars Ofce, American Medical Technologists, 710 Higgins Rd., Park Ridge, IL 60068-5765 or www.amt1.com

CHAPTER

Professionalism
Learning Objectives
Upon completion of this chapter, the student will be able to: dene key terms list and describe the characteristics of a professional discuss the medical assistants responsibility as a positive role model describe a personal plan to avoid potential barriers to professionalism explain what is meant by the term team player and discuss the medical assistants role as a member of the health care team.

3
Accountability Positive Attitude Professional Appearance Daily hygiene Makeup Jewelry Tattoos Hair Attire

ABHES Competencies
Professionalism
Project a positive attitude Be a team player Exhibit initiative Adapt to change Evidence a responsible attitude Be courteous and diplomatic

Communication
Recognize and respond to verbal and nonverbal communication Professional components Allied health professions and credentialing

Medical Assistant as a Role Model

Qualities of a Good Role Model

Barriers to Professionalism
Bad Habits Reactive versus Proactive Personal Problems at Work Rumors and Gossip

Chapter Outline
Characteristics of a Professional
Accuracy Courteousness and Respectfulness Dependability Flexibility Commitment to Lifelong Learning Tactfulness

CAAHEP Competencies
General Competencies Professional Communications
Recognize and respond to verbal communications Recognize and respond to nonverbal communications

Becoming a Team Player Chapter Summary Team Work Exercises Case Studies Resources

19

Key Terms
accountable

Characteristics of a Professional
Because many patients view medical assistants as representatives of the physician and health care facility, one of the unofcial duties of medical assistants is public relations. Keeping this in mind, medical assistants must consistently demonstrate professional behavior in all of their interactions with others. Not surprisingly, the qualities of professionalism that patients seek in their health care providers are the very same qualities that employers look for when hiring a medical assistant:

Willingness to account for or be responsible for ones own actions

continuing education units

Credits awarded for attendance at classes, workshops, or seminars

courteous

Behavior that is polite, considerate, and helpful

dependable

Characteristic of being reliable and trustworthy

exible

Adaptable to change; able to bend without breaking

reactive

Responding without considering the situation at hand

respectful

Behavior that treats a person or object with honor or esteem

tactful

Displaying sensitivity and courtesy in behavior and comments to avoid offending others

accuracy courteousness and respectfulness dependability exibility commitment to lifelong learning tactfulness accountability positive attitude professional appearance.

Accuracy
A medical assistant should strive for accuracy in everything she does. When a medical assistant performs accurately, she sends the message that she cares about safety and quality. Through her dedication to quality and efciency, she will reap many rewards, including fewer errors, less need for damage control, and greater job satisfaction. In addition, patients will form a more positive impression of her, her coworkers, and her employers. Of even greater importance is the safety and well-being of patients who rely on health care providers to administer medications accurately and perform procedures safely. When dealing with human lives, it does not pay to take short cuts.

Courteousness and Respectfulness

Courteous behavior should be standard practice for a medical assistant as she interacts with patients and coworkers. This behavior is polite, considerate, and helpful. Even simple measures, such as making eye contact to acknowledge someones presence, smiling, and saying please, thank you, and you are welcome, go a long way in creating a pleasant, professional environment. Respectful behavior is similar to courteous behavior and involves treating others with honor, esteem, courteous regard, and thoughtful consideration.

Dependability
Dependability is critically important in winning the trust and respect of others. Being dependable means that a person is reliable and trustworthy. These qualities are important

CHAP TER 3

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to everyone with whom the medical assistant interacts. Her employer depends on her to demonstrate consistent punctuality and performance. Coworkers depend on her to help out in a cooperative manner. Patients depend on the medical assistant to relay messages, return phone calls, and carry out other promised duties in a timely and professional manner.

Flexibility
Flexibility is the quality of being adaptable to change. One common analogy regarding flexibility is a tree branch, which is able to bend with the wind without breaking. In a fast-paced health care environment, unexpected events commonly occur. A medical assistant who is adaptable to change and able to think on her feet will thrive. A medical assistant who demonstrates the ability to recognize problems and move quickly toward a solution will earn the appreciation of her employer and coworkers. (See Flexibility equals value.)

Commitment to Lifelong Learning

Medical assistants are members of a profession in which things are continually changing. New medications enter the market frequently. Technology is becoming integrated into nearly every aspect of health care and technological changes continue to develop at a dizzying pace. It seems that new tests, treatments, and procedures enter the health care scene daily. Current understanding of the human body and the disease process also continues to deepen as a result of ongoing research. Keeping up with this fast-paced and

ever-changing profession requires a commitment from all members of the health care team. Medical assistants are no exception. Anyone who enters a health care profession must be willing to commit herself to lifelong learning in order to stay current. There are a number of ways medical assistants can pursue continuing education, including attending workshops, college classes, and reading professional journals. Most health care employers offer mandatory and optional continuing education courses. Medical assistants can benet greatly from attending as many of these offerings as possible. A medical assistant should keep a personal folder or notebook in which she records all continuing education activities. In many cases, continuing education units (CEUs) are offered for these activities. CEUs are credits awarded for the attendance of classes, workshops, or seminars that are designed to keep individuals current in their eld of expertise. They may be required for earning or renewing licensure or certication. The medical assistant may also categorize these units according to their general area, such as administrative or clinical and so forth. When it is time for medical assistants to renew certication, the needed data will be organized and close at hand. (See Learning with a buddy.)

Tactfulness
A tactful person is one who demonstrates the ability to respond to others with sensitivity and courtesy in their behavior and comments to avoid giving offense. Such persons are commonly described as diplomatic. Being tactful requires a medical assistant to think before she speaks, especially when tempers rise. She must resist the impulse to be so honest that her patient or coworker is offended. She must also strive to state things in a positive manner, using an even,

Front ofceBack ofce connection

Flexibility Equals Value

When a coworker asks for help, the last thing she wants to hear is thats not my job. Regardless of whether a medical assistant primarily works in the administrative or clinical setting, she can earn the respect and high regard of her coworkers and employer by demonstrating her willingness to help out when and where she is needed. For example, if the receptionist or administrative medical assistant is overwhelmed with ringing phones, the clinical medical assistant might step in to help answer phones. If the back ofce is short-staffed or overwhelmed with unexpected events, the administrative medical assistant might help out by weighing patients, escorting them to examination rooms, and checking their vital signs. Medical assistants will do well to remember the old saying, What goes around, comes around. The person a medical assistant helps out today will feel more inclined to return the favor the next time she is in need.

Front ofceBack ofce connection

Learning with a Buddy

To remain current and educated in all settings in her eld, a medical assistant should consider teaming up with another medical assistant who works in an area different from hers. She can make an agreement to teach the other medical assistant something new about her area of expertise at least once each month in exchange for the same education from her learning buddy. For example, an administrative medical assistant might review the latest changes in coding or data entry with her friend who is a clinical medical assistant. In return, the clinical medical assistant might teach her administrative medical assistant friend about the newest types of medications or diagnostic tests.

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pleasant tone of voice. Because the medical assistant cannot take back words once they leave her mouth, it is always better to be discreet and say less, rather than more, when she is unsure of what to say. Language use should include proper grammar and be free of slang terms and vulgarity. In doing so, she creates a more professional impression and enhances effectiveness and accuracy when communicating with someone from another culture who speaks another language.

Professional Appearance
Appearance is a critical part of the professional role. Generally, the more conservative a persons appearance on the job, the better. Working on the job as a medical assistant is not the time to express individuality in a amboyant or radical manner.

Daily Hygiene
Daily hygiene for the medical assistant should include a shower, use of a deodorant, and good oral hygiene. She should pay special attention to her hands, because keeping her skin clean and intact will protect the medical assistant and her patients from microorganisms. She should avoid fragrances, because not everyone appreciates them. More importantly, many patients and even other health care workers suffer from allergies and respiratory disorders, and some fragrances could exacerbate their symptoms.

Accountability
The medical assistant who is accountable for her actions is someone who is willing to take responsibility for what she does. She must also admit her errors and work positively to take corrective measures if needed. In addition, a medical assistant who is accountable is empowered to create the positive work environment she wishes to experience, rather than feeling powerless to effect change or feeling victimized by others.

Makeup
The medical assistant should be conservative with the application of makeup, keeping it to a minimum. She must keep her ngernails clean, smooth, and no longer than the tip of her nger. She should avoid long nails and articial nails, because they tend to harbor microorganisms which can then be passed from person to person.

Positive Attitude
In most work environments, and especially in health care, attitude is everything. The saying Hire the attitude, and train the skill is common among health care employers. While doing so is not realistic in many cases, the statement points out how highly most employers value having employees with positive, professional attitudes. It also points out how difcult it can be to work with, not to mention change, someone with a bad attitude. Attitudes can be changed, but the motivation for change must come from the individual. Therefore, it is up to each person to notice her responses, thoughts, feelings, habits all of the things that go into her attitudeand then make the effort toward needed change. It takes work, but the results are well worth it. However, many people nd it challenging to view themselves objectively. Therefore, even though it feels risky, it may be enormously helpful for a medical assistant to solicit feedback from friends and coworkers. A safe way to begin might be to approach a trusted friend by saying, I am setting some goals for myself in the area of professionalism. I would appreciate some honest feedback based on your observations. Regarding my general attitude and communication with others, what do you think are my greatest strengths? And what are some areas you believe I need to strengthen? The next step is to set simple, measurable goals, such as getting though one work day without discussing personal problems, complaining about work conditions, or watching the clock. On a more positive note, one could make a mental (or actual) list of the things about the job that are enjoyable, positive, or interesting and then review the list at the start and end of each day. Focusing on the positive can have a signicant impact on a persons outlook. Since attitudes seem to be contagious, medical assistants should commit themselves to spreading positives ones.

Jewelry
Jewelry should be conservative and minimal. Acceptable jewelry might include an engagement ring and/or wedding band, a wristwatch, and a single pair of small earrings. Jewelry related to body piercing is not appropriate in the health care setting.

Tattoos
A medical assistant should think carefully before making the decision to get a tattoo, because tattoos are deemed unprofessional by many people. Any tattoos the medical assistant already has should be covered if possible.

Hair
Men and women alike should keep their hair clean, neatly styled, out of the face, and pulled back when assisting with sterile procedures so that the sterile field and patient are not compromised. While many people enjoy expressing themselves through their hairstyles, medical assistants should resist the urge to wear wild hairstyles to work. A conservative appearance is always perceived as more professional.

Attire
Clothing should be clean and wrinkle-free and conform to the standards designated by the employer. In most cases, a medical assistant wears a uniform, good-quality scrubs, or professional-looking clothes, such as slacks and a shirt or a

CHAP TER 3

Professionalism

23

others do not. When a person takes on a professional role, especially in a service-oriented profession such as medical assisting, this kind of responsibility takes on special meaning. Patients look to health care providers for help, information, and guidance. Furthermore, they observe and take note of such characteristics as lifestyle, attitude, behaviors, and habitshealthy and unhealthy. They may be inspired by good examples of healthful living and may be negatively inuenced by unhealthful ones. With this power of inuence in mind, the medical assistant must carefully consider the type of role model she wishes to be.

Qualities of a Good Role Model

Good role models practice what they preach. While no one leads the perfect life, health care professionals are viewed by others as examples of how one ought to live. At the very least, health care workers should avoid aunting bad habits in front of patients (such as smoking in front of the medical building). Better yet, they should strive to develop the same healthful habits that they encourage in their patients. (See Teaching by example.)

FIG 3-1 Professional attire for a medical assistant.

Patient Education

dress with a white laboratory coat and a name badge (see Figure 3-1). The medical assistant must be sure to button a laboratory coat when performing invasive procedures, such as injections and drawing blood. Because a medical assistant is exposed to ill patients continually, daily laundering of professional clothing is a must. She must wear undergarments, which should be esh- or neutral-colored and free of designs or lettering so that they do not show through the uniform. A medical assistant commonly spends a great deal of time on her feet. Therefore, comfortable, good-tting shoes are of utmost importance. Shoes should conform to the dress code of the facility, and the medical assistant must keep them clean and in good repair. Many health care providers (male and female) who spend long hours on their feet make it a habit to wear support hose, which are available in knee-high length in a variety of colors. They come in various compression strengths and help reduce leg fatigue and aching and minimize the development of varicose veins.

Teaching by Example
Patients sometimes learn more from the medical assistant by her actions than from her words. Because she is a role model, the information that she gives patients about lifestyle modication will have a greater impact if the patients see her practicing what she preaches. If she teaches them about weight loss or smoking cessation, yet is signicantly overweight herself or smells of tobacco smoke, her message loses impact. On the other hand, if patients see a medical assistant who practices healthy behaviors, it makes a positive impression. They are then more likely to heed her words of advice. Although this may not seem fair, it is true. So the medical assistant should take every opportunity to lead others by example. Healthy behaviors for the medical assistant that have an impact on patients and patient education include: getting regular exercise, such as going to the gym, walking the dog, and riding a bike eating a nutritious diet

Medical Assistant as a Role Model

Everyone is a role model in some respect. Everyone has some degree of inuence on those with whom they come into contact. Some people welcome this responsibility, while

nding a balance between work and play getting regular health checkups maintaining optimal weight avoiding tobacco or illicit drug use.

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Barriers to Professionalism
In addition to qualities of professionalism that a medical assistant should look to acquire, there are some barriers to professionalism that she should try to avoid, including:

Rumors and Gossip

Because rumors and gossip have a negative impact on employee morale, the medical assistant should avoid engaging in such conversations at all costs. She must remember that the grapevine generally distorts the truth more and more with each retelling of a story. It is also worth noting that nobody is immune to the pain and damage that gossip inflicts. Professional medical assistants must understand that the best way to earn the goodwill and respect of coworkers is to treat them with respect and goodwill and to assume the best of others, rather than the worst.

indulging in unhealthy or impolite habits being reactive bringing personal problems to work engaging in rumors and gossip.

Bad Habits
The medical assistant should carefully consider eliminating behaviors that are unhealthful as well as those deemed illmannered or unprofessional. At the very least, she should refrain from such habits while performing her job. Examples of such behaviors include tobacco use, gum chewing, and vulgar language.

Becoming a Team Player

All employers agree that one of the qualities they most desire in their employees is the ability to be a team player. With an individual sport, such as running a marathon, a person sets individual goals, plans independently, and develops a strategy based on personal strengths and weaknesses. The person relies only on herself to accomplish the task, arrives at the finish line alone, and takes personal credit for the accomplishment. With a team sport such as soccer, goals are shared by the entire team, and the game plan is communicated and agreed upon between players. On the field, players pass the ball to each other and lend support when and where it is needed. Everyone contributes to the process, and nobody performs alone. Personal sacrices are made for the good of the team with the goal of achieving a team victory. Credit for the results, regardless of the nal score, is shared by everyone on the team. Even players who may not particularly like one another understand that the welfare of the team comes before personal issues. They learn to work together effectivelyputting personal feelings asideand as a result develop a measure of respect for one another. Similarly in the health care setting, such goals as providing top-quality patient care and creating a profitable medical practice are shared by the entire team. Effective communication is critical to the process and members of the team lend one another support when it is needed. Nobody performs in isolation. Everyones contribution and cooperation is essential. On occasion, personal sacrifices are made for the good of the team so that the goals can be achieved. Although it is preferable, it is not mandatory for all employees to like one another. Even so, they must develop the ability to work together in a cooperative and respectful manner. Medical assistants who develop the ability to be true team players will be highly appreciated and valued by everyone.

Reactive Versus Proactive

The hallmark of a true professional is the ability to maintain a professional demeanor under trying circumstances. Because the fast-paced environment of the medical ofce can be stressful, a medical assistant may, at times, nd her energy and enthusiasm diminishing. When her energy lags and her patience runs low, her temper may easily air. As a result, the medical assistant may be reactive, or respond without considering the situation at hand, resulting in words and actions that she regrets later. To avoid such situations, the medical assistant should strive to develop good organizational strategies to minimize the risk of such events and effective coping skills to better deal with them if they occur. She will expend less energy striving to behave professionally in a stressful situation than she would trying to apologize or make amends to upset patients or coworkers if she loses her temper.

Personal Problems at Work

If a medical assistant is not careful, problems and stresses from her personal life may threaten to intrude into the workplace and impact her attitude, energy level, and ability to focus. In these times especially, it is important for her to remember that each patient deserves the same measure of caring, attention, and respect, regardless of the medical assistants personal issues. Therefore, she must learn how to place such personal problems aside when she goes to work each day, so she can give her full attention to the job at hand. Learning to focus on her immediate situation will assist the medical assistant in making this transition each day. Furthermore, if she discusses personal problems repeatedly in the workplace, she may eventually alienate her coworkers and have a negative impact on patients.

CHAP TER 3

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25

Chapter Summary

Medical assistants are viewed as representatives of the physician and the health care organization. Therefore, they must consistently demonstrate professional behavior in all of their interactions with others. Medical assistants should strive for accuracy in everything they do. When a medical assistant performs accurately, she indicates that she adheres to the standard of care and takes care in all that she does to avoid errors. Through her dedication to quality and efciency, she will reap many rewards, including fewer errors, less need for damage control, and greater job satisfaction. Courteous behavior that is polite, considerate, and helpful should be standard practice for medical assistants as they interact with patients and coworkers. Being dependable means being reliable and trustworthy. These qualities are important to everyone with whom medical assistants interact. Medical assistants who are adaptable and exible will quickly earn the appreciation of their employers and coworkers. Medical assistants are members of a profession in which things are continually changing. They must be willing to commit themselves to lifelong learning in order to keep up. Some ways they can do this is by attending workshops and college classes and reading professional journals. A tactful person is one who demonstrates the ability to respond to others with sensitivity and courtesy to avoid causing offense. Because the medical assistant cannot take back words once they leave her mouth, it is always better to be discreet and say less, rather than more, when she is unsure of what to say. Accountability refers to a willingness to be responsible for and answer for ones actions, own up to any errors, and work positively to take any corrective measures if needed. In most work environments, and especially in health care, attitude is everything. The saying Hire the attitude, and train the skill is common among health care employers. Attitudes can be changed, but the motivation for change must come from within the individual. Appearance is a critical part of the professional role. Generally, the more conservative a persons appearance is on the job, the better. Paying careful attention to appearance includes taking care with hygiene, wearing minimal makeup and jewelry, avoiding displaying tattoos, and keeping hair out of the face and eyes. Clothing should be neat and clean and conform to standards designated by the employer. Because medical assistants commonly

spend long days on their feet, they should carefully select footwear and hosiery. Patients look to health care providers for help, information, and guidance. Furthermore, they observe and take note of such things as lifestyle, attitude, behaviors, and habitshealthy and unhealthy. Medical assistants must be aware that they are role models and strive to be positive ones. Potential barriers to professionalism include such bad habits as tobacco use, gum chewing, and vulgar language. Other barriers include being reactive rather than proactive when responding to others, bringing personal problems to work, and participating in gossip. All employers agree that one of the qualities they most desire in their employees is the ability to be a team player. Professional medical assistants should recognize that the welfare of the team sometimes must take priority over personal issues, and everyones contribution and cooperation is essential. Medical assistants who develop the ability to be true team players will be highly appreciated and valued by everyone.

Team Work Exercises

1. Gather into teams of three to four students each. Each team will select one of the following assignments: a. Each team member must interview someone who works in a managerial or supervisory capacity (in any profession) and ask them to identify what qualities they look for in prospective employees. Each person should report her ndings back to the team. The team must then prepare a poster presentation based on the compiled results. b. Each team member should contact the nearest local AAMA chapter and nd out what types of continuing education unit (CEU) offerings or meetings are planned during the next 3 months. The team should report its ndings to the class. c. Contact the national AAMA and find out what types of CEU offerings or meetings are planned during the next year. Report your findings back to the class. 2. Gather into teams of three to four students each. Read the scenario below together. Brainstorm with your team members and come up with a plan for addressing the issue in a positive and professional manner. A coworker in your medical ofce has good skills as a CMA but has poor personal hygiene. On several occasions, you and others have noticed that she has bad breath and occasional body odor. You like her and respect her knowledge and skills. However, you are concerned about the impact that this problem has on others, especially patients.

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Case Studies
1. Olivia Bianchi works as an administrative CMA in a sports medicine clinic. She tells you she is feeling frustrated with her job and her coworkers, and cannot understand why they do not seem to like her. She states that she gets paid on an hourly basis to work from 9:00 a.m. to 5:00 p.m., 4 days a week. She says she thinks that others in the ofce resent her because she doesnt have to work 5 days a week like they do and she has an active personal life. She has seen some roll their eyes when she walks in the door promptly at 9:00 a.m. and out the door promptly at 5:00 p.m. If they ask her to come early or stay late to help open or close the ofce or complete other tasks, she states, Thats not my job. I was hired to answer phones and make appointments. After all, I dont want to be a workaholic like some of you. She further states that setting these clear boundaries is an important part of her self-care so that others do not take advantage of her. What advice might you offer to Olivia so that she can develop better relationships with her colleagues? 2. Gloria Chatzi is a coworker in the medical ofce where you work. You like her but are beginning to tire of her

many stories about all of her personal problems. Her life always seems to be in turmoil and she wants to ll you in on every detail. You nd yourself trying to avoid her, which is difcult because the ofce is fairly small. You realize that your growing resentment is beginning to impact your attitude toward her and your enjoyment of your job. In addition, you notice that patients sometimes overhear bits of Glorias stories and worry about the impression they get from this. Finally, you realize that you cannot tolerate the situation any longer and must resolve this problem. Describe what you will do and say to address this issue.

Resources

AAMA information on continuing education: www .aama-ntl.org/viewceus.aspx AMT information on continuing education: www.amt1 .com/site/epage/9360_315.htm Information on professionalism in the workplace: www .sideroad.com/Human_Resources/professionalism.html

CHAPTER

Health Care Yesterday and Today

Learning Objectives
Upon completion of this chapter, the student will be able to: dene key terms describe ancient beliefs about health and illness list key people in the history of medicine and describe their contributions to the profession discuss at least ve signicant developments in the medical profession during the past century differentiate between acute, longterm, subacute, home, and ambulatory care settings compare the sole proprietorship, partnership, and corporation forms of business organization and list the potential benets and disadvantages of each describe the role and education of medical doctors list and describe the characteristics of at least 10 different areas in which physicians may specialize list and describe four types of nonmedical physician specialties describe the role of each member of the health care team.

4
Therapists Physical therapist Occupational therapist Respiratory therapist Speech therapist Registered Dietitian Prehospital Care Specialists Emergency medical technicians Paramedics Technicians Phlebotomist Radiologic technicians Medical laboratory technicians Administrative Specialists Medical coding specialist Medical transcriptionist

CAAHEP Competencies
General Identify community resources

ABHES Competencies
Communication
Serve as liaison between physician and others

Chapter Outline
Brief History of Medicine
Ancient Health Care Early Development of Medicine Current Medicine Future of Medicine

Health Care Settings

Hospitals Long-Term Care Subacute Care Home Care Ambulatory Care

Chapter Summary Team Work Exercises Case Studies Resources

Types of Medical Practices

Sole Proprietorship Partnership Corporation

Health Care Team

Physicians Other Practitioners Nurses Physician Assistants Medical Technologists

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Key Terms
acute care

long-term care

Setting in which short-term health care is delivered to patients who are experiencing sudden illness or injury
ambulatory care

Health care setting that provides care for people who are deemed medically stable, yet unable to provide for their own needs, or people who require end-of-life care
medical asepsis

Facility, such as a medical clinic, that provides medical care to nonresidential patients, who arrive and leave on the same day
assisted living

Practice that frees a specic environment from microorganisms that might cause disease
partnership

Residential facilities with minimal health care, common dining and social activities, and usually transportation assistance
associate practice

Creation of a legal agreement between two or more licensed physicians that species the rights, obligations, and responsibilities of each
pasteurization

Sole proprietors who share resources, such as ofce space, equipment, and employees
caduceus

Process of heating a uid to a moderate temperature to destroy bacteria without changing the chemical composition of the uid
resident

Ancient symbol of the Greek god Hermes that consists of a staff with two serpents entwined around it, surmounted by two wings, and used today by some medical groups to symbolize medical care
cloning

Physician who obtains further medical training after internship, usually as a member of the house staff of a hospital
roentgenography

Creation of cells, tissue, or an embryo without the fertilization of an egg

corporation

Practice of using radiation technology to examine the bones and other dense structures of a patients body; also called radiology and x-ray
sole proprietor

Physician in a solo practice

staff of Asclepius

Body that is granted legal status with rights, privileges, and liabilities separate from those of its members
dissection

Separation and delineation of animal or human tissues for study

ether

Ancient symbol of the Greek god Asclepius that consists of a staff with a single serpent entwined around it and used today as a symbol of medical care
subacute care

Organic compound once used for anesthesia; also called diethyl ether
genome

Health care setting in which temporary care is provided with the goal of helping the patient to regain strength, mobility, and function in order to return home or to an assisted-living setting
teaching hospital

Complete set of chromosomes and, thus, the complete genetic information present in a cell
group practice

Medical group with three or more licensed, full-time physicians

Hippocratic oath

Hospital that is afliated with a medical school, where residents provide much of the physician-related care under the supervision of licensed physicians

Oath of medical ethics created by Hippocrates

histologist

Specialist in the study of cells and microscopic tissues

home care

Health care assistance for a person living in his or her own home
hospital privileges

Permission granted by a hospital that allows a physician to see patients and practice medicine within that hospital
humor

Term created by Claudius Galen that refers to any uid or semiuid substance in the body

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Brief History of Medicine

To better understand the role of medical assistants within the profession of medicine, it is helpful to understand the medical profession itself, its origins, history, and present-day culture.

Ancient Health Care

Earliest records indicate that the rst health care professionals were priests and other religious leaders. At that time, human anatomy was poorly understood and microorganisms had yet to be discovered. For these reasons, the prevailing belief of the time was that illness and disease were caused by evil spirits or were punishment from the gods for sinful behavior. Consequently, treatment commonly involved rituals and ceremonies that combined religion, mythology, and nature. For example, early priests in Greek temples believed in the power of nonpoisonous snakes and commonly used them in their healing rituals. Drawings of the staff of Asclepius depicting the god of healing, Asclepius, holding a staff with a serpent coiled around the shaft are thought to be the origins of one of the symbols used today in the medical profession. Another symbol, the cadeceus, which is a staff with two serpents entwined around it surmounted by two wings, comes from the Greek god Hermes, who was the protector of alchemists (among others). Although the caduceus is sometimes used to symbolize the medical profession (for example, as a symbol of the U.S. Army Medical Corps), the staff of Asclepius is usually considered the more appropriate symbol. (See Figure 4-1.) Some ancient healing techniques are still practiced today. For example, Greek priests were known to use exercise,

massage, and hygiene treatments. In such countries as India and China, extensive use of drugs is recorded as early as 1500 to 3000 B.C. The technique of acupuncture was also introduced by the Chinese during this same time period. These therapies have evolved over the years, but they have withstood the test of time and are still widely used today. The most notable gure in ancient medical history was Hippocrates (460377 B.C.). He was born in Greece at a time when medical scholars were beginning to reject many of the teachings of the past. He embraced the newer practice of observing the sick and studying the human body with the goal of identifying the cause of disease and illness. For example, one of his observations included listening to an ill persons chest to help learn about and understand the course of the illness. Perhaps he noticed sounds of lung congestion and correlated it with patients coughing and difculty breathing. In any case, his technique was validated and rened over 2000 years later by Rene Laennec (17811826), who invented the rst stethoscope. Based on his ndings, Hippocrates rejected the traditional explanations of priests and philosophers that illness had a spiritual cause and asserted that illness was caused by physical factors. His belief that a healthy diet, hygiene, rest, and fresh air provide healing properties is still relevant today. Hippocrates, who became known as the Father of Medicine, traveled throughout Greece teaching others his methods and is best remembered for writing the Oath of Medical Ethics, known today as the Hippocratic oath. (See Figure 4-2.)

(A)

Staff of Asclepius

(B)

Caduceus FIG 4-2 Hippocrates, the Father of Medicine. (Used with permission from The Library of Congress.)

FIG 4-1 Ancient symbols used in medicine today. (A) Staff of Asclepius. (B) Caduceus.

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Claudius Galen (c. A.D. 129c. A.D. 216) was a Greek physician who followed the teachings of Hippocrates. Galen furthered his understanding of anatomy and the physiology of traumatic injuries while serving as a surgeon at a school for gladiators, where his study subjects often suffered traumatic injury. However, because Galen lived in a time when human dissection (surgical separation and delineation of tissues for study) was not acceptable, much of his research involved the dissection of animals. He subsequently produced numerous writings and illustrations based on his research. Unfortunately, much of his teaching was awed, because it was based on animal anatomy. Galen became famous for his theory that disease and illness were caused by an imbalance of the four humors: black bile, yellow bile, phlegm, and blood. Although Galen used the term humor to describe only these four uids, it came to be used to describe any uid or semiuid substance in the body. Even now such medical terms as aqueous humor, which is a uid substance found in the eye, carry this meaning. Galens teachings were generally accepted for the next 1300 years.

Italian, was the rst person to study and identify the link between veins and arteries. As a result of his work, Malpighi became known as the rst histologist (a specialist in the microscopic study of cells and tissues). During the 18th century, Edward Jenner (17491823) saved the world from the devastating effects of smallpox by developing a smallpox vaccine. He developed the vaccine by observing that a dairymaid seemed to be immune to smallpox because of her previous infection with cowpox. His colleagues initially scoffed at this idea, but he subsequently proved his theory correct when he inoculated a young boy with the cowpox virus and then exposed him to smallpox. When the young boy failed to contract the deadly smallpox disease, Jenners theory was validated. Signicant contributions to the medical profession during the 19th and 20th centuries were so numerous that they cannot all be described in this text. However, here are a few key events:

Early Development of Medicine

After the Catholic church relaxed its control over scientic and intellectual activities, human dissection became legal and was given a measure of respectability when practiced by classical artists such as Leonardo da Vinci (14521519) and Michelangelo (14751564), who desired to draw the human body and human anatomy accurately. Human dissection was also practiced extensively by Andreas Vesalius (15141564), a Belgian anatomist and physician, who became known as the Father of Modern Anatomy after he published a book titled De Corporis Humani Fabrica in 1541. This book contained hundreds of anatomical illustrations and corrected many of Galens erroneous theories. The advent of the printing press in the 15th century revolutionized medical education by allowing widespread dissemination of information and illustrations. Signicant contributions that might otherwise have been ignored were now widely accessible by other like-minded persons. For example, the discoveries of Antoni van Leeuwenhoek were widely distributed by the Royal Society of England (a scientic organization) and subsequent discoveries were made based on such work. Antoni van Leeuwenhoek (16321723) was a Dutch linen draper and manufacturer of mens clothing whose hobby was grinding lenses. (See Figure 4-3, A.) He eventually developed magnifying lenses that allowed him to observe microorganisms. (See Figure 4-3, B.) His observations and descriptions led to the development of bacteriology and protozoology. Because of his skill in grinding lenses that were superior to any of his time, he made a signicant contribution to the continued evolution of the microscope. Building on van Leeuwenhoeks studies, Marcello Malpighi (16281694), an

Crawford Williamson Long (18151878) was with a group of medical students at a party, known as an ether frolic, when he observed that people under the inuence of ether (a gas used as an early inhalation anesthetic) did not seem to feel pain. Subsequently, his successful surgery on a patient anesthetized with ether led to its common use as a general anesthetic. Elizabeth Blackwell (18211910), who was initially refused admittance to medical school because of her sex, eventually became the rst woman in the United States to receive a medical degree. She subsequently established the New York Inrmary for Indigent Women and Children, a hospital staffed entirely by women. She later returned to her native England to become professor of gynecology at the London School of Medicine for Women. (See Fig. 4-4.) Louis Pasteur (18221895) became known as the Father of Bacteriology as a result of his work in recognizing the relationship between bacteria and infectious disease. He discovered that if a substance such as milk was heated during processing, bacteria would be destroyed. This process became known as pasteurization. Joseph Lister (18271912) applied Pasteurs ndings to the area of surgery. He developed methods of sterilizing instruments and even washed his own hands with carbolic acid prior to performing surgical procedures. Until that time, other physicians had accepted postsurgical infection as an unfortunate but inevitable part of the healing process. However, Listers patients exhibited a much lower rate of infection and much greater success in recovery. Therefore, others began following Listers example, and the practice known today as medical asepsis, or trying to eradicate an environment of disease-causing microorganisms, was born. Lister has since been remembered as the Father of Sterile Surgery.

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Image rights not available.

Wilhelm Konrad Roentgen (18451922) was a German professor of physics who discovered electromagnetic radiation as a result of his experiments involving electrical currents passed through sealed glass tubes. (See Figure 4-5, A.) This radiation, which he called x-rays, eventually became known as roentgenography and is most commonly known today as radiology. (See Figure 4-5, B.) Florence Nightingale (18201910) is considered the founder of modern nursing. During the Crimean War, Nightingale was in charge of a core of 38 volunteer nurses who provided care to wounded British troops. Through her determination and keen medical understanding, she greatly improved the deplorable conditions in which she found the soldiers living. She earned the title of The Lady with the Lamp because of her habit of making late-night rounds to check on her patients with a small lamp to light her way. After the war, she continued to advocate for sanitary living conditions for patients and is credited with signicantly lowering the death rate of soldiers during war and peacetime. She then turned her attention to the design of hospitals, continuing to stress the importance of sanitation, hygiene, and ventilation. In 1860, she started the Nightingale Training School for nurses, which set the example for nursing schools that followed. (See Figure 4-6.)

B
FIG 4-3 (A) Antoni van Leeuwenhoek (Used with permission from The New York Public Library) (B) and his microscope (Used with permission from Bettmann/CORBIS).

Current Medicine
Over the past century, the frequency of medical breakthroughs has increased dramatically. Many of these breakthroughs involved the development of new drugs, including

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Image rights not available.

and insulin pumps, seems to increase at a daily rate. Procedures such as organ and tissue transplantation and in vitro fertilization, which were once considered revolutionary, not to mention controversial, have become commonplace. Scientists have successfully mapped the human genome by identifying all of the 30,000 genes present in the human body. (See Figure 4-7.) Current research is underway on human stem cells and even in the controversial area of cloning.

Future of Medicine
What medicine and science will accomplish in the next 100 years is anyones guess, given the phenomenal increase in the growth of science, technology, and medicine in the recent past. However, it is safe to say that science, technology, and medicine will continue to develop at a rapid rate. Stem cell research, while currently a subject of some controversy, will likely continue as well. Robotics in medicine has already proven useful and will likely develop further. For all of these reasons, hope for cures or remedies for many diseases and disorders that currently plague the human race is not unfounded.

B
FIG 4-5 Wilhelm Konrad Roentgen (A) (Used with permission from The Library of Congress) and one of his rst x-rays (B) (From McKinnis: Fundamentals of Musculoskeletal Imaging, 2nd ed. FA Davis, Philadelphia, 2005, p. 5, with permission).

vaccines, antibiotics, antivirals, insulin, and thousands of others. Medical advancements have included such diagnostic procedures as magnetic resonance imaging (MRI), computerized axial tomography (CAT), ultrasonography, and countless others. The number of highly technological medical devices, such as pacemakers, implantable debrillators,

FIG 4-7 The human genome.

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Health Care Settings

Physicians and other health care practitioners provide health care to people in a variety of settings depending on their needs. Common health care settings include hospitals and long-term, subacute, home, and ambulatory care facilities.

have opportunities for social, physical, and creative activities.

Subacute Care
Subacute care facilities provide a level of care somewhere between that of the acute care and long-term care facilities. A patients stay in such a facility is usually longer than in acute care, but still temporary. The purpose of the patients stay is commonly rehabilitation activities with the goal of supporting the patient in regaining enough strength, mobility, and function to return home or to a semi-independent assisted-care setting.

Hospitals
Hospitals are acute care settings, in which health care professionals deliver care to patients who are experiencing sudden illness or injury. Patients may be treated in the emergency department or admitted for medical and nursing care on a 24-hour basis. Depending on the size and type of hospital, it may include a number of specialty units, such as orthopedics, medical, oncology, pediatrics, maternity, surgery, and intensive care. Hospitals may be designated as providing Level I, II, or III trauma care, depending on the types of injuries they are equipped to deal with. Some hospitals, designated as teaching hospitals, are afliated with medical schools. Teaching hospitals employ medical school residents, who are physicians in the process of obtaining further clinical training after internship, usually as a member of the hospital staff. These residents provide much of the physician-related care in these hospitals under the supervision of licensed physicians. A growing number of hospitals have day-surgery units where uncomplicated surgeries are performed. Patients generally are admitted and discharged from such units in the same day. Hospitals are further designated as private or nonprofit. Private hospitals are commonly owned by stockholders and run by companies. Nonprofit hospitals have a community-service focus and are generally run by a board of directors. While these hospitals may make a profit, all such monies must be reinvested in the hospital. Physicians must possess hospital privileges in order to see patients in a hospital. Before a hospital grants such privileges, it will consider such factors as the physicians education, licensure, experience, and prior revocation of privileges or actions against the physicians license.

Home Care
Home care is a setting in which individuals are able to remain in their own private homes with the help of private nurses, trained aides, chore services, and other types of assistance. Another setting that falls under the umbrella of home care is the increasingly popular adult family homes that are becoming more common in many communities, also known as assisted living facilities. The owners of such facilities are generally licensed by the state to provide housing, meals, and limited health care services to a specied number of residents. Most adult family homes accept only private-pay patients and do not provide intensive nursing care. However, they are an attractive option for people who are unable to live independently yet are not in need of LTC placement.

Ambulatory Care
The term ambulatory means to walk or move about freely. An ambulatory care facility is one that provides medical care to nonresidential patients who do not stay overnight. Most medical assistants work in ambulatory care settings, such as physicians ofces and medical clinics.

Types of Medical Practices

Physicians have a number of options when choosing the type of medical practice in which they wish to participate. Choices include sole proprietorships, partnerships, and corporations. All types of medical practices are likely to employ medical assistants.

Long-Term Care
Long-term care (LTC) facilities, also known as nursing homes, provide skilled nursing care for people who are deemed medically stable yet unable to attend to activities of daily living (ADLs) without assistance. Such people are generally referred to as residents rather than patients because the LTC facility is their home. Sometimes, a persons stay at an LTC facility may be temporary; however, it is more commonly permanent. While nurses and nurses aides provide care for the residents, the aim of care is to create a homelike atmosphere to the greatest extent possible, where residents

Sole Proprietorship
Historically, physicians worked as sole proprietors within their own ofces. They were in charge of their practices and could operate them as they wished. Being self-employed, they enjoyed a certain level of independence and exibility. Patients liked knowing that they could count on seeing their own doctors and appreciated the personal nature of health

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care. As sole proprietors, physicians were the owners of their practices and could employ whomever they wished, even other physicians. However, sole proprietorships are becoming less common as physicians these days are more aware of the disadvantages in this type of arrangement. Such disadvantages include potential liability for acts of all employees, long work hours, and being on call virtually 24 hours per day, 7 days per week. Furthermore, physicians must bear all nancial responsibility of the practice and, unless they sell them to someone else, their practices end when they retire or die. In recent years, many physicians began joining together to form associate practices. This arrangement allows them to enjoy the benets of a sole proprietorship while sharing resources, such as ofce space, equipment, and employees. While associate practices help alleviate the burden of a sole proprietorship somewhat, physicians still must deal with issues of liability, long hours, and continuous on-call time.

Corporation
A corporation is an articially created body with legal and business status that is regulated by the state. The corporation exists independently of shareholders or employees and has a continuous life that does not end or change with a change in the shareholders or employees. Physicians in the corporation are usually shareholders as well as employees of the corporation. This status provides them with signicant income and tax advantages, along with attractive benet packages. Furthermore, as professional employees of the corporation, they are not liable for the acts or debts of other employees of the corporation. Therefore, their personal assets are not in jeopardy if others are involved in litigation. A health maintenance organization (HMO) is one type of a corporation in which physicians commonly practice.

Health Care Team

There are many members of a general health care team. Medical assistants should familiarize themselves with each of these specialties so they can communicate with others in an informed and effective manner. (See Members of the team.)

Partnership
Because sole proprietorships and associate practices require such a substantial commitment, many physicians are nding partnerships to be more attractive. A medical partnership is created when two or more physicians create a legal agreement that species the rights, obligations, and responsibilities of each. There are many advantages of a partnership, including an increased potential prot because physicians share expenses and pool such resources as ofce space, equipment, employees, and insurance. They can also enjoy more freedom because they alternate taking calls for all patients in the practice. (See On-call system.) The main disadvantage of a partnership is the potential liability for a partners debts. A partnership with three or more licensed, full-time physicians is known as a group practice.

Physicians
Physicians, or medical doctors (MDs), are qualified to diagnose and treat patients for illness and disease, prescribe medication, and perform surgery. Their education usually involves 4 years of premed undergraduate coursework, 4 years of medical school, and then 3 to 8 years of an internship or residency, commonly in a specialty area. Many physicians also earn board certification in their chosen specialty by passing a certification examination. Physicians must have a license in the state in which they practice medicine and must participate in continuing education for license renewal.

Patient Education

On-call System
Patients usually hope to talk with their own physicians when they contact the call service on weekends or evenings. Furthermore, they usually expect their own physician to provide care should they be hospitalized. However, physicians in a group practice or corporation usually share on-call duties and, if a physician is out of town, hospital visitation as well. Dealing with a different physician can be disconcerting to patients who have their heart set on seeing or speaking to their own doctor. Therefore, the medical assistant should carefully explain the practices policy regarding after-hours calls and hospital care to patients at the time that care is established.

Patient Education

Members of the Team

Just as with medical specialties, most patients are confused by the many types of therapists, technicians, and other health providers who are members of the health care team within a medical ofce or clinic. To reduce this confusion and increase patient understanding about who the members of the health care team are and what they do, the medical assistant should consider creating a pamphlet that describes the members of the team as well as their education and role.

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Because medical assistants may assist with patient referrals to other physicians, they should become familiar with the many areas in which physicians specialize. (See Medical specialties.) Furthermore, such knowledge may be useful to medical assistants as they decide in which areas they are most interested in working. (See Explaining specialties, page 37.)

Other Practitioners
There are some health care practitioners whose education and specialty differs from that of medical physicians. These practitioners include chiropractors, dentists, optometrists, and, in some cases, naturopathic physicians. Although these practitioners are specialists in their own right, their practice

Medical specialties
This table lists and describes common medical specialties along with their titles.

Specialty and Title

Allergy and Immunology Allergist, Immunologist Anesthesiology Anesthesiologist Cardiology Cardiologist Dermatology Dermatologist Emergency Medicine Emergency Physician Endocrinology Endocrinologist Family Practice Family Practitioner Gastroenterology Gastroenterologist General Surgery Surgeon Geriatrics Gerontologist Gynecology Gynecologist Hematology Hematologist Infertility Infertility Specialist Internal Medicine Internist Medical Genetics Geneticist

Description
Diagnosis and treatment of patients with allergies and immune system disorders

Administration of anesthetics to patients during surgery; pain management intervention for patients with severe, intractable pain Diagnosis and treatment of patients with heart disorders

Diagnosis and treatment of patients with skin disorders

Diagnosis, stabilization, and initial treatment of patients with traumatic injury or acute illness in the emergency department or in urgent care centers Diagnosis and treatment of patients with endocrine system disorders

Care for members of the whole family, from newborn to elderly, focusing on health maintenance and illness prevention Diagnosis and treatment of patients with disorders of the stomach and intestines

Diagnosis and treatment of patients with diseases, disorders, or injuries by using surgical procedures

Diagnosis and treatment of patients with diseases and disorders associated with aging

Diagnosis and treatment of patients with diseases and disorders of the female reproductive system

Diagnosis and treatment of patients with diseases and disorders of the blood and blood-forming tissues

Diagnosis and treatment of patients with fertility problems

Diagnosis and treatment of patients with diseases and disorders of the internal organs

Diagnosis and treatment of patients with genetic diseases and disorders, possibly including genetic screening and genetic counseling

Continued

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Medical specialtiescontd
Specialty and Title
Nephrology Nephrologist Neurology Neurologist Nuclear Medicine Nuclear Medicine Specialist Obstetrics Obstetrician Occupational Medicine Occupational Medicine Specialist Oncology Oncologist Ophthalmology Ophthalmologist Orthopedics Orthopedist Osteopathy Doctor of Osteopathy Otorhinolaryngology Otolaryngologist Pathology Pathologist Pediatrics Pediatrician Physical Medicine and Rehabilitation Physiatrist Plastic Surgery Plastic Surgeon Podiatry Podiatrist Psychiatry Psychiatrist Pulmonology Pulmonologist Radiology Radiologist Sports Medicine Sports Medicine Specialist Urology Urologist Diagnosis and treatment of patients with diseases and disorders of the urinary system in females and the genitourinary system in males Diagnosis and treatment of patients with athletic-related injuries Diagnosis and treatment of patients with various disorders using radiologic procedures (x-rays) Diagnosis and treatment of patients with diseases and disorders of the lungs Diagnosis and treatment of patients with mental health disorders Performance of surgical procedures for reconstruction in patients who have suffered disguring injuries as well as elective enhancement procedures Diagnosis and treatment of patients with diseases and disorders of the feet Analysis of tissue samples to conrm diagnosis of various disorders or performance of autopsy to determine cause of death Diagnosis and treatment of childrens disorders with a strong focus on health promotion and illness prevention Diagnosis and treatment of patients with physical disabilities or musculoskeletal disorders or those who are suffering from chronic pain secondary to injury with the goal of restoring optimal function Diagnosis and treatment of patients with diseases, disorders, or injuries of the bones, muscles, tendons, and ligaments Treatment of patients using medicine, surgery, and osteopathic manipulative therapy (OMT), with a strong focus on a conservative holistic approach Diagnosis and treatment of patients with diseases and disorders of the ears, nose, and throat (ENT) Diagnosis and treatment of patients with diseases and disorders of the eye Diagnosis and treatment of patients with cancer Diagnosis and treatment of patients with diseases and disorders related to their occupation Care and treatment of women during pregnancy, childbirth, and the postpartum period Diagnosis and treatment of patients with various disorders by using radiation and imaging technology Diagnosis and treatment of patients with diseases and disorders of the nervous system

Description
Diagnosis and treatment of patients with diseases and disorders of the kidneys

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Patient Education

Nurses
Nurses are licensed professionals who are closely involved in patient care. Their practice is dictated by the state board of nursing in each state and is legally independent of physicians. However, nurses commonly work closely with physicians in the provision of patient care. Their role and duties include, but are not limited to, patient assessment, nursing care plan design, implementation of physician orders, communication of data about patient status with physicians as well as other members of the health care team, and education of patients and family members. Nursing titles and legal designations vary depending on the nurses education and legal credential earned. Nurses practice in a wide variety of areas in public, private, acute, long-term, and home care settings. (See Nursing credentials, page 38.)

Explaining Specialties
Most patients are confused by the many types of physicians and specialty practices. Therefore, a medical assistant who works in an ofce that provides primary care services should provide pamphlets for patients that list and explain who the specialists are and what type of services they offer.

differs from that of traditional medical doctors and they may have limited authority to prescribe medications and treatments. (See Nonmedical physician health care providers.)

Nonmedical physician health care providers

This table lists some of the most common nonmedical physician health care specialties along with titles, a brief description, and education and licensure requirements.

Specialty and Title

Chiropractic Chiropractor

Description of Specialty Area

Treatment through manipulation of the spine for patients who suffer disorders related to misalignment of the vertebrae

Education and Licensure

Undergraduate degree plus 3 years of chiropractic school Licensed by state, with a continuing education requirement for renewal

Dentistry Dentist

Diagnosis and treatment of patients with diseases and disorders of the teeth and gums

Undergraduate degree plus 4 years of dental school Licensed as a doctor of dental medicine (DDM) or Doctor of Dental Surgery (DDS) Continuing education required to maintain the license, generally 10 to 25 hours per year, depending on the state

Optometry Optometrist

Evaluation and measurement of visual acuity and prescription of corrective lenses

Undergraduate degree plus 4 years at a school of optometry Licensed by the state (sometimes confused with ophthalmologists, who are licensed medical doctors) Continuing education required to maintain the license, generally 8 to 50 hours per year, depending on the state and the specic type of license

Naturopathy Naturopathic Physician

Treatment of patients using natural means, such as nutrition, sunlight, dietary supplements, herbal medicine, homeopathy, acupuncture, and massage

Licensed in some states

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Nursing credentials
This table lists the most common nursing credentials along with a description and the education requirements and degree for each.

Credential
Certied Nursing Assistant (CNA) or Nursing Assistant, Certied (NAC)

Role Description
Assists nurses with basic patient care activities such as feeding, dressing, toileting, and hygiene

Education and Degree

120 hours of coursework, including 16 hours of supervised clinical training Nursing assistant certicate Prerequisite coursework (1 to 2 years) 1 year of nursing education Certicate in nursing

Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN)

Assists registered nurse with care of noncritical patients Delegates appropriate tasks to nursing assistants

Registered Nurse (RN)

Designs plan of nursing care and provides care for all types of patients with a strong focus on leadership, commonly working in management roles Delegates appropriate tasks to LPNs and nursing assistants

Associates Degree in Nursing (ADN) Prerequisite coursework (1 to 2 years) 2 years of nursing education Bachelor of Science in Nursing (BSN) 4 years of liberal arts and sciences coursework, including 2 years of nursing curriculum 4-year liberal arts and sciences degree, including 2 years of nursing curriculum 1 to 3 years of graduate school in nursing area of specialty Master of Science in Nursing (MSN) (graduate degrees and titles vary with specialty)

Advanced Practice Nurse (Nurse Practitioner [NP], Clinical Nurse Specialist [CNP], Certied NurseMidwife [CNM], and Nurse Anesthetist [CRNA], among others)

Provides advanced care to patients in designated specialty areas, which may include diagnosis, medication prescription, and treatment In many states, practices legally as an autonomous practitioner (without association of a physician)

Physician Assistants
The role of the physician assistant (PA) was created by physicians to provide them with assistance in the evaluation, diagnosis, and treatment of patients. Historically, the first PAs were selected for their experience as medics in the military, nurses, or some other health care field. Further training was then provided by physicians in certificate programs. Currently, there are more than 130 PA programs in the United States. Some programs provide a 2-year Associates degree; however, most are now 4-year Bachelor of Science degree programs. In addition, Masters degree programs are now available in some states. After completing their education, PAs must pass a certification examination, which earns them the right to list the PAC (physician assistant, certified) credential after their name. PAs can work in more than 60 specialty areas. Their specific duties are determined by state law and their supervising physician. They have prescriptive authority based on this relationship. Most PAs are directly involved in patient assessment, diagnosis, and treatment in the ambulatory

care setting, and some PAs are trained to assist physicians in specialty settings such as surgery.

Medical Technologists
Medical technologists (MTs) earn a Bachelor of Science degree. They are credentialed with a license or certificate to perform diagnostic testing on blood and body fluids to aid in the diagnosis of diseases and disorders. Those who pass the certification examination earn the right to list the ASCP (American Society for Clinical Pathology) credential after their name. Medical technologists work in laboratories of clinics, hospitals, or universities performing a full range of simple and complex laboratory tests. They work with and may supervise medical laboratory technicians. In the course of their work, they operate electronic equipment, computers, and precision instruments in five laboratory areas:

blood banking chemistry

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hematology immunology microbiology.

Therapists
All therapists work with clients to help them regain or achieve an optimal level of function. However, their education, training, and roles vary greatly. Some of the most common types of therapists found in the health care setting are physical therapist, occupational therapist, speech therapist, and respiratory therapist.

Physical Therapist
A physical therapist (PT) earns a Master of Science degree and may earn a doctorate as well. The PT is a licensed professional and must graduate from an accredited program. Some states require continuing education for license renewal. A PT designs individual therapy programs for clients of all ages in order to restore strength, mobility, and function; decrease pain; and promote overall tness and health. The overall goal of care is to increase the patients ability to function at work and at home. Physical therapy treatment methods include exercise, stretching, heat or cold application, ultrasound, electrical stimulation, and massage. PTs teach patients to use such assistive devices as wheelchairs, walkers, crutches, and prosthetics. They may specialize in a variety of areas, including pediatrics, geriatrics, sports medicine, orthopedics, cardiopulmonary rehabilitation, and aquatic therapy. They supervise and delegate tasks to physical therapy assistants (PTAs), who are also valuable members of the therapy team.

RTs also work in a variety of settings, including acute care, ambulatory care, home care, and private businesses. RT duties include helping patients experiencing breathing problems in emergency situations, setting up ventilators, and assisting in the care of patients on life support. RTs may assist physicians with diagnosis by performing pulmonary function tests (PFTs), provide oxygen therapy via various delivery devices, administer such breathing treatments as nebulizers and chest percussion therapy (CPT), teach patients to use respiratory equipment, and deliver and set up oxygen equipment in patients homes and teach them to use it. Their goal is to help clients achieve and maintain an optimal level of respiratory function. Educational preparation for respiratory therapists is an Associates degree.

Speech Therapist
A speech therapist (ST) diagnoses and treats patients with speech, voice, or language disorders. STs develop and implement individualized therapy programs based on input from and consultation with other professionals, such as physicians, nurses, and social workers. STs are uniquely qualied to evaluate patients experiencing swallowing difculties and recommend appropriate dietary and safety modications accordingly. Requirements to practice speech therapy include a Masters degree in speech pathology plus 375 hours of supervised clinical practice, passing a national examination, and 9 months of postgraduate experience.

Registered Dietitian
A registered dietitian (RD) is an expert in the area of food and nutrition. An RD acts as a consultant in hospitals, long-term care facilities, HMOs, community and public health organizations, and medical centers. RDs also work in sports nutrition, food- and nutrition-related businesses, and research. They may specialize in working with pediatric, renal, and diabetic patients. A Bachelors degree is required for entry to practice. However, many RDs earn their Masters or Doctorate degrees as well. After graduation, RDs must complete a supervised practice program and pass a national examination. Continuing education is required to maintain registration.

Occupational Therapist
An occupational therapist (OT) is a licensed professional who may earn the OTR (registered) credential upon passing a certification examination. A Masters degree is required for entry into practice as an OT. OTs work with patients with a variety of disabilities from physical or natural causes. An OT designs an individual therapy program for each patient that helps him or her achieve an optimal level of function in the performance of his or her ADLs, such as bathing, dressing, and eating. OTs may also assist patients in regaining optimal function in their occupational setting. Such a program may include designing or prescribing special equipment to help a patient function at home or at work or developing computer-aided adaptive equipment and teaching a patient to use it. OTs may specialize in specific patient populations, such as pediatrics, geriatrics, or mentally handicapped patients.

Prehospital Care Specialists

Some health care providers are educated and trained to provide emergency care and transport for those who experience injury or illness. Such individuals generally are employed by re departments or ambulance companies. Examples of prehospital care specialists are emergency medical technicians and paramedics.

Respiratory Therapist
A respiratory therapist (RT) treats patients with a variety of pulmonary disorders and works with patients of all ages.

Emergency Medical Technicians

Emergency medical technicians (EMTs) are trained members of the emergency management services (EMS) team

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and assist paramedics in the stabilization and transportation of patients to the hospital. They are usually dispatched to the scene of an emergency by the 911 operator and may work with police or fire department personnel. They must know how to evaluate the scene to identify potential hazards; provide emergency, lifesaving interventions such as CPR; control bleeding; and possess other first aid skills. There are several levels of certification that may be obtained to increase the EMTs skills and responsibilities. Such skills include obtaining IV access, administering IV fluids, and using defibrillators. EMTs work for ambulance services, fire departments, police departments, and hospitals. Training includes completion of an accredited EMT program, usually 6 months in length. However, training may take longer, depending on the level of certification. EMTs are certified or registered by passing an examination.

Radiologic Technicians
Radiologic technicians help physicians diagnose a patients disorder by creating images of internal organs, tissues, and bones. Common procedures include x-rays, which show bones, and uoroscopies and sonograms, which show soft tissues by using sound, magnetic, and radio waves. Radiologic technicians analyze the images and consult with physicians about their signicance. They take special precautions to protect themselves and patients from unnecessary radiation exposure. Training usually consists of an Associates degree in a professional technical program or a Bachelors degree. People with experience in another health care eld may be able to complete a 1-year certication program.

Medical Laboratory Technicians

Medical laboratory technicians (MLTs) assist in the diagnosis and treatment of patients by performing tests on blood, body fluids, or tissue specimens using microscopes, computers, and complex laboratory equipment. They work under the supervision of a medical laboratory technologist (MT), pathologist, or other professional. They may specialize in one of five different areas, including chemistry, blood banking, hematology, immunology, and microbiology. Other MLT duties include equipment and records maintenance and results reporting. Most MLTs work in laboratories of hospitals, public health organizations, universities, pharmaceutical companies, biomedical companies, or the armed forces. MLTs must complete an Associates degree program and pass a national certification examination.

Paramedics
Paramedics are trained to provide emergency interventions for ill or injured patients with the goal of stabilizing them enough for transport to the hospital. They are usually dispatched to the scene of an emergency by the 911 operator and work with and supervise EMTs and, possibly, police or re department personnel. They must know how to evaluate the scene to identify potential hazards; provide emergency, lifesaving interventions such as CPR; control bleeding; and perform other basic and advanced lifesaving skills. Paramedic programs vary in length by state and whether they are full-time or part-time. Training includes advanced cardiac life support (ACLS), pediatric advanced life support (PALS), and other emergency care courses.

Administrative Specialists
Administrative specialists help with such administrative duties as coding, transcription, data entry, and medical records. Two types of administrative specialists are medical coding specialist and medical transcriptionist.

Technicians
A variety of technicians work in the hospital and clinic settings to aid in the diagnosis and treatment of illness or injury. Some of these technicians include phlebotomists, radiologic technicians, and medical laboratory technicians.

Medical Coding Specialist

A medical coding specialist reads and analyzes documentation of physicians and other health care providers to gather data about diseases, injuries, and procedures and translates it into diagnostic and procedural codes. Accuracy in assigning correct codes is critically important for compliance with federal regulations and insurance reimbursement. The medical facility may also use this data for planning and marketing as well as the preparation of management reports. Medical coding specialists work in hospitals, clinics, long-term care facilities, home health agencies, dental ofces, insurance companies, and government agencies. Training may be available on-the-job or through continuing education; however, an Associates degree is recommended. To become a certied medical coder, an individual must pass examinations offered by the American Health

Phlebotomist
Phlebotomists are trained to draw blood from patients for laboratory testing or from blood donors for blood banks. They spend time working directly with patients, taking blood, and monitoring the patients response. They also assist the laboratory technologists by helping prepare and process the tests. Other tasks may include updating records, preparing stains and reagents, and cleaning and sterilizing equipment. Phlebotomists work in the laboratories of hospitals, clinics, and blood banks. They may be trained on the job or may complete an accredited 1-semester or 1-year program, earning a diploma or certicate.

CHAP TER 4

Health Care Yesterday and Today

41

Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC).

Medical Transcriptionist
Medical transcriptionists work in partnership with health care providers to document patient care. They are health care professionals with expertise in medical language who translate a physicians dictation of a patients medical history, diagnosis, treatment, and prognosis into written form. Transcriptionists must use common sense and sound judgment, knowing when to seek clarication and verify information in order to ensure the accuracy of the medical record, which is considered a legal document. Certication may be earned by passing an examination and is maintained through continuing education. Medical transcriptionists work in physicians ofces, hospitals, clinics, laboratories, insurance companies, government facilities, legal ofces, and research centers. Some medical transcriptionists also work out of their homes as independent contractors.

Chapter Summary

To better understand their role within the profession of medicine, medical assistants should understand the origins, history, and present-day culture of medicine. Earliest records indicate that the rst health care professionals were priests and other religious leaders. The prevailing belief of the time was that illness and disease were caused by evil spirits or were punishment from the gods for sinful behavior. Some ancient healing techniques, such as massage and acupuncture, are still practiced today. Hippocrates (460377 B.C.) is known as the Father of Medicine and was the author of the Hippocratic oath. As a result of his studies of the sick and the human body, he rejected historical explanations that illness had a spiritual cause and thought the cause was instead a physical one. His beliefs that a healthy diet, hygiene, rest, and fresh air provide healing properties are still relevant today. Claudius Galen (A.D. 129) was a Greek physician who wrote and illustrated numerous studies of animal anatomy. He became famous for his theory that disease and illness were caused by an imbalance of humors. Once human dissection became legal, Andreas Vesalius (15141564) was able to create many accurate illustrations of human anatomy based on his studies. During the 15th century, the advent of the printing press revolutionized medical education by allowing widespread dissemination of information and illustrations.

The rst microscope was developed through the efforts of Antoni van Leeuwenhoek (16321723), a Dutch linen draper. Marcello Malpighi (16281694), an Italian scientist used van Leeuwenhoeks discoveries to study capillaries and was the rst to determine the link between arteries and veins. As a result of his work, Malpighi subsequently became known as the rst histologist. During the 18th century, Edward Jenner (17491823) developed the smallpox vaccine after noting that a dairymaid was immune to smallpox because of her previous infection with cowpox. Signicant contributions to the medical profession during the 19th and 20th centuries included the development and use of ether as a general anesthetic by Crawford Williamson Long (18151878); the rst woman physician, Elizabeth Blackwell (18211910); development of the process now known as pasteurization by Louis Pasteur (18221895), who became known as the Father of Bacteriology; methods of sterilizing instruments prior to performing surgery by Joseph Lister (18271912); and the discovery of x-rays by Wilhelm Konrad Roentgen (18451922). Over the past century, the number of medical breakthroughs has increased at a dramatic rate. Just a few examples include the development of many new drugs, diagnostic procedures, and highly technical medical devices. It is safe to say that science, technology, and medicine will continue to develop at a rapid rate in the years ahead. Common health care settings include hospitals and longterm, subacute, home, and ambulatory care facilities. Physicians have a number of options when choosing the type of medical practice in which they wish to participate. Choices include sole proprietorships, partnerships, and corporations. All types of medical practices are likely to employ medical assistants. There are many members of the general health care team. Medical assistants should familiarize themselves with each of these specialties so they can communicate with others in an informed and effective manner. Physicians may specialize in any number of areas. Other health care providers whose education and specialty differ from that of the medical physician include chiropractors, dentists, optometrists, and naturopathic physicians. Nurses are licensed professionals who are closely involved in patient care. Their practice is dictated by the state board of nursing in each state and is legally independent of physicians. However, nurses commonly work closely with physicians in the provision of patient care. The role of the physician assistant (PA) was created by physicians to provide them with assistance in the evaluation, diagnosis, and treatment of patients.

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Medical technologists (MTs) are credentialed with a license or certicate to perform diagnostic testing on blood and body uids to aid in the diagnosis of diseases and disorders. All therapists work with clients to help them regain or achieve an optimal level of function. Their education, training, and roles vary greatly. Some of the most common types of therapists found in the health care setting are physical therapists, occupational therapists, speech therapists, and respiratory therapists. Registered dietitians (RDs) are experts in food and nutrition. They act as consultants in hospitals, long-term care facilities, HMOs, community and public health organizations, and medical centers as well as in other areas. Prehospital care specialists include emergency medical technicians (EMTs) and paramedics. They provide emergency care to ill and injured individuals and transport them to the hospital for further care. A variety of technicians work in the hospital and clinic settings to aid in the diagnosis and treatment of illness or injury. Some of these technicians include phlebotomists, radiologic technicians, and medical laboratory technicians. Administrative specialists help with such administrative duties as coding, transcription, data entry, and medical record keeping. Two types of administrative specialists are the medical coding specialist and medical transcriptionist.

c. whether they are licensed, certied, or otherwise credentialed d. settings in which they typically work e. average wages f. any other data of interest. 2. Divide into teams of three or four. Each team will select or be assigned one of the physician specialists listed in the Medical specialties table on pages 35 and 36 and design a brochure or pamphlet that describes their specialty area. Be sure to include: a. typical education b. job description c. type of patients seen d. settings in which they typically work e. any specialty credentials required other than a medical license f. any other data of interest.

Case Studies
1. Atsuko Katsumi is an elderly woman who fell and broke her hip. Describe the type of health care settings she may experience in the course of her recovery and give a brief description of the type of care she would receive in each. 2. Elsa Yager has been a medical assistant for the past 4 years and is considering going back to school. She would like to become a nurse but isnt sure how long that will take or what type of setting she would prefer to work in. What advice can you give her?

Team Work Exercises

1. Divide into teams of three or four students. Each team will select or be assigned one of the providers listed below and create a brochure or pamphlet that describes that providers specialty area. a. nurse b. medical laboratory technician c. respiratory therapist d. physical therapist e. speech therapist f. occupational therapist g. medical coding specialist h. transcriptionist i. dietitian j. radiologic technician. Be sure to include: a. typical education b. job description

Resources

American Dietetic Association: www.eatright.org Association for Healthcare Documentation Integrity (AHDI): www.aamt.org Information on medical technologist careers: www.ascp .org/Careerlinks/LabCareers/default.aspx Information on naturopathic medicine and careers: www.aanmc.org/car_prac/index.php Information on paramedics: www.uihealthcare.com/ depts/emslrc/paramedics.html Information on physician assistant programs: paprogram .medicine.uiowa.edu/ Information on physical therapists: www.apta.org and www.bls.gov/oco/ocos080.htm Information on miscellaneous health care careers: www .mshealthcareers.com and www.allalliedhealthschools.com

CHAPTER

Therapeutic Communication
Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell key terms list, dene, and describe eight parts of the communication cycle discuss the impact of nonverbal communication on verbal communication describe examples of nonverbal behaviors that may enhance the effectiveness of communication demonstrate active listening through role playing demonstrate various communication patterns through role playing and include passive, passive-aggressive, assertive, and aggressive communication patterns dene and give examples of seven defense mechanisms that impede effective communication describe six strategies for effectively dealing with difcult people

5
Compensation Regression Repression Displacement Denial Projection Strategies for Dealing with Difcult People Focusing on the patient Acknowledging the patient Validating the patients feelings Using I language Moving to a solution Setting boundaries

ABHES Competencies
Professionalism
Be courteous and diplomatic Be attentive, listen, and learn

Communication
Be impartial and show empathy when dealing with patients Recognize and respond to verbal and nonverbal communication Principles of verbal and nonverbal communication

Chapter Outline
First Impressions Communication Cycle
Referent Message Sender and Receiver Channels Feedback Interpersonal Variables Environment

Cultural Variables Chapter Summary Team Work Exercises Case Studies Resources

Verbal Communication Nonverbal Communications Active Listening Giving Advice Communication Patterns
Passive Passive-Aggressive Assertive Aggressive

CAAHEP Competencies
General Competencies Professional Communications
Recognize and respond to verbal communications Recognize and respond to nonverbal communications

Communication Challenges
Defense Mechanisms Rationalization

43

Key Terms
aggressive

passive-aggressive

Quality of striving to meet ones own needs while disregarding the rights and needs of others
articulate

Manipulative behavior that appears initially passive but seeks to control by retaliation in the form of procrastination, stubbornness, and forgetfulness
projection

To verbally express oneself clearly and easily

assertive

Psychological response in which a person accuses others of that persons own feelings, attitudes, or behaviors
proxemics

Quality of advocating for ones own rights while respecting the rights of others
boundary

Study of how much personal space people prefer and how it relates to culture and environment
rationalization

Physical or psychological space that indicates the limit of appropriate versus inappropriate behavior
channel

Psychological response in which a person makes excuses to justify inappropriate behaviors

receiver

Mode of conveying a message, including vision, hearing, and touch

communication

Person who receives a message and decodes it

referent

Stimulation or motivation to communicate

regression

Process of sending and receiving information between two or more individuals

compensation

Psychological response in which a person reverts to behaviors associated with earlier (younger) developmental stages
repression

Psychological response in which a person offsets feelings of inadequacy in one aspect of that persons life by achievement in another aspect
congruent

Psychological response in which a person eliminates from conscious thought traumatic experiences or certain impulses that the person believes are unacceptable
sender

Consistent or matching
decoding

Person who delivers a message

Process by which the receiver of a message extracts its meaning

defense mechanism

Unhealthy coping strategy that a person may employ when feeling emotionally threatened in some way
denial

Psychological response by which a person refuses to acknowledge the validity or reality of something that is obvious to others
displacement

Psychological response by which a person expresses anger or another emotion at a person or object that is not the cause of those feelings
environment

Setting in which a communication experience occurs

feedback

Message returned by a receiver as a response to the senders message

interpersonal variables

Factors that impact a receivers interpretation of a message

message

Content of a communication, including verbal, nonverbal, and symbolic language

norms

Unwritten rules of socially acceptable behavior

passive

Quality of submitting or yielding without offering resistance

CHAP TER 5

Therapeutic Communication

45

First Impressions
Because a rst impression is so important, a medical assistant must help ensure that each patients rst impression of the medical ofce is a positive one. Good communication is one of the most essential skills for ensuring a positive rst impression. Communication is a complex, continuous, multidimensional process. The message, or content, of communication includes not only what a person says but also the nonverbal and symbolic language of facial expressions, body language, and vocal inections. Thus, a medical assistant must be sure the message she sends with her body language is congruent, or consistent, with the message she sends with her words.

receives a message, the message also becomes a referent for that person, who in turn may respond with another message.

Sender and Receiver

The person who delivers the message is the sender. This person is responsible for the emotional tone and accuracy of the message. The sender can increase the effectiveness of the communication experience by using clear speech, simple language, and adequate volume as well as facial expressions and body language that are congruent with the spoken message. The sender should observe the person to whom he is sending the message for signs of understanding or confusion. A receiver is the person who receives the message and decodes it, or extracts the meaning of the message. The accuracy with which the receiver understands the message depends, in part, on how well the receiver pays attention to the sender. Paying close attention involves focusing, listening, and noting verbal and nonverbal cues. The roles of sender and receiver are uid, meaning they change back and forth as the communication cycle continues. Compatibility, familiarity, and commonality between sender and receiver enhance their communication and understanding.

Communication Cycle
Communication, or the process of sending and receiving information between two or more individuals, occurs in a cycle. The main features of the communication cycle include the referent, sender, receiver, message, channels, feedback, interpersonal variables, and environment. (See Figure 5-1.)

Referent
The referent is what stimulates or motivates the communication. It might be an object, a sight, a sound, an idea, a sensation, or anything that prompts a person to communicate.

Channels
Channels are the means of conveying messages, such as vision, hearing, and touch. Such channels may incorporate facial expressions, voice volume, vocal inection, touching a persons shoulder, and so on. The more channels a sender uses, the more clearly he conveys the messageas long as all of the channels are consistent with the message he or she is sending.

Message
The message is the content of the communication. It includes verbal communication through words, nonverbal communication through gestures such as head nodding, and communication through symbolism, as with such commonly understood symbols as ( for male and & for female. When a person

Feedback
Feedback is the message returned by the receiver, which reects his or her level of understanding. It also may include the receivers response to the original message.
Noise

Referent

Environment

Encode Interpersonal variables Sender Decode

Feedback Words, gestures, facial expressions, touch, etc.

Decode Receiver Interpersonal variables

Message Words, gestures, facial expressions, touch, etc.

Encode

Channels Environment FIG 5-1 Communication cycle.

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Interpersonal Variables
Communication is greatly impacted by interpersonal variables, or factors that inuence the receivers interpretation. Such factors include personal biases, education, developmental level, sociocultural background, values, beliefs, emotions, gender, health issues, roles, relationships, and prior experiences.

Environment
The communication environment is the setting in which the communication experience occurs. A number of environmental factors can interfere with the accuracy of communication, including pain, medication effects, room noise, temperature, humidity, lack of privacy, and inadequate space. In the medical ofce, a medical assistant is responsible for ensuring accurate communication with patients and coworkers. Therefore, she must address environmental and patient comfort issues in order to minimize distractions and maximize the patients ability to focus, listen, and understand.

Verbal Communication
Spoken language is a key means of communication. However, the meaning of words can change, depending on vocal pitch and inection, word emphasis, and pauses. Therefore, the medical assistant must consistently speak clearly, enunciate carefully, use a pleasant tone of voice, and keep her mind on the messages she is conveying. She must also remember that many patients, especially the elderly, may have some degree of hearing loss. When speaking to such individuals, she should face toward them so that they can see her lips and use adequate volume without shouting.

Nonverbal Communications
When a discrepancy exists between verbal and nonverbal messages, a listener will tend to believe the nonverbal message. Therefore, the medical assistant must pay careful attention to her body language. Body language encompasses many components, including hand gestures, mannerisms, facial expressions, posture, touch, and the use of personal space. A medical assistant in a closed stance with her arms crossed, who is looking away from the person and wearing a solemn expression, conveys disinterest or displeasure. To help patients feel welcome and at ease and to project the message of concern, caring, and openness, the medical assistant should use an open body stance, make frequent eye contact, and maintain a pleasant expression, punctuated by an occasional, genuine smile. An important feature of body language is personal space. The study of how much personal space people prefer and

how it relates to cultural and environmental factors is known as proxemics. Proxemics of people in the United States reveal a preference for public space up to 25', social space between 4' and 12', personal space from 112' to 4', and intimate space as 0' (direct touch) to 112'. People are generally reluctant to give up these barriers without a compelling reason. For example, most people are willing to stand closer than usual to a stranger in a crowded elevator or when exiting a crowded concert hall. Even so, there are commonly additional unspoken rules that dictate acceptable behavior in such situations. For example, when riding in crowded elevators, people rarely speak to one another, always face forward, and avoid making eye contact. In waiting rooms, patients rarely choose to sit directly next to a stranger if other options exist. Some may even choose to remain standing in order to maintain control over personal space. Most people do not invite others into their personal space until a degree of trust and rapport has been established. Yet the health care arena necessitates some exceptions to the rules of personal space. When a patient seeks medical care, he or she generally expects a certain amount of touching to be involved. However, because the touching is extremely personal in some cases, as with a female pelvic examination, the knowledge that such touch is necessary does not automatically make patients feel comfortable with it. Therefore, the medical assistant and other members of the health care team must treat each patient with respect and sensitivity. Most patients feel vulnerable in such situations and want to trust that all touching is appropriate and professional. To earn and maintain such trust, the medical assistant must protect the patients privacy and dignity. Touch can be used in an emotionally therapeutic manner to convey interest, sincerity, and empathy. Examples of such touch might include a warm, rm handshake; a pat on the arm; or gently assisting someone as they stand to their feet or get off an examination table. Many patients welcome such forms of appropriate touch and report that it helps them to feel acknowledged and cared for. However, because not all patients welcome such touch, the medical assistant must learn to read the body language of the patient and follow his or her cues. It is always best to err on the side of caution, using less, rather than more, touch when unsure especially when dealing with the opposite sex.

Active Listening
One of the most important parts of effective communication is active listening. Active listening involves 90% listening and 10% speaking. Most people overestimate their skills as a listener. When a person should be attending to what a speaker is saying, most are thinking about what they want to say next. Additionally, people sometimes become distracted

CHAP TER 5

Therapeutic Communication

47

and let their minds wander to other matters. Some, in an effort to be active listeners, jump in and nish the speakers sentences. Others interrupt the speaker to get in their own thoughts and opinions. In these examples, the listeners are not listening well at all. Rather, they are attending to what they want to say, or even their desire to end the conversation and move on to other things. As a result, a speaker can feel unheard, unacknowledged, and uncared for. True active listening requires more energy than most people realize. It entails attending to the speakers words and body language, allowing the speaker adequate time to formulate and articulate the message, and then reecting, or paraphrasing, the message that was heard to verify understanding and seek clarication as needed.

The passive communication pattern is sometimes described as a lose-win pattern, which means the individual sacrices her needs in order to defer to the needs of others. However, in reality, neither party wins.

Passive-Aggressive
People who have a passive-aggressive communication style usually present themselves in a passive manner. However, this presentation is actually an attempt to manipulate others by deferring initially but then seeking revenge or nding ways to meet their needs by undermining others. They are commonly critical and sarcastic behind the backs of those people to whom they behave passively. They seek control through indirect means, such as sabotage, procrastination, stubbornness, or feigning forgetfulness. Such behaviors may be conscious or unconscious. For example, a passive-aggressive person who is afraid to say no when asked to work late and close the ofce, might later get revenge by forgetting end-of-shift duties and leaving them for the morning shift. Also, a person who behaves nicely when talking with a supervisor might then be critical of the supervisor to coworkers. A simple way to describe the passive-aggressive communication style is that it is a pseudo (false) lose-win style. Because the person defers her needs to the needs of others in the short-term but then seeks revenge, she ultimately undermines everyone.

Giving Advice
Medical assistants are commonly asked for medical advice by family and friends as well as patients. As much as a medical assistant may feel tempted to respond with advice, she must proceed cautiously. She must diligently avoid the appearance of dispensing medical advice outside of her scope of practice. Such action could put herself and her employers in legal jeopardy. While on the job, the medical assistant must take care to dispense information that is appropriate and consistent with her level of education and role within the medical practice. While away from her job, the wisest policy she can follow is to avoid dispensing any medical advice at all and, instead, suggest that people contact their own health care providers.

Assertive
People who are assertive come across as clear, professional, and articulate. They are not afraid to share their opinion or to speak up and ask for help. Even so, they are able to keep their feelings and opinions to themselves when common sense and professionalism dictate. An assertive medical assistant understands that her priority at work is to meet the needs of her patients and her physician employers, which sometimes means that her own needs take a back seat. She is willing to listen to the opinions and ideas of others and is interested in learning and growing on a personal and professional level. A simple way to describe the assertive communication style is that it is win-win. An assertive communicator understands how to attend to the needs of others without completely sacricing herself in the process. She is able to set appropriate limits with others when necessary and attend to her own self-care needs, while keeping her professional focus where it belongs: on the patient.

Communication Patterns
To become an effective communicator, a medical assistant must understand the different communication styles. These styles include:

passive passive-aggressive assertive aggressive.

Passive
People who are passive come across to others as weak and submissive. They commonly lack self-condence and usually defer to others, while keeping their own opinions and needs to themselves. Passive patients may be too embarrassed to admit they are confused and too reluctant to ask questions or seek clarication. As a result, they might leave the ofce feeling frustrated with unmet needs. A passive medical assistant lacks the condence needed to ask the physician questions and advocate for her patients when the need arises.

Aggressive
People who are aggressive come across to others as angry, pushy, bossy, selsh, or insensitive. They rarely hesitate to voice their opinions, regardless of the situation. They disregard the feelings and opinions of others in order to get their own needs met. A medical assistant who is aggressive is not afraid to speak up and advocate on behalf of her patients

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when she recognizes the need. Unfortunately, because of her insensitivity, she can miss subtle but important cues from her patients (and everyone else) and commonly ends up offending or otherwise alienating others. In defense of aggressive communicators, most of them have no idea how aggressive they are. Rather, they usually view themselves as being assertive and commonly think they are great communicators. Sadly, they are the only ones who think so. A simple way to describe the aggressive communication style is that it is win-lose. These people are so concerned with getting their own needs met that they commonly do it at the expense of others.

Regression
When a person reverts to behavior associated with earlier (younger) developmental stages, he or she is exhibiting signs of regression. For example, a 12-year-old child might regress to thumb-sucking behaviors when hospitalized or when dealing with family trauma, such as death or divorce. Self-limiting regressive behaviors provide emotional protection and comfort during a time of emotional trauma. The behavior usually disappears when the emotional turmoil ends. However, prolonged periods of regression may signal serious adjustment difculties and the need for therapy.

Repression

Communication Challenges
Most individuals are not nearly as good at communication as they believe. This misperception sets the stage for miscommunication and misunderstanding, even in the best circumstances. In addition, many people unintentionally block effective communication without realizing it. However, the medical assistant who understands these challenges to communication and has strategies for dealing with them will be a successful communicator.

Repression occurs when a person eliminates from conscious thought traumatic memories or painful or conflictual thoughts or impulses that the person believes are unacceptable. For example, an adult who forgot for many years about experiencing sexual abuse as a child has repressed those memories. Yet the experience has the potential to have a lasting impact on his or her ability to form healthy relationships. A man who nds himself physically attracted to his wifes best friend and recognizes his impulse to act on these feelings as unacceptable may continually forget the womans name.

Defense Mechanisms
Defense mechanisms are unhealthy coping strategies that people employ to protect themselves when they feel emotionally threatened. Some of the most common types of defense mechanisms include:

Displacement
When a person expresses anger or another emotion at a person or object that is not the cause of those feelings, he or she is employing the defense mechanism of displacement. For example, a man who is angry at his boss goes home and vents his anger on his family by picking a fight with his wife and yelling at his children. In the workplace, this behavior sometimes manifests in coworkers mistreating one another, rather than addressing issues they have with the manager.

rationalization compensation regression repression displacement denial projection.

Denial
When a person refuses to acknowledge the validity or reality of something that is obvious to everyone else, he or she is said to be in denial; for example, a person who suffers health problems, relationship problems, and professional problems due to chronic alcoholism but refuses to acknowledge that he or she has an alcohol problem. Friends, family and coworkers are usually well aware of the problem that the individual himself or herself refuses to acknowledge. In some cases, those persons closest to the individual join in the denial. For example, the wife of an abusive alcoholic who makes excuses for her husbands actions is also in denial.

Rationalization
When a person makes excuses to justify inappropriate behavior, that person is making rationalizations for her behavior. For example, when an employee steals supplies from the workplace, she might rationalize such actions by stating, They dont pay me enough anyway.

Compensation
Compensation is a psychological response in which a person attempts to offset feelings of inadequacy in one aspect of life by achieving success in another. This response is not always unhealthy, but certainly may be. For example, a parent who feels guilty for not spending time with his or her child might attempt to compensate by buying the child expensive toys.

Projection
When a person accuses others of having certain feelings, attitudes, or behaviors that he or she has, he or she is projecting. For example, a man who projects feelings of guilt

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about cheating on his wife might accuse her of being unfaithful to him.

Validating the Patients Feelings

When a patient feels upset, they do not want someone to argue with them or trivialize her feelings. Such treatment will simply further upset the patient. On the other hand, if the medical assistant responds with a calm voice and validates the patients feelings in a kind, empathetic manner, her response will most likely have a soothing effect that deescalates the situation. However, it can be difcult for a medical assistant to validate a patients feelings without implying agreement with the patients statement. For example, a patient complains to the medical assistant, saying, I cant believe that I wasted $65 on a worthless medication. You people are incompetent! The medical assistant can simply validate the patients feelings by saying, You are feeling concerned that the medication was ineffective. Then, she can offer a temporary solution by saying, Since you are not feeling better, you should probably speak with the physician. (See Teaching strategy.)

Strategies for Dealing with Difcult People

For most medical assistants, working with and helping people is the most rewarding part of the job. However, working with people can also be the most challenging part of the job. Because of pain or illness, patients do not always behave at their best. They may be upset with their lowered quality of life or feeling frustrated and angry over their lack of improvement. They sometimes seem to have unrealistic expectations of what the physician and medical science are able to offer. They may be feeling frightened, vulnerable, angry, or confused. As a result, patient behavior can sometimes be unpredictable and unpleasant. During such times, a medical assistant can become a convenient target and can nd it challenging to maintain her professional demeanor. However, it is especially during such times that her degree of professionalism becomes apparent. To help during such times, a medical assistant can employ several strategies, including:

Using I Language
Communication with others is vital in reaching agreements, resolving conicts, and creating a positive work environment. However, when peoples emotions rise and tempers are, their efforts at communication may quickly deteriorate into accusations and arguments. In order to avoid such a situation, people should try to plan such conversations for a time when the persons involved are not feeling angry or upset. They should also remind themselves that the goal is to achieve a positive resolution for everyone. When attempting to address a conict or disagreement, the medical assistant who uses I language, rather than you language, can help ensure a successful conversation that does not make the other persons involved feel as though they must defend themselves. For example, the medical assistant who is

focusing on the patient acknowledging the patient validating the patients feelings using I language moving to a solution setting boundaries.

Focusing on the Patient

It is not easy to avoid taking personal offense at criticism or other negative comments from a patient. However, the medical assistant must remind herself to keep her focus on the patients needs, rather than on herself. By doing so, she is less likely to feel personally upset or offended by the patients words or behaviors. In addition, the medical assistant who tries to treat others as she would want to be treated maintains the ability to empathize with her patients. This empathy makes her less likely to react in anger and more likely to respond with compassion.

Patient Education

Teaching Strategy
Health care providers sometimes dispense what they believe is good patient education without rst taking the time to inquire about the patients concerns. A patient who is preoccupied with fear and anxiety may hear and remember little of what she taught. A more effective teaching strategy is to ask the patient to identify his or her greatest concerns. Doing so can help her feel acknowledged and that his or her concerns have been validated. When the patient is able to address these issues, he or she is then better able to hear, understand, and remember other information provided. More importantly, the patient will leave the ofce feeling cared about and having his or her needs met.

Acknowledging the Patient

All people like to feel acknowledged, and no one likes to be treated as if they were a number or an object. If patients believe they are being treated as an object rather than a person, they will be offended, angry, and frustrated. A medical assistant may be extremely busy dealing with multiple patients, ringing telephones, physicians, coworkers, and numerous other demands. However, she must never fall into the habit of viewing patients as an inconvenience. Patient care is at the heart of the profession of medical assisting. Regardless of how busy a medical assistant is, it takes no more time to look a patient in the eyes, speak in a kind voice, and smile than it does to deal with that patient in a harried, distracted manner.

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feeling annoyed with her coworker for always returning from lunch late might yell at her as she comes in the door, You are always late and messing up our schedule, and Ive had it! Doing so will probably put her coworker on the defense and start an argument. A better approach would be to wait until feelings of anger subside and then nd an opportunity to have a private conversation where patients cannot overhear. She then might state something like Ive noticed that youve been taking 45 minutes for lunch lately. Because we are each supposed to take 30-minute lunches, this is affecting patient scheduling. I am feeling frustrated but do not want this to hinder our working relationship. I would like to nd a solution that meets both of our needs. Of course, there is no guarantee that the coworker will respond as desired, but he or she is much more likely to do so when he or she realizes the impact his or her behavior is having on others and when he or she does not feel that his or her personal character is being attacked.

Front ofceBack ofce connection

Resolving Conict in the Ofce

In a medical ofce, conict can occur even in the best circumstances. In most cases, the underlying cause is miscommunication. To help enhance communication and resolve conict, ofce staff, including administrative and clinical workers, should get together on a regular basis for staff meetings. Not only is this a great time to share announcements and discuss changes in policies or procedures but it is also a great time to resolve any identied problems. Discussions will be most productive if everyone uses the same therapeutic communication skills with one another that they use with their patients. They should also agree to follow common ground rules, such as keeping language and behaviors professional, using I language, and moving toward nding solutions rather than staying stuck on the problem.

Moving to a Solution
A medical assistant is most effective when she learns to avoid getting stuck in argumentation with patients, coworkers, or physicians. When she is in a conversation involving conict, the medical assistant should direct the conversation toward clarifying the problem without pointing blame. Then she can begin discussing possible solutions. If an upset colleague or patient seems intent on laying blame, the medical assistant should tactfully, yet assertively, change the subject by asking a question such as What solution to this problem do you have in mind? In addition, the medical assistant should learn to monitor her own behavior. When she notices herself feeling upset or starting to assign blame, she should refocus her attention on nding a positive solution instead.

Cultural Variables
Body language and verbal communication takes on different meanings depending upon the cultural norms of those involved. Medical assistants should familiarize themselves with cultural norms of the ethnic groups most commonly seen in their facility. (See Cultural variations in communication.) Familiarity with this information helps them interact more knowledgeably with others and decreases the likelihood of communication mishaps. (See Cultural competence in the medical ofce, page 51.)

Setting Boundaries
While a medical assistant should always behave in a tactful, professional manner, she is not obligated to subject herself to verbal or physical abuse. Whether the aggressor is a patient, colleague, or even a physician, the strategies above should be employed. Medical assistants must sometimes set or enforce boundaries, or physical or psychological space that indicates the limit of appropriate versus inappropriate behavior. If such interventions fail to work and the behavior escalates, the medical assistant should solicit the intervention of the department or ofce manager. This person may have the ability to provide a fresh, unbiased perspective and also has a greater level of authority to help identify a solution to the problem. The medical assistant should report any threats of physical violence per ofce policy. If a patient or another person becomes physically violent, the medical assistant should immediately summon help, such as calling security or even calling the police, per ofce policy. (See Resolving conict in the ofce.)

Patient Education

Cultural Variations in Communication

Well-intended efforts to educate patients can sometimes be wasted energy if medical assistants unintentionally offend or confuse patients through cultural insensitivity. For example, use of direct touch, prolonged eye contact, or an overly casual greeting can be so offensive to some individuals that they cannot adequately attend to the message of the speaker. Medical assistants should strive to become culturally competent and, when unsure of how to proceed, should err on the side of addressing their patients in a more conservative, formal manner.

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Front ofceBack ofce connection

Cultural Competence in the Medical Ofce

No one has the time or resources to fully understand the variations in communication styles for every culture. However, the medical ofce team should meet to brainstorm about ways they could all increase their knowledge and understanding of cultures common to their patient population. For example, each member could take responsibility for choosing a culture of interest, learning about it, and then teaching coworkers about it. That person could serve as the ofce expert and a resource for coworkers. Before getting started, the team should agree on what information is most valuable to know. Clinical and administrative medical assistants may have different ideas, depending on the needs they have observed in their areas. Therefore, the team should collaborate in creating the must-have list of information. Then the ofce could distribute cheat sheets for each cultural group researched, which could be kept on hand as a quick reference for all ofce staff.

One of the most important parts of effective communication is active listening. Most people overestimate their skills as a listener. Active listening involves reecting or paraphrasing the message that was heard and seeking clarication as needed. The medical assistant should resist the temptation to offer medical advice outside her scope of practice. Such action could put her and her employers in legal jeopardy. To communicate effectively and develop positive professional relationships, the medical assistant must understand the differences between passive, passive-aggressive, assertive, and aggressive communication styles. Common roadblocks to effective communication include the defense mechanisms of rationalization, compensation, regression, repression, displacement, denial, and projection. Communicating effectively can be especially challenging in certain situations. Patients may be ill, in pain, upset, angry, or otherwise unhappy. Therefore, the medical assistant must learn specic strategies to help her maintain her professionalism during trying times. Such strategies include focusing on the patients needs, acknowledging the patient, validating the patients feelings, using I language, directing the conversation toward nding a solution, and setting appropriate boundaries.

Team Work Exercises Chapter Summary

Good communication skills are essential for the medical assistant to ensure that each patients rst impression of the medical ofce is a positive one. Communication includes the sending and receiving of information between two or more individuals. Factors in the communication cycle include the referent, sender, receiver, message, channels, feedback, interpersonal variables, and environment. A medical assistant must take care that her verbal and nonverbal communication is congruent with the message she is trying to convey. Otherwise, listeners will believe the nonverbal communication. Most people are not comfortable letting others enter their personal space and touch them until a degree of trust has been established. Therefore, the medical assistant must treat patients with respect and sensitivity. Touch can be used in a therapeutic manner to convey interest, sincerity, and empathy. Patients commonly welcome appropriate touch and report that it helps them to feel acknowledged and cared for. Body language and verbal communication take on different meanings in different cultures. The medical assistant should strive to become familiar with the cultural norms of her patient population.

1. Divide into groups of ve or six students. Create a poster or presentation that identies common roles within a group, such as the leader, peacemaker, antagonist, clown, and so forth. Assign each team member a role to research. Make sure that the presentation describes how each role can help or hinder effective group processes. 2. Divide into pairs and designate one person as partner A and the other as partner B. Partner A should think of a problem that he or she is comfortable sharing and then begin describing it. Partner Bs job is to practice active listening, meaning the focus must remain on partner A and cannot shift to partner B. Incorporate eye contact, body language, paraphrasing, and other active listening strategies. After 10 minutes or so, the partners may trade roles and repeat the exercise. Afterwards, partners should give each other feedback about their listening skills along with suggestions for improvement.

Case Studies
1. A new family has come to the clinic for health care. During the initial interview, the receptionist learns that they are Jewish. What information will the staff need to know to communicate effectively without causing offense? 2. Mrs. Kamell has recently emigrated from the Middle East to live with her son and daughter-in-law. The Kamell family just started coming to the clinic for health care 2 months ago. You have noticed that they have

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arrived late again today and seem reluctant to answer many of the questions that are asked. Furthermore, Mrs. Kamell seems content to let her son speak for her. Based on preliminary testing, the physician is concerned that Mrs. Kamell may have cancer, but must do further diagnostic testing to be sure. What information should the medical staff be aware of to help them interact effectively with this family? What guidelines should they follow?

Resources

Communication Improvement Free Resource Center: www.work911.com/communication/index.htm Cultural competency articles from the American Medical Student Association: www.amsa.org/programs/gpit/cultural .cfm and www.amsa.org/div/cstudies.cfm Mind Tools: www.mindtools.com/page8.html

CHAPTER

Legal Considerations
Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell key legal terms dene licensure and certication as well as their purposes dene the scope of practice and its importance discuss the standard of care for health care professionals describe negligence and the 4 Ds of malpractice compare and contrast the three main business structure forms for medical ofces discuss implied consent and informed consent and when they are appropriate compare and contrast intentional and unintentional torts compare and contrast civil and criminal law as it applies to health care explain how the Good Samaritan law protects individuals in cases where consent cannot be obtained describe procedures used to release a noncompliant patient and how such a release can help prevent a charge of abandonment describe the purpose of a durable power of attorney and a living will describe a patient release of information and how it is obtained list the circumstances where patient authorization to release information is not necessary describe reporting requirements for child and elder abuse.

6
Scope of Practice Standard of Care
Consent Implied consent Informed consent Malpractice

CAAHEP Competencies
General Competencies Professional Communications
Respond to and initiate written communications

Legal Concepts
Identify and respond to issues of condentiality Perform within legal and ethical boundaries Establish and maintain the medical record Document appropriately Demonstrate knowledge of federal and state health care legislation and regulations

The Lawsuit Process

Subpoenas and Depositions Trial Malpractice Insurance Intentional torts Criminal versus Civil Law Patient Noncompliance Statute of Limitations Risk Management Documentation Condentiality Exceptions to disclosure rules

ABHES Competencies
Professionalism
Conduct work within scope of education, training, and ability

Durable Power of Attorney and Living Wills Reporting Abuse

Child Abuse Neglect Emotional abuse Physical abuse Sexual abuse Elder Abuse Neglect Physical abuse

Communication
Fundamental writing skills

Legal Concepts
Determine needs for documentation and reporting Document accurately Use appropriate guidelines when releasing records or information Follow established policy in initiating or terminating medical treatment Maintain licenses and accreditation Monitor legislation related to current health care issues and practices Perform risk management procedures

Chapter Summary Team Work Exercises Case Studies Resources

Chapter Outline
Legal Relationship of the Patient and Physician Medical Practice Act Licensure
Revoking a License

53

Key Terms
abandonment

licensure

Failure to make arrangements for a patients continued medical care

age of majority

Designation signifying that a person has met the standards and requirements of her profession and is legally able to offer specic services for monetary reimbursement
litigation

Legal status of adulthood, as recognized by the state

against medical advice (AMA)

In medicine, a legal action that determines the rights and remedies a patient can pursue in the event of suspected medical malpractice
living will

Designation for a patient who leaves the hospital even though his doctor disagrees with the decision to leave
agent

Representative of a facility, hospital, or doctors ofce who represents in word and action the supervising physician
assault

Written directions to a physician that instruct the physician about whether or not to maintain life-support systems in the event of a patients terminal illness
malfeasance

Unlawful act that causes harm

malpractice

Threat or perceived threat to do bodily harm to another person

battery

Action by a health care professional that injures a patient and fails to meet reasonable standards of professional care
negligence

Intentional act of touching another person in a socially unacceptable manner without her consent
breach of contract

Unintentional failure of a health care professional to meet his responsibilities to a patient, resulting in injury to the patient
noncompliance

Failure to comply with an established agreement as specied in a written contract

civil law

Failure of a patient to follow his physicians treatment plan

nonfeasance

Branch of private law that deals with accidental, rather than intentional, injury to a person or personal property
criminal law

Failure of a health care professional or organization to perform a task or deliver a service, resulting in harm or injury to a patient
perjury

Branch of public law that deals with the rights and responsibilities of the government to maintain public order
damages

Act of lying in court, despite taking an oath to tell the truth

plaintiff

Monetary award paid by the physician to the patient as directed by the court
defamation

Person bringing charges in court

res ipsa loquitur

Providing false information (written or spoken) that causes harm to the reputation of another
defendant

Latin phrase meaning the thing speaks for itself and used in legal situations when negligence is clearly evident
respondeat superior

Person accused in a court of law

deposition

Latin phrase meaning let the master answer, a legal doctrine that places responsibility on a physician for the actions of her employee
restitution

Formal method of gathering information in which a person testies to the actions of herself and coworkers
durable power of attorney

Monetary compensation for a loss or injury

risk management

Written legal designation of a person to make medical decisions on behalf of another person
emancipated minor

Proactive management that seeks to reduce potential risks of a lawsuit before it occurs
scope of practice

Person under the age of majority who has been declared by a court to be independent and responsible for his own debts
expert witness

Range of services a professional can offer, based on training, ability, and licensure
slander

Person who is called to testify in court due to her status as an expert on a given subject or in a specialty
felony

Dishonoring or defaming a person through verbal attacks

statute

Law
statute of limitations

Serious crime against the public that is punishable by serving time in prison
fraud

Law that sets a time limit within which a person can bring a lawsuit
subpoena

Intentional misrepresentation of a situation for nancial gain

gross negligence

Intentional failure to provide care or the commission of an act by an individual with reckless disregard for consequences that endanger a patient
implied consent

Legal document that noties a person that he is required to appear in court or be available for deposition
subpoena duces tecum

Acceptance of treatment expressed through a patients actions, such as rolling up his sleeve for blood pressure measurement
informed consent

Latin phrase meaning bring with you under penalty of punishment, a legal document that requires a person to appear in court with specied documents, such as patient records
tort

Wrongful act committed by a person that causes harm to another person or property
vicarious liability

Document that a patient signs, which is a written agreement for treatment

libel

Liability of an employer for the wrongdoing of an employee while on the job

Dishonoring or defaming a person through written documents

CHAP TER 6

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55

Legal Relationship of the Patient and Physician

A patients relationship with her physician is complex, not only from the standpoint of her health care but also in the many legal implications that arise from such a relationship. A person who seeks care from a licensed professional is entering a contract with that professional. Once a relationship between the patient and the physician is established, the parties have entered a contract. The contract is the agreement by the physician to provide services and the patient to pay for services, either out of her own pocket or by using a third-party payor (health insurance). Failure of either party to abide by the contract is a breach of contract. The patient must pay for services, and the physician must provide services. In addition, if the physician fails to attempt to provide continuous health care to a patient, such as by moving to another city or retiring without forwarding medical records, such an action is considered abandonment and is a form of breach of contract. Because medical care of patients must be continuous, it is the responsibility of a physician to provide care or offer an alternative, such as forwarding medical records to another physician. To enter a contract, individuals must be competent adults or emancipated minors. Minors can enjoy the same rights and responsibilities as adults, including being responsible for their own debts if declared independent by a court. Teenagers who are married or parents commonly can become emancipated minors and, therefore, enter into contracts. In such situations, responsibility to pay for services is that of the minor, not a parent or guardian. It is the responsibility of everyone in the physicians ofce to follow legal and ethical principles that safeguard a patients privacy and physical safety and keep a patient informed regarding her health care. The medical assistant acts as an agent of the physician by representing in actions and words the intention of the physician. Recognition of the physicians responsibility to supervise her medical assistants is called respondeat superior. This Latin phrase translates to let the master answer, which means that if a medical assistant injures a patient, it is the responsibility of the physician to make restitution, or monetary compensation for the injury. Respondeat superior is a form of vicarious liability, in which the employer is responsible for the actions of an employee. For example, if a bus is in an accident, injured passengers seek restitution from the bus company, not the individual driving the bus. Although responsible for her actions as a professional, a medical assistant who accidentally injures a patient is not the liable partythe supervising physician is.

Medical Practice Act

As an agent of the physician, the medical assistant must act within the laws of the state when performing health care procedures, maintaining medical records, and disclosing personal medical information to third parties for treatment, payment, or operations. All 50 states have a Medical Practice Act, which is a statute, or law, that regulates the practice of medicine. Failure to follow her states Medical Practice Act can result in the medical assistant committing a tort. A tort is a wrongful act for which a patient can request compensation or other legal remedies (but does not involve a breach of contract). Harm associated with a tort commonly results in a lawsuit. Although harm caused to the patient may be unintentional, penalties can be severe and can range from suspension or revocation of a physicians license, monetary nes, or imprisonment for more serious violations. Following legal and ethical standards of care protects the medical assistant and the physician as well as the patient.

Licensure
Most health professions have some form of regulation to ensure the competence of their members. A license is a legal document that allows an individual to offer a set of services to the public for compensation (payment). Licensure is obtained by passing an oral and a written examination. To be eligible to take a medical physician licensing examination, an individual must:

complete education requirements through an approved medical school. complete an approved residency program. attain an age of majority, which is a legal recognition of adulthood as dened by an individual state so that a person can enter legally binding contracts with others (something a child is not legally allowed to do).

When a person passes the licensure examination in a given state, she can obtain a license to practice medicine in another state by a process of reciprocity. Simply stated, reciprocity is one state accepting the current license of a practitioner from another state. When a physician obtains a license to practice medicine, she is able to practice within the scope of her specialty for compensation. Licenses must be renewed every two years and state dues must be paid each year. Proof of continuing education as well as proof of 5 hours of risk management training is required in all states. If the license is not renewed by the deadline, it becomes invalid, medical malpractice insurance becomes inactive, and the individual cannot practice medicine. Practicing medicine

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without a license by failing to renew a license but continuing to treat patients is a felony, a serious crime that usually carries a stiff penalty, such as imprisonment. The law makes no distinction between a physician who lets her license expire and a person who never went to medical school and represents herself as a physician. Each individual is committing a felony and can be punished in a court of law under the guidelines for a felony conviction.

Revoking a License
A state may revoke a physicians license for just cause, including:

practice or medical assistant. Such action may result in monetary compensation to the patient for harm done by the unlawful actions of the medical assistant or the physicians failure to oversee her actions appropriately. Even if injury to the patient does not occur, the consequences may still be signicant, including legal expenses, damage to the reputation of the practice, and even loss of licensure. For example, medical assistants can be trained to assist in minor ofce surgery but cannot perform the surgery itself. If a physician were to allow an unlicensed employee to perform an ofce surgery, the physicians license would be revoked or suspended.

conviction of a crime felonymurder, rape, practicing without a license, selling prescription drugs or signed prescription pads fraudbilling for treatments never provided, changing dates of service, falsifying medical records. unprofessional conduct addiction to drugs or alcohol breach of condentiality false advertising unethical behaviors toward patients inability to perform duties fee splitting or other inappropriate billing practices.

Standard of Care
A standard of care, or the minimum safe professional conduct under specic conditions as determined by professional peer organizations, must be maintained at all times. Failure to perform to the standard of care is called negligence. If negligence results in harm to a patient, it is considered an unintentional tort and the patient can le a lawsuit against the physician or physicians agent, such as the medical assistant. An act of negligence can involve:

In addition to maintaining her own licensure and continuing education, a physician is legally responsible for the actions of her employees while on the job. Because a physician is directly responsible for the actions of her medical assistant employee, a physician employer depends on credentialing of medical assistants to ensure proper training. Medical assistants can become certied through the AAMA or the AMT. Certication of a medical assistant can be a deciding factor in a physicians choice of which candidate to hire as an employee and patient care agent.

nonfeasance, or failure to do what a prudent person would do that results in harm to a patientfor example, failure to monitor a patients warfarin (Coumadin) levels, which results in the patient being hospitalized for internal bleeding (also called omission) malfeasance, or performance of an improper act that results in harm to a patientfor example, prescribing a medication to a patient with a known allergy, which results in the patients death (also called commission) res ipsa loquitor, a Latin phrase that means the thing speaks for itself, indicating an unintentional tort that is an obvious mistake in which negligence is clearly evidentfor example, a patient with a tumor on the right leg is brought to the operating room where surgeons amputate the left leg. The negligence speaks for itself.

Scope of Practice
Whether the health care provider is licensed (such as a medical doctor, chiropractor, osteopath, or registered nurse) or certied (such as a medical assistant), that professional must practice within her scope of practice, or the range of services a professional can offer, based on training, ability, and licensure. For example, a pediatrician may not ll cavities in a patients teeth. A dentist is not licensed to give immunizations to a patient. The medical assistant who performs medical procedures that she is untrained or unlicensed to do is putting the practice at risk for a lawsuit, or litigation. In such a suit, a patient can seek legal action against the

Consent
In addition to performing procedures in accordance with the standard of care, the medical assistant or physician must also obtain the patients consent to perform the procedure. There are the two types of consent that may be obtained when providing care to a patient: implied and informed.

Implied Consent
Implied consent occurs when a patient consents to treatment through her actions, such as rolling up her sleeve to have her blood pressure checked. A medical assistant must never force a patient to have a procedure performed. If a patient declines a procedure, such as drawing blood or a

CHAP TER 6

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blood pressure check, the medical assistant must note the refusal in the patients chart. Facility policy may also require her to report the refusal of care to the physician.

Informed Consent
When a patient is scheduled to undergo invasive treatment, such as surgery, the physician must obtain informed consent, which involves a written form that is signed by the patient. The physician must ensure that the patient understands:

the procedure why the procedure is being performed who will perform the procedure expected results of the procedure risks of performing the procedure and of doing nothing available alternative treatments and how the risks and benets compare to those of the recommended procedure.

DutyThe prosecution must prove that a patient-physician relationship existed. A medical chart can be used to show proof of a physicians duty to care for a patient. Dereliction of dutyThe prosecution must prove that the physician failed to meet the standard of care. In court, the prosecution can produce an equally trained physician to testify as an expert witness. Commonly, an expert witness in a malpractice case practices the same specialty as the defendant. The expert witness can testify that she would act differently than the accused physician (defendant) and that the result to the patient would be better, resulting in no damage or less damage to the patient. Direct causeThe prosecution must prove that the damage suffered by the patient is a direct result of the actions of the physician. DamageThe prosecution must prove that omission or commission by the physician caused the patient injury or harm.

The medical assistant may ask the patient if he has any further questions for the physician. If she suspects that the patient does not understand the procedure, she should inform the physician immediately.

The Lawsuit Process

A patient who brings a lawsuit against the physician is the plaintiff, the person who seeks monetary damages for the tort allegedly committed against him. The plaintiff will hire a lawyer to represent him in court. The accused physician is the defendant, the person who must defend or explain her actions before the court. She will also hire an attorney to defend her actions and notify the malpractice insurance carrier.

Barriers to Informed Consent

An interpreter may be required to obtain informed consent from a patient who is hearing impaired or speaks a different language than her physician. Sometimes, the physician may not be able to obtain informed consent. In an emergency situation, a patient may be unconscious or in too much pain to comprehend the physicians explanation of care. In such a situation, where the life, health, and safety of a patient depend on the physicians quick response, the Good Samaritan law protects the physician from litigation. The Good Samaritan law extends to anyone who offers emergency help within the scope of their training and abilities, including anyone who administers CPR or first aid while waiting for emergency services personnel to arrive at the scene of an accident. If a patient regains consciousness during the course of administering first aid, the prudent rescuer should ask, May I continue? For example, lifeguards are trained not only to rescue swimmers in trouble but also to administer CPR and first aid. They are, therefore, covered under Good Samaritan laws. (Note that Good Samaritan laws vary by state but always cover aid given in good faith by a person trained to do so.)

Subpoenas and Depositions

During the collection of information, the medical assistant may be issued a subpoena, which is a legal document that requires a person to appear in court or be available for deposition. A deposition is a formal gathering of information during which the individual who has received the subpoena must answer questions. It is important to remember that, while giving a deposition (also called being deposed), the individual is under oath. The medical assistant is bound by law to tell the truth. To lie or omit information in a deposition is a crime, called perjury, and is punishable by law. Another method used to gather information is a subpoena duces tecum, which requires that the individual appear in court with specic documentation, usually the patients medical record.

Malpractice
Malpractice, the medical form of negligence, is proven by four criteria, commonly known as the four Ds. If the prosecution can prove that all of these criteria apply in a certain case, the physician will be found guilty of malpractice and a monetary settlement will be awarded:

TIP Preparing for a Deposition Many medical assistants will never be deposed or called as a witness in a medical malpractice lawsuit. If a medical assistant is called, however, she should be prepared by:
reviewing the medical record, to be sure that her recollection of events is as accurate as possible

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only responding to questions to which she knows the answer, being brief in her answers, and answering only what is asked making eye contact with the attorneys, judge, and jury and maintaining a professional demeanor dressing appropriately for court (business attire).

Malpractice Insurance
Most physicians have malpractice insurance out of which the settlement and legal fees are paid in the event of a malpractice lawsuit. Many states have mandatory malpractice laws that require physicians to have a minimum dollar amount of malpractice insurance. If a physician has no malpractice insurance or limited coverage, his personal assets may be seized, depending on how his practice is structured. (See Medical practice business structures.)

Trial
In preparation for a trial, attorneys for the defense and the prosecution will gather necessary information. Patient medical records and depositions from witnesses are collected. Expert witnesses are contacted to give testimony during the trial and a trial date is set by the court. The lawyers from both sides choose a jury, and the trial begins. Each attorney makes opening statements and then calls witnesses. Both attorneys are given the opportunity to question the witnesses through examination and cross-examination. Both attorneys make closing statements explaining to the jury how they proved their argument. The judge will give instructions to the jury and ask them to reach a verdict based on the evidence presented. The jury deliberates or discusses what they saw and heard in the courtroom and reaches a decision. If the jury nds the defendant (physician) not guilty, the case is dismissed. If the jury nds that the physician is guilty of malpractice, a monetary settlement is awarded.

Intentional Torts
Malpractice insurance does not cover intentional torts. An intentional tort is considered gross negligence, a form of negligence that involves an intentional act or failure to act that causes harm. Harm done to a patient by a physician or an agent that is determined intentional results in a monetary award, or damages, paid to the patient and can also result in criminal charges led against the physician, agent, or both. Intentional torts include:

assaultAn assault is a threat or perceived threat of bodily harm to another person. An assault can involve hitting and punching or just threatening to hurt another person. This situation is easily avoided by maintaining professional decorum.

Medical practice business structures

Incorporating a medical practice as a business offers protection to the individual provider against losing his personal property as a result of a malpractice lawsuit. Each state has its own incorporation procedures and costs. The table below outlines possible business structures for a medical practice, along with a description, legal implications, advantages, and disadvantages.

Business Structure
Sole proprietorship

Description
One owner-operator physician

Legal Malpractice Implications

Person can be sued for personal assets in malpractice.

Advantages
Owner-operator makes all the decisions. Overhead is low. Owner keeps all the prots.

Disadvantages
Personal nancial liability for malpractice claims

Partnership

Two or more partners acting as owneroperators

Individual doctors can be sued for personal assets and may be liable for damage incurred by partners.

Partners share costs of medical ofce personnel and overhead. Partners cover each other for vacation and on-call times.

Personal nancial responsibility for conduct of self and partners Consultation with partners necessary for business decisions

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Medical practice business structurescontd

Business Structure
Limited Liability Corporation (LLC) OR Personal corporation (PC)*

Description
Corporation that acts as an independent business entity

Legal Malpractice Implications

Physician cannot be sued for personal assets in malpractice.

Advantages
No personal nancial liability in case of malpractice Many people available to cover vacation and on-call hours Some tax advantages to incorporation

Disadvantages
Costs incurred to form corporation, such as attorney fees More difculty dissolving a corporation than a partnership Corporation taxes due in addition to personal income taxes of physicians Consultation with large group for business decisions

*Titles of small corporations vary from state to state.

batteryBattery involves touching someone in a socially inappropriate way without her permission. The prudent medical assistant must obtain consent before touching a patient. defamationTo cause harm to a persons reputation by providing false information in writing (libel) or by spoken word (slander) is considered a crime. The medical assistant must be careful not to talk about a physician, colleague, or patient in an unprofessional manner. If a physicians practice suffers a loss of patients due to slander, a lawsuit for defamation can be brought against the medical assistant or her employer. Writing derogatory comments in a patients chart can be considered libel, so care should be used in describing a patients demeanor. Gossiping about a patient can be considered slander and the patient can bring a lawsuit against the medical ofce. Disclosing or discussing a patients sexual history, human immunodeciency virus status, or drug treatment history could compromise his job, marriage, and mental health. The patient may also feel that the staff is not attentive to his needs and that the gossiping created an atmosphere in which he received substandard care. (See Libelous charting, page 60.) false imprisonmentHolding a patient against her will is considered false imprisonment. Hospital patients are not required to stay for treatment and are always free to leave. Forcing a patient to stay in the hospital is an imprisonment that, without due process of law, is illegal (or false). An inpatient should always be able to leave the hospital, even

if it is against the recommendation of her physician. In such a situation, a patient is allowed to sign out of the hospital against medical advice (AMA). The patient indicates that she is aware that she is AMA by signing a document in which she acknowledges that the physician does not recommend that she leave the hospital but that she has decided to disregard the physicians advice. fraudFraud is the intentional misrepresentation of facts for nancial gain. For example, charging an insurance company for services not performed or changing dates of service to accommodate eligibility of benets is fraud. invasion of privacyThe public release of a patients information without his consent is considered an invasion of the patients privacy. If a practice wants to use pictures of a patient for an ofce brochure or advertisement, the ofce must obtain the patients consent to use the photo. Without the patients consent, a physicians ofce cannot release medical information. For example, if a physician treats a celebrity, no personal medical information can be released to the media without consent.

Criminal Versus Civil Law

Criminal law is enacted to protect the welfare and safety of the public by determining what is legal and illegal. A person charged with a felony is brought to court and is charged by the state. If a person is accused of murder, the court record will show, for example, Thomas Jones vs. State of Illinois. Although the defendant is accused of murdering an individual, the crime is considered to be perpetrated against

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Libelous charting
Writing derogatory statements about a patient in her chart can be seen as libel. To avoid the risk of a lawsuit, the medical assistant should always use professional, objective language when documenting care, as in the rst charting
Date 02/17/08; 10:30 a.m. Patient describes deep aching pain in my lower belly. She appears to be in acute distress; she states that she hasnt slept in a week. -------------------------------------- C. Smith, CMA Charting example #1

example below. If the patient were to see charting example #2, she would be offended. She may feel so offended that she would bring charges against the author.

Date 02/17/08; 10:30 a.m. Patient describes deep aching pain in my lower belly. She appears to be faking acute distress (again drug-seeking); she smells of tobacco and has not showered or bathed for what smells like at least 3 days. She claims that she hasnt slept in a week.---------------------------- C. Smith, CMA Charting example #2

society or the state. Offenses that are criminal are most commonly punishable by imprisonment. Examples of criminal offenses include murder, robbery, larceny, kidnapping, rape, and arson. Civil law, also called private law, is enacted to protect the rights of individuals, as in contract disputes, divorce, family law, inheritance law, contract law, and tort law (which covers malpractice lawsuits). Civil law is the most commonly exercised type of law in ambulatory care. The punishment for civil offenses is usually payment of a monetary award to the individual whose rights were violated. Criminal charges are brought by the state; civil claims are brought by individuals. In civil law, the dispute is considered to be between individuals and the state is not represented as the accuser in the court docket. If a physician is accused of malpractice, the court record will show, for example, Jayne A. Veins, MD vs. Marjorie Wells. The accuser is the individual patient. If found guilty, the physician owes monetary compensation to the patient, not to the state where she holds a license to practice medicine. The physician may, however, be investigated by the state if the state suspects that the physician has engaged in criminal behavior.

noncompliance, can compromise his health. Physicians are responsible for treating a patient once a medical chart has been established. A contract is in effect when a patient seeks and receives treatment. The physician, by agreeing to treat the patient, fullls his portion of the contract by:

diagnosing and treating the patient to the best of his ability being available to the patient for care and return phone calls arranging for a different physician to be available in the event of the physicians absence.

The patient is responsible for his portion of the contract in that he agrees to pay copayments, provide insurance information to the ofce, and comply with treatment recommendations. If a physician suggests treatment and the patient refuses that treatment, the patients chart should reect that the patient has been informed of the physicians recommendations but has decided not to comply. Patients have the right to refuse treatment, but the physician is no longer responsible for the outcome. It is reasonable for a physician to expect a patient to:

Patient Noncompliance
Patients who fail to comply with treatment recommendations cannot expect the treating physician to be responsible for the outcome of care. The patients failure to comply, called

truthfully relate his medical history follow treatment recommendations, including medication, physical therapy, and lifestyle changes keep scheduled appointments pay copayments or deductibles as agreed.

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Either party may end the patient-physician relationship. If a physician feels that the relationship must end, the medical assistant should send a registered letter to the patient to document the severing of the physician-patient relationship. (See Figure 6-1.) If a physician were not to write a letter of formal discharge to the patient, but merely refused to see the patient again, the physician can be charged with abandonment and could be held responsible for the poor outcomes of the patients condition due to a lack of care.

time. The information contained in the medical record may exonerate the physician from liability. If a patient was noncompliant in her care and the noncompliance is well documented, that information would help defend the physician from being held responsible for a poor medical outcome.

Risk Management
The best defense against a malpractice lawsuit is to avoid being accused. The medical staff and physician can prevent lawsuits from occurring by following risk management guidelines, which outline appropriate behaviors and procedures that decrease the risk of patient dissatisfaction during an ofce visit. Proper documentation, presenting reasonable expectations, and being kind and empathetic toward patients all decrease the risk of a malpractice lawsuit being brought against a medical practice. (See Risk managment dos and donts, page 62, and Best face forward, page 62.)

Statute of Limitations
Each state determines the length of time during which an individual can bring a lawsuit, called the statute of limitations. Malpractice statutes of limitations vary from state to state and can dictate how long medical records should be kept. If the statute of limitations is 10 years, it would be unwise to destroy medical records prior to that length of

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CONNECTICUT 06000 860-555-3212

June 20, 2008 Dear Mr. Nicewicz, It is unfortunate that I must withdraw my services as your physician. As stated at your office visit on May 16, 2008, you continue to ignore my recommendations regarding your multiple medical problems. I will be available to you on an emergency basis only until July 15, 2008, which should give you time to find a new physician. In the meantime, you should call your insurance provider to find a cardiologist to care for you. I will forward all of your records upon request, and speak to your new physician regarding your past care. At this time your physical problems include: hypertension, decreased kidney function, chronic obstructive pulmonary disease, and decreased heart function. These are serious medical conditions that require immediate attention. Thank you for your anticipated cooperation. Sincerely,

Robert Greer, MD
Robert Greer, MD FIG 6-1 Withdrawal of care letter.

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Risk management dos and donts

A patient who feels judged or disrespected is more likely to le a lawsuit than the patient who enjoys a professional relationship with her physicians ofce. The nice factor is a well-known theory suggesting that patients dont sue physicians who are nice to them. The medical assistant, as an agent of the physician, can also inuence the patients experience at the ofce by being friendly and respectful. The guidelines below list some of the most common dos and donts that will help the medical assistant, physician, and other medical staff decrease their risk of a medical malpractice lawsuit. Follow up with test results and promised phone calls in a timely manner. Practice safe work habits. Use gloves and other personal protective equipment (PPE) when appropriate. Keep the environment safe for yourself and your patients. Recheck patient release of information before releasing medical information to attorneys or other physicians.

Donts
Never promise a specic outcome to a treatment. For example, never say something like, Youll be completely curedno pain, no stiffness. My sister had the procedure last year and shes ne now. Never complain about the physician or other members of the medical staff to a patient. For example, do not say, Dr. Ramirez is so slow, I hope he doesnt make you wait too long. Never give medical advice or a diagnosis; do not represent yourself as something you are not, such as a doctor or nurse. Always perform within your scope of training and abilities. For example, do not say, I wouldnt take that medication, it can damage your liver. I would try this herbal remedy. Never use corrective ink to correct errors in a chart. Instead, cross out the error with a line and initial the change. Never leave test result information on an answering machine. Never gossip about patients or divulge personal or medical information. For example, do not say, Mrs. Jones is having a gastric bypass; how about just bypassing the spoon and fork! Do not judge the decisions your patient makes regarding his health. For example, do not say, I cant believe you still smoke. Do you want to die?

Dos
Treat all patients with respect and courtesy. Document performed procedures accurately and in a timely manner. Putting off charting procedures increases the risk that you will forget to do so. A court of law considers an undocumented procedure to be one that was never done at all. Use the patients words in the chart, as in example B below.
11/07/08; 3:10 p.m. The patient complains of dyspnea. --------------------------------------------------------------------------------------------Sharon Lind, MA

Charting example A 11/07/08; 3:10 p.m. The patient states I cant get my breath, especially on the stairs. -------------------------------------------------Sharon Lind, MA

Charting example B

Document phone calls and chart missed appointments in the patients chart. Advice given to a patient on the phone, such as stopping medication and answering questions pertinent to the patients care, should always be added to the chart. Failed appointments should be charted so that the patient cannot claim that he was not given an appointment and that the physician therefore failed to treat him.

Front ofceBack ofce connection

Documentation
In order to maintain complete, accurate records, each procedure must be recorded in the patients medical record. Remember, if a lawsuit were to be brought, the patients medical record could be used against the physician. If a medical assistant took a patients blood pressure but did not record it in the medical record, there is no legal proof that the blood pressure was ever measured. (For more information on proper procedure documentation, see Chapter 20, The Patient Interview, page 307.)

Best Face Forward

The receptionist is the rst person that the patient sees and sets the tone of the visit. An abrupt, rude, or judgmental receptionist makes the work of the clinical medical assistant harder. The patient will expect the same rude behavior from the clinical staff and may not be forthcoming with medical information. By being pleasant to your patients, you make your coworkers jobs easier.

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Condentiality
Personal medical information is condential and should never be released without proper patient consent or establishment of the receivers need to know. In general, a patients medical and personal information can be used for payment, treatment, and administrative operations. A medical assistant can release a patients name, address, diagnosis, and other necessary information to an insurance company in order to receive payment for services. Medical assistants and physicians can share information in a patients chart with other health care professionals in order to treat the patient. A medical assistant can refer to a patients chart and disclose information to a hospital in order to schedule a surgery or computed tomography (CT) scan. For all of these disclosures, the patient must sign authorization to release her personal and medical information. The physicians ofce will have release of records forms available for patients to sign. Release forms for minor children and incompetent adults, such as mentally retarded patients and Alzheimers patients, must have the signature of a parent or legal guardian. Disclosures to others, such as an attorney for use in an automobile accident claim or workers compensation claim, must be requested and documented. See Chapter 7, HIPAA and a Patients Rights, for samples of release of information forms used by attorneys. (See Authorization to release health care information, page 64.)

reporting victims of abuse, neglect, or domestic violence (health care providers are legally responsible for reporting such cases to social services and law enforcement) when there is a perceived serious threat to the patient

if organ donor is indicated on the deceased patients drivers license, which allows access to medical records without the consent of the next of kin only for the purpose of organ and tissue transplant or donation to track vital statistics, such as births and deaths, which are recorded by town and city clerks without consent.

Durable Power of Attorney and Living Wills

Sometimes a patient is unable to speak for himself and make medical decisions. A document such as a durable power of attorney, or designation of health care surrogate, allows a patient to name another person to make medical decisions on his behalf. These documents may allow another person to manage finances and personal matters or solely to make medical decisions. Each state has standard forms used to designate a medical spokesperson. In addition to these documents, a patient can also outline what type of care he would want in the event of severe injury. Choices for life support, feeding tubes, and ventilators can be outlined in a document called a living will. (See Durable power of attorney for health care, pages 65 to 67, and Living will, page 68.)

Exceptions to Disclosure Rules

There are some circumstances where patient authorization to release medical information is not necessary. It is wise to check each circumstance to ensure that patient privacy is not violated. The following situations permit disclosure without the individuals authorization:

if the requesting party has a court order, such as in a workers compensation hearing when a patients medical le is needed to determine injury and award monetary compensation if an impact on public health or safety is possible, for example: reporting communicable diseases and work-related illnesses and accidents identifying missing persons or a suspect, such as disclosing to the police the identity of a gunshot victim in the emergency department (ED) alerting the police to the death of a suspect, such as disclosing the identity of a person who died in a violent manner and whose body is brought to the ED when protected health information (PHI) is evidence of a crime or can be used as such, as in the identity of a severely beaten woman brought to the ED, which can be disclosed to social services against the womans wishes

Reporting Abuse
Medical assistants are required by law to report all suspected child abuse, spousal abuse, elder abuse, and drug abuse. Procedures and reporting forms will vary from state to state. The medical office will have information regarding the reporting procedure in the offices policies and procedures manual. The medical assistant can give information to adult patients who are suspected of being drug abusers or victims of domestic violence regarding drug treatment programs or battered womens shelters. As adults, they are legally entitled to accept or refuse care. The states Department of Social Services can take elders and children who are suspected victims of abuse from their abusers. After the medical assistant notifies Social Services, who then notifies the police, custody of the victims is decided by state authorities. There are several signs and symptoms that will help the medical assistant detect suspected abuse of a child or an elder.

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Authorization to release health care information

Because information regarding human immunodeciency virus (HIV) status, mental health, and substance abuse is considered highly sensitive, authorization to release that information must be explicitly outlined. Below is an example of an authorization form that outlines information to be released.
AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION

Jillian Marecki October 09, 2008 Patient ____________________________________ Date ___________________ 5150308 Patient ID# ______________________________________ Jillian Marecki information of ____________________________________ to:
Carla J. Simmons Attorney at Law 211 Main Street Lovely, CT 06111 NAME OF MEDICAL PRACTICE PATIENTS NAME

Blueville Family Medicine I request and authorize _____________________________ office to release the health care

Blueville F amily Medicine ___________________________________ 15 Main Street ___________________________________ Blueville, CT 06000 ___________________________________
This request and authorization applies to: (please sign appropriate lines)

THE PERSON OR AGENCY (LAW OFFICES) WHERE THE INFORMATION IS TO BE RELEASED IS SPECIFIED AND THE ADDRESS OF THE AGENCY IS INCLUDED. NAME AND ADDRESS OF THE DESTINATION OF THE MEDICAL INFORMATION

1. All health care information EXCLUDING specific information relating to sexually transmitted diseases, HIV/AIDS diagnosis and treatment, alcohol and/or drug history, and any care related to psychiatric disorders and mental health.

Jillian Marecki ___________________________________

2. All health care information INCLUDING specific information relating to sexually transmitted diseases, HIV/AIDS diagnosis and treatment, alcohol and/or drug history, and any care related to psychiatric disorders and mental health. ___________________________________ I understand that my expressed consent is required for release of information relating to diagnosis and treatment of sexually transmitted diseases, HIV/AIDS, drug and alcohol abuse, and psychiatric disorders and mental health care. If I have been tested, diagnosed, or treated for the aforementioned, permission by my signature at the item authorizes you to release information regarding that testing, diagnosis, and/or treatment.

SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE

Jillian Marecki

Self
RELATIONSHIP TO PATIENT

October 09, 2008

DATE

Child Abuse
Child abuse can occur as neglect, emotional abuse, physical abuse, or sexual abuse. Each form of abuse has many possible signs and symptoms.

Neglect
Suspect that a child is neglected if you see any of these signs or symptoms:

young child left unattended child not fed or bathed manner of dress of the child inappropriate for cold weather failure to seek medical attention for the child failure to child-proof house, such as locking up poisons and cleaners.

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Emotional Abuse
Suspect that a child is the victim of emotional abuse if you see any of these signs or symptoms:

caregiver yells at child, calls child names, or curses the child caregiver does not comfort the child by hugging, touching, or showing concern for the childs welfare.

immersion burns (where child is placed into boiling water) cigarette burns fractures of the nose, skull, legs, or arms leg fractures in babies who do not yet walk bite marks on any area of the body childs fear of the caregiver.

Physical Abuse
Suspect that a child is the victim of physical abuse if you see any of these signs or symptoms:

Sexual Abuse
Suspect that a child is the victim of sexual abuse if you see any of these signs or symptoms:

bruises on face, buttocks, back, chest, abdomen, or inner thighs welts that take the shape of an object, such as a belt, chain, hanger, bat, or rope

bruising or bleeding of the genitalia, rectum, or mouth stains in underwear difcult or painful urination

Durable power of attorney for health care

The following form shows a standard type of durable power of attorney for health care.
DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Walter Mayhew I,____________________________________, am of sound mind, and I voluntarily

(PRINT OR TYPE YOUR FULL NAME)

make this designation.

Eleanor Mayhew spouse I designate ____________________________, my _________________________,

(INSERT NAME OF PATIENT ADVOCATE) (SPOUSE, CHILD, FRIEND, ETC.)

living at

27 Ridgemont Ave. Blueville, CT 06000

(INSERT ADDRESS OF PATIENT ADVOCATE)

as my patient advocate to make care, custody, and medical treatment decisions for me in the event I become unable to participate in medical treatment decisions. If my first choice cannot serve, I designate

Brenna Kramer Daughter _____________________________________, my __________________________,

(NAME OF SUCCESSOR)

living at

15 Longfellow Drive Lovely, CT 06111

(ADDRESS OF SUCCESSOR)

to serve as patient advocate. The determination of when I am unable to participate in medical treatment decisions shall be made by my attending physician and another physician or licensed psychologist. In making decisions for me, my patient advocate shall follow my wishes of which he or she is aware, whether expressed orally, in a living will, or in this designation. My patient advocate has authority to consent to or refuse treatment on my behalf, to arrange medical services for me, including admission to a hospital or nursing care facility, and to pay for such services with my funds. My patient advocate shall have access to any of my medical records to which I have a right. OPTIONAL I expressly authorize my patient advocate to make decisions to withhold or withdraw treatment that would allow me to die, and I acknowledge such decisions could or would allow my death.

Walter Mayhew
(SIGN YOUR NAME HERE IF YOU WISH TO GIVE YOUR PATIENT ADVOCATE THIS AUTHORITY)

Continued

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Durable power of attorney for health carecontd

My specific wishes concerning health care are the following: (if none, write none)

None
I may change my mind at any time by communicating in any manner that this designation does not reflect my wishes. It is my intent that my family, the medical facility, and any doctors, nurses, and other medical personnel involved in my care shall have no civil or criminal liability for honoring my wishes as expressed in this designation or for implementing the decisions of my patient advocate. Photostatic copies of this document, after it is signed and witnessed, shall have the same legal force as the original document. I sign this document after careful consideration. I understand its meaning and I accept its consequences.

Walter Mayhew Signed ________________________________________

Address:

October 09, 2008 Date: ______________________

27 Ridgemont Ave. Blueville, CT 06000

NOTICE REGARDING WITNESSES You must have two adult witnesses who will not receive your assets when you die (whether you die with or without a will), and who are not your spouse, child, grandchild, brother or sister, an employee of a company through which you have life or health insurance, or an employee at the health care facility where you are a patient. STATEMENT OF WITNESSES We sign below as witnesses. This declaration was signed in our presence. The declarant appears to be of sound mind and to be making this designation voluntarily, without duress, fraud, or undue influence.

Eric VanOrden Signed by witness: _________________________________ Eric VanOrden _________________________________

(PRINT OR TYPE FULL NAME)

October 09, 2008 Date: ______________________

Address:

10 Apple Hill Drive, Lovely, CT 06111 October 09, 2008 Date: ______________________

Susan Bancroft Signed by witness: _________________________________ Susan Bancroft _________________________________

(PRINT OR TYPE FULL NAME)

Address:

22 Ridgemont Ave. Blueville, CT 06000

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Durable power of attorney for health carecontd

ACCEPTANCE BY PATIENT ADVOCATE (A) This designation shall not become effective unless the patient is unable to participate in treatment decisions. (B) A patient advocate shall not exercise powers concerning the patients care, custody, and medical treatment that the patient, if the patient were able to participate in the decision, could not have exercised on his or her own behalf. (C) This designation cannot be used to make a medical treatment decision to withhold or withdraw treatment from a patient who is pregnant that would result in the pregnant patients death. (D) A patient advocate may make a decision to withhold or withdraw treatment which would allow a patient to die only if the patient has expressed in a clear and convincing manner that the patient advocate is authorized to make such a decision and that the patient acknowledges that such a decision could or would allow the patients death. (E) A patient advocate shall not receive compensation for the performance of his or her authority, rights, and responsibilities, but a patient advocate may be reimbursed for actual and necessary expenses incurred in the performance of his or her authority, rights, and responsibilities. (F) A patient advocate shall act in accordance with the standards of care applicable to fiduciaries when acting for the patient and shall act consistent with the patients best interests. The known desires of the patient expressed or evidenced while the patient is able to participate in medical treatment decisions are presumed to be in the patients best interests. (G) A patient may revoke his or her designation at any time or in any manner sufficient to communicate an intent to revoke. (H) A patient advocate may revoke his or her acceptance to the designation at any time and in any manner sufficient to communicate an intent to revoke. (I) A patient admitted to a health facility or agency has the rights enumerated in Section 20201 of the Public Health Code, Act No. 368 of the Public Acts of 1978, being section 333.20201 of the Connecticut Compiled Laws. I understand the above conditions and I accept the designation as patient advocate for

Walter Mayhew
October 09, 2008 Eleanor Mayhew Date: ______________________ Signed ____________________________________________

vaginal discharge, odor, or evidence of a sexually transmitted disease pregnancy unusual sexual knowledge for the childs age.

poor personal hygiene weight loss from poor food and uid intake medications that are not taken properly and prescriptions that are not lled.

Elder Abuse
Elder abuse can occur as neglect or physical abuse. Each form of abuse has many possible signs and symptoms.

Physical Abuse
Suspect that an elderly person is the victim of physical abuse if you see any of these signs or symptoms:

Neglect
Suspect that an elderly person is neglected if you see any of these signs or symptoms:

frequent injuries or trips to the emergency department bruises or broken bones (due to injury, not osteoporosis) patients fear of the caregiver.

unclean or unsafe living conditions preoccupation of patient with money (for example, My daughter wont want to pay the $5 copayment for the visit.)

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Living will
The following form shows a standard type of living will.

LIVING WILL OF ____________________________________

Jennifer L. Chen

Jennifer L. Chen Lovely I, ____________________________________ a resident of the City of _________________, Barrington Connecticut _________________________ County, State of _____________________, being of sound and disposing mind, memory, and understanding, do hereby willfully and voluntarily make, publish, and declare this to be my LIVING WILL, making known my desire that my life shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
1. This instrument is directed to my family, my physician(s), my attorney, my clergyman, any medical facility in whose care I happen to be, and to any individual who may become responsible for my health, welfare, or affairs. 2. Death is as much a reality as birth, growth, maturity, and old age. It is the one certainty of life. Let this statement stand as an expression of my wishes now that I am still of sound mind, for the time when I may no longer take part in decisions for my own future. 3. If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death is imminent, where the application of life-prolonging procedures and heroic measures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally. I do not fear death itself as much as the indignities of deterioration, dependence, and hopeless pain. I therefore ask that medication be mercifully administered to me and that any medical procedures be performed on me which are deemed necessary to provide me with comfort or care or to alleviate pain. 4. In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical treatment and accept the consequences for such refusal. 5. In the event that I am diagnosed as comatose, incompetent, or otherwise mentally or physically incapable of communication, I appoint _______________________________ to make binding decisions Benjamin Chen concerning my medical treatment. 6. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy. 7. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. I hope you, who care for me, will feel morally bound to follow its mandate. I recognize that this appears to place a heavy responsibility upon you, but it is with the intention of relieving you of such responsibility and of placing it upon myself, in accordance with my strong convictions, that this statement is made.

Blueville Savings IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my seal at _____________________ Bank 9th October 08 ___________________, this _______________ day of _____________________, 20_____, in the presence of the subscribing witnesses whom I have requested to become the attesting witnesses hereto.
DECLARANT

Jennifer L. Chen

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Living willcontd
The declarant is known to me and I believe him/her to be of sound mind.

Gina DeCarlo
WITNESS SIGNATURE

Gina DeCarlo
PRINT NAME OF WITNESS

24 North Ridge Road, Lovely, CT

WITNESS ADDRESS

October 09, 2008

DATE

Jennifer L. Chen Subscribed and acknowledged, before me by ____________________ and subscribed and sworn 9th October 08 before the witnesses, on the ____________ day of ________________,20_____.

MY C O

ISSION E MM MBER 2 X
VE

RES PI

NO

Jennifer Chen, Benjamin Chen Copies of this instrument have been given to: _____________________________________________ October 09, 2008 Receipt and acknowledged & date: _______________________

TE

O OT I A RY P U B L

OF

C NNE

CT

IC

UT

10

A ST

Chapter Summary

Failure to follow the Medical Practice Act can result in suspension or revocation of a physicians license, monetary fines, and imprisonment (for more serious violations). Documents such as a durable power of attorney and a living will outline who can make medical decisions or inform the health care staff of the patients own wishes. These documents should be honored and followed as directed by the physician. The medical assistant must: follow legal and ethical principles to safeguard a patients privacy and physical safety and keep the patient informed of her health care

maintain complete patient records, disclose information only when appropriate, and treat patients with respect and kindness help avoid lawsuits by avoiding such hazards as gossiping, promising a cure, and being disrespectful report incidents of suspected child or elder abuse as mandated by the state avoid violating the Medical Practice Act of her state by always practicing within the scope of her training and ability.

Team Work Exercises

1. Role-play physician, patient, and family members in explaining the uses of a durable power of attorney and a living will. 2. Research child abuse reporting laws for your state. Create a guide for a physicians ofce to use as a reference for

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reporting child abuse. Discuss with the class how to handle a suspected abusive caregiver who brings a child in for care. When should the police be contacted? When can you let the child go home with the suspected abuser?

2. Mike Jones calls the ofce and asks for the results of a pregnancy test on his wife, Ann Jones, who came in earlier today. What circumstances would allow you to release that information? Discuss your thoughts with your classmates.

Case Studies
1. Your sister tells you that she has begun dating a great guy. When she introduces you to him, you recognize him as a patient in the medical ofce where you work. The man has a long history of drug and alcohol abuse and is currently receiving treatment. He has been arrested several times for drunk driving. What information (if any) can you disclose to your sister? Is it appropriate for you to speak to the man directly about his alcoholism and the fact that he is dating your sister? Discuss your thoughts with classmates.

Resources

Durable power of attorney form (printable version): www.med.umich.edu/1libr/aha/umlegal02.htm Good Samaritan law: pa.essortment.com/goodsamaritanl_ redg.htm Living will (printable version): www.med.umich.edu/1libr/ aha/umlegal04.htm

CHAPTER

HIPAA and a Patients Rights

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the words presented in the key terms table describe the two components of HIPAA Public Law 104-191 describe the three components of the security standard describe who may be listed as a covered entity and the responsibilities of the various entities describe treatment, payment, and operations (TPO) describe how to obtain consent to disclose protected health information (PHI) for TPO describe the patients rights to PHI and how it is obtained describe the PHI that a patient does not have the right to access discuss the roles and responsibilities of a HIPAA compliance ofcer list at least four safeguards of PHI in each category list at least seven components of a medical record discuss the importance of a written release of PHI list the required privacy policy documents and their purposes describe the PHI that may be verbally disclosed discuss the penalties of failing to comply with HIPAA guidelines.

7
Procedures
Release of PHI for non-TPO purposes Providing and explaining the NPP

CAAHEP Competencies
Administrative Competencies Perform Clerical Functions
Organize a patients medical record

Process Insurance Claims

Apply managed care policies and procedures Apply third-party guidelines

Chapter Outline
HIPAA
Title I: Insurance Reform Title II: Administrative Simplication Reduced cost Privacy protection Patients right to access

General Competencies Legal Concepts

Identify and respond to issues of condentiality Perform within legal and ethical boundaries Establish and maintain the medical record Document appropriately Demonstrate knowledge of federal and state health care legislation and regulations

HIPAA Compliance
HIPAA Compliance Ofcer Safeguards for PHI Administrative Technical Physical

ABHES Competencies Professionalism

Maintain condentiality at all times Be cognizant of ethical boundaries Conduct work within scope of education, training, and ability

HIPAA Documents HIPAA Noncompliance Chapter Summary Team Work Exercises Case Studies Resources

Communication
Be impartial and show empathy when dealing with patients Adapt what is said to the recipients level of comprehension

Administrative Duties
Locate resources and information for patients and employers

Legal Concepts
Determine needs for documentation and reporting Document accurately

71

Key Terms
authorization

HIPAA
The Health Information Portability and Accountability Act of 1996 (HIPAA) mandates privacy for health information, standards for electronic transactions of health information and claims, security of electronic health information, and national identiers for the parties in health care transactions. HIPAA privacy principles pertain to what is called protected health information (PHI), which is information from a patients medical record that contains details that could be used to identify the patient to whom it relates. Per HIPAA, it is the responsibility of the physician and other parties handling this information to protect it from misuse, regardless of the form of media it is in (such as electronic or print copy) and whether it is at rest (such as in a le that is accessed, stored, processed, or maintained) or in transit (such as sent through the U.S. mail or via fax or e-mail). Information included on the new patient registration, or intake, form is considered PHI, along with many other components of a persons medical record. (See Figure 7-1.) Thus, a practice must monitor its disclosureits process of releasing, transferring, providing access to, or divulging information in any manner to a second partyof PHI for health care practices (business activities of the practice, including employee training, marketing, fund-raising, licensing, and quality assessments) to ensure compliance with HIPAA. (See PHI in the medical record.)

Written permission to disclose protected health information (PHI) when a consent form does not apply or another exception is evident
business associate

Person who, on behalf of the covered entity, performs or assists in the performance of a function or activity involving the use of individually identiable health information (IIHI)
business associate contract

Document that describes the obligation of an outside entity that uses PHI to protect the privacy of the PHI as an extension of the physicians ofce (also called data use agreement)
de-identied information

Health information data set from which all personal identiers are removed
disclosure

Process of releasing, transferring, providing access to, or divulging information in any manner to a second party
health care operations

Business activities of the practice, including employee training, marketing, fund-raising, licensing, and quality assessments
individually identiable health information

Medical information contained in a patients record that could be used to identify the patient
Notice of Privacy Practices

Document that describes the use of PHI for carrying out treatment, payment, or health care operations
privacy standard

Policies and procedures in a facility that determine who has access to protected health information (PHI)
protected health information

PHI in the medical record

In addition to the patient registration form, protected health information (PHI) in the medical record includes: insurance information consent forms HIPAA forms health history form physical examination notes progress notes laboratory reports diagnostic reports (such as x-rays, scans, and electrocardiograms) medication record physical and occupational therapy reports home care reports hospital documents (operating room report, discharge notes, pathology reports) correspondence (medical and nancial) consultation reports.

Information from a patients record that contains details that could be used to identify the patient
security standard

Policy that protects the condentiality, integrity, and availability of PHI

termination policy

Written policy that mandates termination of an employee who fails to comply with internal privacy policies and procedures
transaction

Exchange of information between two parties to carry out nancial or administrative activities related to health care
transaction code sets

Standardized codes used to represent health care concepts and procedures for health-care-related nancial and administrative procedures

CHAP TER 7

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CONFIDENTIAL PATIENT INFORMATION

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CT 860-555-3212 Name Address Home phone Insured name Insured employer Insurance carrier HEALTH HISTORY Have you ever suffered from: Asthma Diabetes High blood pressure Migraine headaches Fatigue Cancer (If so, what kind?) FAMILY HISTORY Cancer (Who?) High blood pressure (Who?) Diabetes (Who?) MEDICATIONS AND SUPPLEMENTS Do you take any medications? Do you take any nutritional supplements? If so, please list (include dosages): If so, please list: _____________________________________________ ________________________________________________________ _____________________________________________ ________________________________________________________ _____________________________________________ ________________________________________________________ _____________________________________________ ________________________________________________________ _____________________________________________ ________________________________________________________ REASON FOR TODAYS VISIT Check up Physical for school, sports, or employment Other (please explain) Women only Date of last menstrual period Number of pregnancies Number of children Men only Have you ever had erectile difficulty? Do you get up at night frequently to urinate? Date of birth City Cell phone Insured date of birth Employer address ID# Full-time student Yes No

Relationship to patient Group #

Fainting Anxiety Bleeding disorder Constipation Stress

Muscle weakness Difficulty sleeping Allergies Stomach upset Mental disorder Chronic pain (If so, where?) What type?

Lower back pain Difficulty swallowing Neck pain or stiffness Diarrhea Infection

Miscarriages? Difficult or painful menstruation?

Prostate problems?

I understand that Blueville Family Medicine will file my insurance for payment of services rendered. I also understand that I am responsible for any amount due Blueville Family Medicine if my insurance is denied. Signature of patient or guardian Relationship to patient Robert Greer, MD Sharon Piecek, APRN Hector Rodriguez, MD Henry Lee, MD Anne Wilson, MD Date

FIG 7-1 New patient registration form.

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HIPAA, Public Law 104-191, contains two main parts:

Title IInsurance Reform Title IIAdministrative Simplication.

Title I: Insurance Reform

The primary purpose of the insurance reform portion of HIPAA is to provide continuous insurance coverage for workers and their insured dependents when they change or lose a job. Prior to the reform act, if an employee left or lost a job and changed insurance coverage, a preexisting condition clause could be added to their new medical insurance. This clause would allow the new insurer to deny coverage for a chronic condition, such as diabetes or heart disease, leaving the patient without any medical insurance for these costly conditions. HIPAA now limits the use of preexisting condition exclusions and prohibits discrimination for past or present poor health. In addition, HIPAA ensures that, upon renewal of an existing health insurance policy, the insurer cannot reduce coverage to exclude previously covered services. In other words, patients never become too sick to receive health insurance.

Title II: Administrative Simplication

The goals of the administrative simplication portion of HIPAA are to reduce administrative costs, ensure privacy, and ensure a patients right to his own health information.

Reduced Cost
To reduce administrative costs, Title II mandates the implementation of standards for electronic and print transactions involving PHI. The word transaction is used to describe any exchange of information between parties that contains PHI. Thus, any communication between the medical office and, say, a billing office or insurer that contains PHI would be considered a transaction. The standards for these transactions as outlined in HIPAA fall into four categories: 1. Standard codes are codes that identify diagnoses, procedures, services, drugs, and supplies. For example, ICD-9 and CPT-4 codes are standard code sets used to describe diseases and procedures, respectively. These code sets are used throughout the United States to communicate details of the medical record. Because these code sets are universally used, they help avoid misinterpretation by persons who use this information for nancial and administrative duties. 2. Unique identiers are numeric and alphanumeric strings attached to a transaction that identify a specic provider, employer, health plan, patient, facility, and so forth. That patients name is not used, which further ensures privacy protection.

3. Transaction code sets are standardized codes used to represent health care concepts and procedures for healthcare-related nancial and administrative purposes. These sets identify the type of information contained in the transaction. There are 10 transaction sets in HIPAA. Each is identied by a three-gure code: 270eligibility, coverage, or benet inquiry (in which the medical ofce inquires about a patients eligibility on a certain date, coverage for a certain service, or how much the insurance company will pay for that service) 271eligibility, coverage, or benet information (in which the insurance company responds to the medical ofces inquiry about a patients eligibility on a certain date, coverage for a certain service, or how much they will pay the medical ofce for that service) 276health care claim status request (in which a medical ofce or afliated billing agency inquires about the status of a claim previously sent to the insurance company for payment) 277health care claim status notication (in which the insurance company responds to the medical ofce or billing agency regarding acceptance or rejection of the claim, whether the claim is pending receipt of more information, or if incorrect information was supplied for the claim) 278request for a health care services review (in which the medical ofce asks the insurance company to authorize payment for a service before that service is delivered, such as hospital admission, nursing home placement, and referrals for specialized care) 278response to a request for a health care services review (in which the insurance company will respond to a medical ofces request for preauthorization for services) 820payment order or remittance advice (in which a sponsor, who is usually an employer, would provide payment to or request payment advice from the insurance company for an employee who is or will be enrolled in the health plan) 834benet enrollment and payment (in which a sponsor, who is usually an employer, enrolls, updates, or cancels enrollment of employees and dependents in a health care plan) 835health care claim payment or advice (in which the insurer provides payment or an explanation of benets [EOB] to a medical ofce) 837health care claim, professional, institutional, dental, and retail pharmacy (in which a medical ofce, hospital or other institution, dentists ofce, or retail pharmacy sends a claim for payment to an insurance company).

CHAP TER 7

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4. Electronic data interchange (EDI) standards are the standards for encrypting the data in a transaction when sent electronically. For example, the medical assistant might use a computer program (or e-mail) to send details of an office visit to an insurer for payment for services. In order to send the information in such a manner, the medical office must comply with EDI standards for such electronic transactions, including using a software program that adequately encrypts, or scrambles, the information so that it is unreadable if intercepted by a third party before arriving at its destination. Several encryption software programs are available. Manufacturers of medical software comply with the HIPAA EDI standards, as enforced by the American National Standards Institute (ANSI). By standardizing the exchange of health care data and increasing the efficiency of computer-to-computer transactions of medical data, analysis costs and data use decrease. In addition, standardized formats for diagnosis and procedure codes and identifiers for providers and health plans reduce the time otherwise needed by the administrative medical assistant to determine what is written in a document. Standardization of information also improves the accuracy of data and decreases revenue cycle time. Claims for payment can be analyzed and paid more quickly.

signing an authorization, which is written permission to disclose PHI when a consent form does not apply or another exception is evident. Privacy and security procedures, mandated in the HIPAA act under Title II, ensure condentiality and prevent the unauthorized disclosure of PHI. However, this component of HIPAA is commonly misunderstood. Unfortunately, these misconceptions have led many health care workers to think, I cant tell anyone anything about a patient. (See Disclosure: What can I say?) While the acts language may be confusing, the intent of the legislation is to keep patient information confidential and secure without limiting access in a way that prevents medical staff from treating patients or receiving payment for care. The security standard in HIPAA, Title II, protects three important elements of PHI:

confidentialityprevention of unauthorized disclosure of data integrityprevention of unauthorized modication to data availabilityprevention of loss of access to resources and data. (See Procedure 7-1: Release of PHI for non-TPO purposes, page 76.)

Privacy Protection
HIPAA allows disclosure of PHI for the purposes of treatment, payment, and operations of the medical practice and mandates that all other disclosures must be specically authorized by the patient. Patients can share PHI with other parties, such as an attorney, by requesting the disclosure and

An exception to privacy protection is the release of de-identied information, which is PHI with all personal identiers removed from the data set, making it impossible to connect the information to an individual. A medical assistant will rarely be involved in transmitting de-identied information. (Such instances may include newborn screening for human immunodeciency virus.) Typically, information that relates to communicable diseases becomes de-identied when a state reports the incidence of disease in that state to the Centers for Disease Control and Prevention.

Disclosure: What can I say?

The processes for written disclosure of PHI are exact and the medical offices policies and procedures manual can be used as a guide for following the rules of disclosure. However, disclosure is commonly given verbally and less formally, so the medical assistant must know what type of information she is allowed to disclose. The table below identifies situations in which disclosure of protected health information (PHI) is acceptable and unacceptable and examples of what the medical assistant should say in those situations.

Situation
If a friend or family member asks for information regarding a specic patient by name,*

Disclose
Patients location and general condition

Example
She is in room 1133, in stable condition. He is in ICU, in critical condition.

Dont disclose
Specic conditions

Example
Her fractured leg has been casted and she has been sedated. Inoperable tumors were found during his surgery.

Continued

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Disclosure: What can I say?contd

Situation
Medical assistant from another ofce calls seeking information on a patients treatment

Disclose
PHI for the purpose of treatment at another ofce

Example
We removed the cast on the leg yesterday; the physical therapist can proceed with rehabilitation per the physicians order.

Dont disclose
Treatment given for an unrelated condition

Example
The patient has a substance abuse history.

Billing company asks for information to receive payment from insurance Local newspaper calls asking if the mayor of the city has been admitted to the hospital

Dates of service and codes for payment inquiry

I can resend the dates of service, diagnoses, and CPT codes.

Payments made by the patient when she had no coverage

Her coverage began on July 1, 2007, prior to that she was self-pay.

No information

I am not permitted to disclose any information to the press. I can refer you to our community relations department.

Any information that would lead the caller to assume that the person was admitted

The mayor was admitted this morning. You can speak to his wife for details.

State Department of Health reports cases of tuberculosis to the Centers for Disease Control and Prevention

Only de-identied information (name of infection and number of cases)

We received reports of 27 cases of tuberculosis in the state of Connecticut in 2007.

Any information that would lead to the identity of the individual patients

Most of the reported cases are employees of the Department of Transportations Tolland County Ofce.

* Conrm the identity of the friend or family member.

PROCEDURE 7-1

Release of PHI for non-TPO purposes

Task Ensure that protected health information (PHI) released for purposes other than treatment, payment, or operations (TPO) is performed with proper patient authorization. Conditions Authorization to Release PHI form Patients medical record Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform a release of PHI for non-TPO purposes. Performance Standards 1. Check the Authorization to Release forms information for completeness, including: a. patients name, date of birth, and Social Security number to ensure that the authorization is for the correct patient and is not mistakenly used for another patient b. patients initials next to the notice of the right to revoke permission to disclose to ensure that the patient understands his rights c. patients or legal guardians signature (original, not a photocopied or faxed signature) to prevent the possibility of forgery d. date signed to ensure that the request is recent and pertains to current information e. information requested for reasonable length of time (for example, not entire record spanning 54 years)

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PROCEDURE 7-1contd

f. HIV, mental health, and substance abuse information specically requested by the patient (separately indicated with initials or signature) to ensure condentiality and protection of personal health information g. indication of recipient of information, including name, address, and other contact information to ensure that the information is released to an individual who has the authority to view the information. 2. Retrieve the patients medical record. 3. Photocopy the documentation requested. 4. Recheck the authorization and photocopied documentation to ensure that only the information requested and authorized is released because a release of

unauthorized information can result in nes to the medical ofce. 5. If a courier is picking up the information, check the identication of the courier to prevent the release of information to the wrong courier. If you are mailing the information, recheck the name and address of the recipient before sending it to ensure the identity and location of the recipient is correct. 6. Document the release of information in the patients medical record to maintain a complete medical record. 7. File the Authorization to Release form in the patients medical record or designated le to ensure that proper documentation is available if a question about the release arises at a later time.

PHI Outside the Ofce

Some medical practices hire a billing company to le health care claims electronically. HIPAA mandates that the practice must treat that billing company as a business associate, a person or organization who, on behalf of the medical practice, performs or assists in the performance of a function or activity involving the use of individually identiable health information (IIHI), or medical information contained in a patients record that could be used to identify the patient. The physicians ofce and the billing company must have a written business associate contract, which is a legal document that species that the physicians ofce is releasing PHI for the purposes of reimbursement and that the billing company may not use the information for any other purpose. The billing company may be required to sign a data use agreement that limits its use of PHI. The names and addresses of the patients, for example, cannot be sold to a marketing company. If the billing company, acting in an effort to collect payment, transmits PHI electronically, the billing company and the physicians ofce are covered entities and must comply with HIPAA. A transfer of information between the physicians ofce and the billing company related to health care may include:

TIP HIPAA in the Mail If an ofce les billing via U.S. mail, does it have to comply with HIPAA? YES! Although the target of HIPPA is electronic information, all forms of PHIwhether written by hand, stored in a computer and transmitted to another agency, or photocopied and put into an envelope for a courier to pick upare personal and condential and should only be disclosed with proper authorization. Note: Providers with 10 or more employees were required to convert to electronic transactions to Medicare by October 16, 2003. Therefore, HIPAA compliance is now mandatory.
Patients Right to Access
In addition to preventing unauthorized use of PHI, the administrative simplication provisions also specify a patients right to his own PHI. Prior to HIPAA, health care providers could deny access to medical records and refuse to share a patients health information with him. A patient now has the right to request:

health care claim forms health care payment and explanation of reimbursement coordination of benets (secondary insurance) health care claim status (denials and requests for further information) enrollment and disenrollment in health care plans eligibility for enrollment in a health care plan health care plan premium payments referrals and preauthorizations for treatment rst report of injury narrative notes.

access to his health information amendment of PHI additional restriction of information alternative means of communicating health information accounting of disclosures of his PHI.

Access to Information
A patient has the right to access, inspect, and obtain a copy of their medical records. The provider may require the request in writing and must fulfill it within 30 days. Reasonable fees may be charged for copies and should be cost-based. In general, copy costs and postage are reasonable. If the patient agrees to a summary in lieu of the complete chart, the cost of preparing the summary may be included but should be disclosed to the patient prior to preparation.

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An ofce can deny a patient access for certain reasons without giving the patient the right to review the denial. Under the HIPAA privacy regulations, a patient does not have the right to access:

psychotherapy notes information compiled in reasonable anticipation of, or for use in, legal proceedings information exempted from disclosure under the Clinical Laboratory Improvements Amendment (CLIA) information that would reveal the identity of and therefore endanger a person other than the health care provider who is a source of information.

A medical ofce must respond to a patients request for amendment within 60 days. Denial of amendments must be accompanied by reasons for the denial. The ofce must also give the patient an opportunity to le a statement of disagreement.

Additional Restriction of Information

A patient has the right to ask for restrictions on how the medical ofce will use and disclose PHI for TPO. A patient may have a previous medical history that is not applicable to current treatment and can request that this information not be shared. Such information as abortions, successful treatment of sexually transmitted diseases (STDs), and cosmetic surgery may be embarrassing to a patient and its disclosure would not effect treatment outcomes. The medical ofce is not required to agree to the requests, but must have a process to review the request in the case of a denial. In some situations, PHI is disclosed for reasons other than TPO. (See PHI and public health and safety.)

HIPAA specically excludes psychotherapy notes from disclosure. Although such notes as medication records, start and stop dates of sessions, diagnoses, test results, and frequency and types of treatment are considered PHI, psychotherapy notes are not stored in the general medical record, nor are personal notes. A psychologist or psychiatrist has the right to deny patient access if she feels that release of the information would be detrimental to the patients health. Denial of release of records by a psychologist or psychiatrist is not subject to any review process. Access to PHI obtained from an individual source other than the health care provider under a promise of condentiality can also be denied if that information would compromise the identity of the source of the information or could be used for legal proceedings. For example, if the medical chart of Mr. Jones refers to his wifes disclosure of domestic violence or evidence of wounds incurred during an attack on his wife, releasing the chart to Mr. Jones could endanger Mrs. Jones.

Alternative Communications
Patients have the right to request condential communications by alternative means. A patient may request that the medical ofce call her only at work, not at home. A request that an answering machine not be used for sensitive information is also appropriate. The alternative communications request must be reasonable; the patient cannot request that she receive phone calls only between 2 a.m. and 5 a.m. The patient does not need to explain her reasons for the alternative communication request; however, if domestic violence is suspected, the medical assistant should follow reporting laws as indicated by her state.

Amendment of PHI
Patients have the right to request an amendment of their PHI if they feel that information contained in the medical record is inaccurate. The provider can require that the request for amendment be in writing and can deny the amendment for these reasons:

PHI and public health and safety

Occasionally, a patients protected health information (PHI) may be disclosed if such a disclosure could positively impact public health or safety. Such situations include: disclosure of psychiatric notes or drug use history of an individual seeking a day care license, teaching certication, or gun permit (requires a court order) sharing information on communicable diseases and work-related illnesses and accidents reporting victims of abuse, neglect, or domestic violence law enforcement purposes, such as allowing investigators to view photographs of wounds taken in the course of treating a person who may have incurred those wounds while committing a violent crime births and deaths.

The provider who is requested to amend the PHI is not the originator of the information. If medical records were transferred from one medical ofce to a second medical ofce, the receiving medical ofce is not responsible for the accuracy of the documents. The patient could then request that the originator amend the document. The provider believes that the PHI is accurate and complete without amendment. HIPAA does not require that the provider make the information accessible to the patient. The information must be one of the four types outlined above in the denial of access to records, including psychotherapy notes, information compiled for a legal proceedings, information exempted by CLIA, and information that could compromise the identity of a source other than the health care provider.

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79

Accounting of Disclosures
Patients have a right to request an accounting of any disclosures of PHI for purposes other than TPO. Patients are entitled to one accounting of disclosures per calendar year, free of charge. Additional requests for disclosures can be granted at a reasonable cost. A log of disclosures, computerized or written, should be maintained in anticipation of a patients request for an accounting. The disclosure log should include:

providing information to patients regarding the proper procedures for requesting amendments, appeals, and rebuttals (See Seven components of a compliance plan.) instituting administrative, technical, and physical measures that ensure reasonable safeguards to PHI from unauthorized use or disclosure. (See HIPAA compliance: Everyones job, page 80.)

date of disclosure name of the agency or individual who received the PHI, including the agencys address (for example, Child Protective Services, Elaine Mendenhall, MSW) brief description of the PHI disclosed (for example, ofce treatment notes 1/15/06 through 4/15/06; x-ray left humerus 2/11/06) brief statement of the purpose of the disclosure (for example, child abuse investigation).

Safeguards for PHI

There are three types of safeguards that a medical practice should institute to avoid the misuse of PHI:

administrative technical physical

Administrative
Administrative safeguards for PHI include:

HIPAA Compliance
Because HIPAA requires physicians ofces to change the way that information is stored, transferred, and utilized, a time frame for compliance with HIPAA was specied. All time frames for compliance are past, with the latest deadline falling on April 21, 2005. Therefore, compliance with HIPAA in transaction and code set standards (October 2003), Medicare electronic claims (October 2003), privacy rules (April 2003), unique identifiers for employers ( July 2004), and security standards (April 2005) is mandatory. By these dates, physician ofces were required to comply with each of the portions of HIPAA.

verifying the identity of an individual picking up health records verifying a patients identity on the telephone after putting the caller on hold and returning to the call immediately reporting a suspected breach of condentiality to the HIPAA compliance ofcer making sure that each patient signs a Notice of Privacy Practices (NPP), a document that explains how the patients medical information will be used to perform duties related to treatment, payment, or operations (TPO), before releasing information for TPO checking a patients medical record for special instructions regarding contacting the patient before making the call

HIPAA Compliance Ofcer

The medical ofce must have a person who assumes the responsibilities of ensuring compliance with HIPAA regulations regarding security, disclosure, and use of PHI. The compliance ofcer, or privacy ofcer, is typically the ofce manager and is responsible for:

Seven components of a compliance plan

The Ofce of the Inspector General recommends the following steps for individual and small-group practices to follow to ensure compliance with HIPAA guidelines: 1. Conduct periodic internal monitoring and audits. 2. Implement compliance and practice standards. 3. Designate a HIPAA compliance ofcer. 4. Conduct training and education. 5. Respond appropriately to detected offenses and develop a corrective action plan. 6. Develop open lines of communication for staff to ask questions and refer to the policies and procedures manual. 7. Enforce disciplinary standards through well-publicized guidelines. (Disciplinary rules should be included in the policies and procedures manual.)

providing training for all personnel regarding the release and use of PHI ensuring that privacy and security rules are outlined in a policy and procedures manual and that this manual is available to personnel for reference providing patients and personnel with a process to register a complaint regarding the misuse of PHI providing disciplinary guidelines for failure to comply with privacy standards (policies and procedures in a facility that determine who has access to PHI), such as verbal and written warnings, employee termination, and a referral to federal agencies for criminal prosecution (if applicable)

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Front ofceBack ofce connection

HIPAA Compliance: Everyones Job

The HIPAA compliance ofcer is responsible for training front and back ofce staff. The staff is responsible for understanding the policies and procedures that protect a patients protected health information (PHI) in both areas. The front desk staff must have an understanding of how test results are kept private and how to release them to a patient. The clinical staff must also have an understanding of how to release PHI and the required paperwork that must accompany the release. When considering patient privacy and patients rights, clinical and administrative staff must be well versed in the laws and adhere to them. They should work together to educate patients, while making PHI available to the patient in a manner that does not violate HIPAA privacy standards. For example, a patient may tell the front desk medical assistant that she cannot accept phone calls at work and ask why the clinical staff cannot call her husband at work with her test results. The front desk medical assistant must be able to explain to the patient that doing so would violate HIPAA privacy standards. The medical assistant should suggest other methods of relaying the information, such as leaving a message (with the patients permission) on her home phone or cell phone.

periodically running virus protection software not allowing personnel to use computers to check e-mail or send personal e-mails to prevent potential corruption of data from viruses acquired through home e-mail addresses.

Physical
Physical safeguards for PHI include:

storing patient les away from patient-accessible areas locking patient les when the ofce is closed ensuring that staff members never leave a patient le open at the reception desk ling medical records before the cleaning staff comes in at night and placing items to be led in a folder making staff aware that conversations at the front desk could be overheard; instructing all staff to close the privacy window and be careful of their voice volume when talking on the telephone. not posting providers schedules with names of patients in an area that can be seen by other patients although patient sign-in sheets are acceptable, making sure to require a patient to sign their name only, without listing a reason for the visit.

HIPAA Documents
HIPAA compliance can be obtained through proper training and adherence to mandated rules. All personnel who have a need to use PHI should undergo training and have access to documents that outline disclosure regulations and patients rights. The documents should be kept in a policies and procedures manual and available for personnel to review. The policies and procedures manual should contain these HIPAA documents:

placing fax machines in private areas, away from patients; making sure personnel never leave information at the fax machine designating a private area for physicians to dictate notes and return phone calls; patients should not be able to hear dictations or phone calls.

Technical
Technical safeguards for PHI include:

requiring a unique username and password for each staff member to use to access patient computer records and setting passwords to expire periodically so that staff members must choose a new password to gain access instituting rewall protection to prevent a compromise in security from an outside source (such as a computer hacker) deleting usernames and passwords when staff members discontinue employment with the practice utilizing practice management software that tracks users and their activities ensuring that staff members always log off when leaving a computer station

Notice of privacy practices describes the use of PHI for carrying out treatment, payment, or health care operations (TPO). (See Procedure 7-2: Providing, explaining, and obtaining acknowledgment of the NPP.) A written acknowledgement is recommended, rather than a verbal one. (See Acknowledgment of NPP.) Consent for use or disclosure for TPO is a patients consent to the use of and disclosure of health information for TPO (optional). Authorization to use or disclose PHI must be obtained when a consent form does not apply or another exception otherwise permitting use or disclosure of PHI does not apply. (See Outside release form, page 82.) Business associate contract, or data use agreement, describes privacy protection for a patients PHI when using outside entities that provide services for your organization whose access to PHI is necessary.

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PROCEDURE 7-2

Providing, explaining, and obtaining acknowledgment of the NPP

Task Use the Notice of Privacy Practices (NPP) to ensure that a patient understands the right to protected health information (PHI) and how the ofce will use the information for treatment, payment, and operations (TPO) and obtain the patients signature on the acknowledgment form. Conditions Notice of Privacy Practices New Patient Registration form Acknowledgment of Receipt of NPP form Patients medical record Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully provide and explain the NPP and obtain the patients signature on the acknowledgment form. Performance Standards 1. Give the patient the Notice of Privacy Practices (NPP) along with the New Patient Registration form so that the patient can read the NPP along with the registration form. 2. Ask the patient to read the NPP and answer any questions that he may have. 3. Ask the patient to sign the acknowledgment of receipt and understanding of NPP. 4. File the acknowledgment in the patients medical record to maintain a complete medical record and ensure proper documentation if questions about privacy arise at a later time.

Patient Education

Acknowledgment of NPP
When a new patient comes to the ofce, he should be given a copy of the Notice of Privacy Practices (NPP) from HIPAA. This document will tell the patient how his protected health information (PHI) will be used for treatment, payment, and operations (TPO). The NPP is usually given to the patient the rst time he receives instructions from the ofce. The rst experience with patient education at the ofce can set the tone for subsequent patient teaching. The medical assistant should create a rapport with the patient, encourage the patient to ask questions, and answer questions as they arise. If this rst experience is positive, the patient may feel more comfortable about asking other staff members medical, nancial, or administrative questions in the future. Because the NPP is about seven pages long, many medical practices laminate a few copies to use for new patient registration. Regardless of how the ofce distributes the NPP, it must include: who within the practice will comply with privacy practices who outside of the practice will comply with privacy practices outline of the practices responsibilities for protecting health information
Continued

ways in which the practice may use or disclose PHI patients rights regarding PHI, along with the procedure for exercising those rights procedure for changing policies outlined in the notice (or the notice itself) contact information for questions or complaints a patient might have regarding the practices disclosure of PHI (including information for contacting the practice and the appropriate government agencies) question-and-answer section outlining the most common questions regarding the NPP.

Acknowledgment form
The patient must sign an acknowledgement form (as shown below) to indicate that he has read the notice and understands the implications such privacy restrictions will have on the handling of his medical record. This signed document will allow the ofce to use PHI for TPO. The medical assistant may have to explain components of the document to the patient. A written, rather than verbal, acknowledgment of this notice is recommended.

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Patient Educationcontd

ACKNOWLEDGMENT FORM

Beryl Travalian I _________________________________ have read and understand the Notice of Privacy Practices Policy.

__________________________________ Signature of patient or guardian

Beryl C. Travalian

08/27/07 _________________ Date

HIPAA compliance officer job description is a written description of the ofcers roles and responsibilities. Termination policy is a written statement that mandates termination of an employee who fails to comply with internal privacy policies and procedures.

HIPAA Noncompliance
Failure to comply with HIPAA regulations can result in serious civil and criminal penalties. The HIPAA legislation

required the U.S. Department of Health and Human Services (HHS) to establish and implement national standards and identiers for electronic transactions and handle ongoing issues involving transaction code sets and security. The HHS developed sample documents for physicians ofces to download and use. The authority to enforce the transaction code set requirements was given to the Centers for Medicare and Medicaid (CMS), formerly the Health Care Financing Administration (HCFA). The Ofce of Civil Rights (OCR) was given the responsibility for ongoing enforcement of the privacy standards and the handling of complaints. The

Patient Education

Outside Release Form

Attorneys will commonly have their clients sign a release of medical information form. The medical assistant should insist that the patient provide an original signature on the form. She should never accept a duplicated or faxed copy of a form requesting the release of protected health information (PHI). Most attorneys ofces will send a letter to the physician requesting release of PHI, along with a release request form signed by the patient. The medical assistant should never release information to an attorney if the request is made without the required release form. When accepting a release of records form that is not generated by the medical ofce, the medical assistant should be sure to inspect the request for completeness, including the elements noted below. The medical ofce can generate the request for release of information and can specify the agency to receive the PHI. By generating the request in house, the medical assistant knows that the documentation is complete and that the patient understands the purpose of the release of information. When asking a patient to sign a release of information document, the medical assistant should explain to the patient where the information will go and for what purposes.

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HIPAA and a Patients Rights

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Patient Educationcontd
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION PATIENTS NAME, DATE OF BIRTH, AND SOCIAL SECURITY NUMBER ARE INCLUDED.

Josefina Marie Simms

Patient name

8/16/54
Date of birth

876-32-1234
Social security #

Josefina Marie Simms I, _________________________________ , authorize the use or disclosure of my protected health information by
PATIENT NAME

Dr. Robert Greer as specified below. I understand that signing this authorization is voluntary and that Dr. Greer may not require me to sign this authorization before Dr. Greer provides me with treatment. I understand that I have the right to revoke this authorization at any time by providing a signed, written notice of such revocation to Dr. Greer. I understand that a description of my rights to revoke my authorization is set forth by Dr. Greer.

RIGHT TO REVOKE THE PERMISSION TO DISCLOSE IS INCLUDED.

Notice of Privacy Practices: I understand that information is being released pursuant to this authorization at my request and that the information may no longer be protected by law or regulation and may be redisclosed by the recipient. INFORMATION TO BE DISCLOSED IS Please use or disclose the following information: SPECIFIED AND THE REQUEST IS X The entire medical record REASONABLE. (FOR EXAMPLE, A The following limited health information REQUEST FOR 45 YEARS OF A ____________________________________________________________________________________________ MEDICAL RECORD IS AN ____________________________________________________________________________________________ REQUEST.) UNREASONABLE ____________________________________________________________________________________________ The following information cannot be disclosed without specific authorization. Please initial next to each item below that you specifically authorize the release of health information relating to the testing, diagnosis, or treatment for:

JMS ______ HIV or AIDS JMS ______ Drug and alcohol abuse JMS ______ Mental health or psychiatric disorders
Please specify the time period for the information you described to be disclosed: All information maintained at this time by Dr. Greer X Information maintained by Dr. Greer from ______________ to ______________ 10/8/2004 2/28/2005 Please specify who may receive the information requested by this authorization: Carla J. Simmons Attorney at Law 211 Main Street Lovely, CT 06111

BECAUSE INFORMATION REGARDING HUMAN IMMUNODEFICIENCY VIRUS (HIV) STATUS, MENTAL HEALTH HISTORY, AND SUBSTANCE ABUSE HISTORY ARE CONSIDERED HIGHLY SENSITIVE, AUTHORIZATION TO RELEASE THAT INFORMATION MUST BE EXPLICITLY OUTLINED.

THE PERSON OR AGENCY (LAW OFFICES) WHERE THE INFORMATION IS TO BE RELEASED IS SPECIFIED AND THE ADDRESS OF THE AGENCY IS INCLUDED.

By signing below, I understand and acknowledge the following: I have read and understand this authorization I am authorizing Dr. Greer to use or disclose the health information to the person(s) identified in this authorization. If I have any questions about disclosure of my protected health information pursuant to this authorization, I may contact Anthony Campbell, Paralegal, law offices of: Carla J. Simmons Attorney at Law 211 Main Street Lovely, CT 06111 ____________________________ Josefina Marie Simms Printed name of patient ____________________________ Josefina Marie Simms Signature of patient

THE DOCUMENT IS SIGNED AND DATED. ______________ 5/24/2008 Date

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OCR refers more serious issues to the Ofce of the Inspector General (OIG). The OIG refers criminal cases to the FBI and other agencies. Penalties for noncompliance include:

privacy, security, and transaction violation$100 to $25,000 ne per person for identical violations in a calendar year knowingly obtaining and disclosing IIHI$50,000 ne obtaining IIHI under false pretenses$100,000 ne obtaining IIHI under false pretenses with the intent to sell, transfer, or use for commercial advantage, personal gain, or malicious harm$250,000 ne and up to 10 years in prison.

The medical assistant may be required to act as a HIPAA compliance ofcer, providing training to personnel and creating and maintaining administrative, technical, and physical safeguards for PHI. Failure to comply with HIPAA mandates can result in serious civil and criminal penalties.

Team Work Exercises

1. In groups of three to eight students, create a HIPAA training session to present to classmates or another class on campus. Include such items as release of PHI, amendments to PHI, and role of the HIPAA compliance ofcer. Include a brief quiz at the end of your presentation. 2. In groups of two students, role-play a medical assistant explaining the purpose of the Notice of Privacy Practices form to a patient.

In addition to safeguarding PHI, the OIG is also responsible for prosecuting fraud, abuse, and waste in claims submission. Health care providers and staff must be aware of the potential liability of submitting fraudulent claims. Patterns of claims submission that result in excessive reimbursement can result in prosecution under HIPAA guidelines. Deliberate unethical behavior can result in prosecution under the Criminal False Claims Act (18 US Code). Such behavior includes:

Case Studies
1. Mrs. Li Chuan Chu is a new patient. She speaks limited English and was unable to have her daughter come with her to the physicians ofce to interpret. Can Mrs. Chu be treated? Can she sign the Notice of Privacy Practices if she doesnt understand the document? Can her PHI be released for TPO? Discuss solutions to the dilemma with your classmates. 2. You receive a faxed authorization for release of PHI to a patients attorney for use in a workers compensation claim case. Can you accept the document? If not, how can you comply with the patients request for release of information?

charging insurance companies for procedures not performed submitting claims for equipment, medical supplies, and services that are not reasonable or necessary willfully omitting or providing misleading information to promote reimbursement of a claim billing for each component of a service, called unbundling, when all-inclusive codes are available and would result in lower reimbursement knowingly using the wrong provider identication numbers so that a nonparticipating physician is paid at the participating physician rate changing dates of service to t patient eligibility.

Resources

Chapter Summary

The Health Information Portability and Accountability Act of 1996 (HIPAA) was enacted to safeguard patients privacy and the security of protected health information (PHI). Following HIPAA mandates ensures the condentiality, integrity, and availability of PHI. Patients have the rights to access their PHI, request an amendment of their PHI, impose additional restrictions on disclosure of their PHI, request alternative communication regarding their PHI, and obtain an accounting of all disclosures of their PHI.

American Medical Association: www.ama-assn.org/ama/ pub/category/424.html Health Insurance Portability and Accountability Act (HIPAA) of 1996: Title 1 Statutory Text: www.cms.hhs .gov/hipaa1/content/HIPAASTA.pdf HIPAA Academy: www.HIPAAacademy.net HIPAA Administrative Simplication, Dept. of HHS: www.aspe.os.dhhs.gov/adminsimp HIPAA EDI implementation guide: www.wpc-edi.com/ hipaa_40.asp Samples of downloadable release forms: www.cms.hhs.gov

CHAPTER

Bioethics
Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell key terms in the glossary compare morals and ethics differentiate between law and ethics dene bioethics discuss the seven ethical principles described in this chapter differentiate between utilitarianism and deontology describe the features of an ethical dilemma explain the purpose of an ethics committee discuss the purpose of a code of ethics identify two codes of ethics relevant to the profession of medical assisting.

8
ABHES Competencies
Professionalism
Maintain condentiality at all times Be cognizant of ethical boundaries Evidence a responsible attitude Be courteous and diplomatic Respect and dignity Commitment to professional development

Chapter Summary Team Work Exercises Case Studies Resources

Chapter Outline
Ethics and Morals Law and Ethics Bioethics Ethical Principles
Nonmalecence Benecence Autonomy Distributive Justice Paternalism Veracity Fidelity

Ethical Philosophies
Deontological Philosophies Teleological Philosophies Philosophical Divide

Anatomy of an Ethical Dilemma

Ethical Decision Making Ethics Committee

CAAHEP Competencies
General Competencies Legal Concepts
Identify and respond to issues of condentiality Perform within legal and ethical boundaries

Ethics and the Medical Professional

Code of Ethics Ethical Behavior in the Medical Ofce Trust and loyalty Condentiality

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Key Terms
ambiguity

Ethics and Morals

Morals and ethics are terms that are sometimes used interchangeably because they are based on values regarding human conduct. However, there are some subtle differences. Morals are deeply held personal beliefs about what constitutes right or wrong behavior. Such beliefs stem from a variety of sources, including religion, family customs, culture, and past experiences. Ethics goes further than a simple pronouncement of moral judgment and involves thoughtful analysis, commonly at a philosophical level. Ethics evaluates human behavior in light of specic ethical principles and looks at the impact of such behavior on individuals and society as a whole. Stated more simply, when one is behaving ethically, one is concerned with the big picture as well as the immediate situation.

State of uncertainty or vagueness

autonomy

Right to self-determination
benecence

Duty to provide a good or benet

bias

Unfair or incorrect belief that stems from prejudice and inhibits impartial judgment or action
bioethics

Study of the ethical implications of discoveries and advances in modern medicine and health care
consent

To agree or give permission

deontology

Ethical philosophy concerned with duties and rights

distributive justice

Principle regarding the fair distribution of scarce resources

ethics

Law and Ethics

Although a behavior may be deemed unethical by some individuals, it is not necessarily illegal. Conversely, a behavior that has been designated as illegal is not necessarily considered unethical by all. All cultures have beliefs about what is considered right and wrong behavior. Actions that are considered most harmful or offensive by the majority may be designated as illegal. Individuals who commit such acts, if caught, will be subject to some form of ne or punishment. For example, in the United States, killing another person for personal gain or other selsh reasons is considered by most people to be morally and ethically wrong. Therefore, the act of murder has been legally designated a crime. Penalties for those convicted of murder are quite severe. Yet killing another individual in self-defense or as part of a governmentsanctioned military action is deemed acceptable, in some cases perhaps even honorable. However, people do not always agree about what constitutes right or wrong behavior. In such cases, there is usually not enough agreement to support legislation making such behavior illegal. For example, consensual sex between unmarried adults is legal in the United States. Some people believe this is wrong, yet others do not. When there is lack of agreement, formation of laws to prohibit such behaviors is unlikely. In some cases, rules may be enacted to regulate, rather than prohibit, specic acts. Such regulation generally species where, when, and by whom such acts may be performed. For example, therapeutic abortion has been legal since the 1973 Roe v. Wade Supreme Court ruling. However, there are specic rules that regulate where such procedures may be performed and by whom. Although abortion is deemed immoral or unethical by some, such beliefs are

Study of human behavior and moral choices based on a set of principles; rules or standards governing professional conduct
delity

Concept of loyalty or faithfulness

justice

Concept of fairness or equity

morals

Judgment regarding the value of certain behaviors based on personal belief

nonmalecence

Duty to do no harm
norm

Unwritten rules of socially acceptable behavior

paternalism

Practice of providing for people without giving them rights or responsibilities

teleological philosophies

Philosophies that focus on consequences or the ends, more than on actions or the means, in determining value
utilitarianism

Ethical philosophy concerned with achieving the greatest good for the greatest number of people
veracity

Quality of truthfulness

CHAP TER 8

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87

not sufcient to make the act illegal. An act only becomes illegal when specic action, such as the passage of a law by a governing body, makes it so. On the other hand, some people might argue that some acts, though illegal, are not morally or ethically wrong. For example, the legal age to buy and consume alcohol varies between states and countries. An 18-year-old who buys or drinks alcohol in one place might be breaking the law, while the same person could travel a few miles over the border to a different state or country and legally commit the same act. Even so, some might argue that even though the issue of legality changed from one place to the other, the issue of morality did not. Some individuals believe that drinking alcohol is wrong regardless of the individuals physical location or age. Others would disagree.

must be made, which is not helpful to anyone. A far better plan is for health care workers to become educated and prepared with information and tools that can help them navigate these difcult waters and provide better guidance to their patients. These tools include an understanding of key ethical principles, ethical philosophies, and a thoughtful plan for responding to ethical dilemmas when they arise.

Ethical Principles
Ethical principles are rules about how people ought to behave. An understanding of these principles is necessary to understand the ethical reasoning process. Upon initial examination, ethical principles may seem simple and straightforward. However, they commonly come into conict with one another, sometimes creating complicated situations. Some of the most common ethical principles applied to health care include:

Bioethics
Biomedical ethics, or bioethics, is a specialized branch of ethics that concerns itself with human behavior within the context of modern medicine. In recent years, modern science has provided humankind with an amazing number of new treatment options. Human cloning, in vitro fertilization, stem cell research, and some forms of organ transplantation once made good topics for science ction novels but were not considered realistic. Today, however, organ transplantation and in vitro fertilization are commonplace. Stem cell research, though still controversial, is currently underway. Animal cloning is currently being done in a limited way. Human cloning, though not common practice, is the subject of much debate. It seems only a matter of time before some form of human cloning takes place, authorized or otherwise. The topics of abortion and euthanasia are not new. Yet our struggle to understand and agree upon standards for human conduct are exemplied by continuous debate on both issues. In addition to these controversial topics are the more common, yet equally difcult, situations that patients and families face on a daily basis. The explosion of medical research has necessarily compounded the complexity of decision making required of patients and family members. In many situations, the right choice is not readily apparent, leaving everyone to agonize and, perhaps, disagree about what ought to be done in any given situation. The number and variety of situations that confront health care providers are innite. Therefore, it is not possible to predict them or to explain what ought to be done in each and every case. So what are health care workers to do? At worst, they can keep their heads in the sand, refusing to discuss and deal with these difcult and painful topics. Doing so tends to result in responses dictated by fear and prejudice when touchy topics arise and difcult decisions

nonmalecence benecence autonomy distributive justice paternalism veracity delity.

Nonmalecence
Nonmalecence refers to the duty of health care providers to do no harm. This principle was rst mentioned in the Hippocratic oath and has since been repeated in one form or another in various professional ethical codes. Few would argue the merit of such a principle. However, the reality of most forms of medical treatment is that there is always the potential for harm. Even something as simple as prescribing an antibiotic to a patient with an infection has some potential to cause harm. Although potential adverse effects of most antibiotics are minor, some could be life-threatening.

Benecence
The principle of benecence goes a step beyond nonmalecence. It states that health care providers must aim to provide benet for their clients in addition to avoiding doing harm. This principle has served to guide some of the changes that have occurred over the past century regarding the regulation of medications. Years ago, virtually anyone could sell their own version of a remedy, sometimes called snake oil, wherever and to whomever they wished. They could make unsubstantiated claims about its curative powers. In most cases, these remedies provided no benet and, worse yet, were sometimes harmful. Since that time, laws have been enacted

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in the United States that require medications to be proven safe as well as benecial before they are approved for sale. Such regulation is an example of the principle of benecence at work. With benecence in mind, physicians are obligated to provide medications and treatments that have a reasonable likelihood of helping patients. As a patient faces a decision regarding possible surgery, a diagnostic procedure, or a new medication, the physician must provide information regarding potential risks and benets. In every case, there is some element of risk, because no procedures or medications are totally risk free. In this decision-making process, the health care provider and patient strive to make a choice that minimizes potential harm (nonmalecence) while maximizing potential benet (benecence).

makes a decision for the good of another person, possibly against that persons wishes. In doing so, the persons right to autonomy is denied. For example, a parent is allowed to give consent for the medical treatment of her child who is a minor, or an adult is the surrogate decision maker for an elderly parent who has been deemed incapable of making her own decisions because of dementia.

Veracity
The principle of veracity refers to the quality of truthfulness. This simple principle is generally understood and valued by most individuals, although it is not always an easy one to follow. For example, a physician may need to nd a kind but honest way to tell a patient that she has cancer, or the ofce manager must nd a tactful way to talk with an employee about her unacceptable behavior. On the other hand, there may be times when complete honesty is not needed or even appropriate to the situation. Consider the following questions: What should a medical assistant say if a patient asks her for the results of a tissue biopsy? Knowing that such information should only be relayed by the physician, how should the medical assistant respond? What should the medical assistant say when a parent asks about the purpose of her 15-year-old daughters appointment with a gynecologist? Should the medical assistants response be any different if the parent happens to be a very good personal friend?

Autonomy
The principle of autonomy refers to the right of individuals to self-determination. This principle includes the notion of freedom of choice that is so highly valued by all Americans. The right to autonomy allows people to make choices about lifestyle, work, education, and many other issues, such as religion, political afliation, marriage, and more. Autonomy also includes the right to choose or reject forms of health care treatment. Respecting a patients right to autonomy means that the physician and other health care workers must enable the patient to make informed choices. For invasive and otherwise risky treatments, health care providers must, therefore, obtain consent (agreement or permission) from patients.

Fidelity
The principle of delity refers to faithfulness, the duty to keep reasonable promises and meet obligations. An example of reasonable expectations includes the patients right to expect health care providers to respect privacy and maintain condentiality. A patient also has the right to expect that health care providers will do what they say they will do (keep promises). For example, if a medical assistant states that a phone call will be made or a message conveyed, then the patient is reasonable in expecting that the medical assistant will carry out these tasks. However, at times patients may have unreasonable expectations. For example, a patient who expects a 100% cure rate with every treatment or medication and becomes angry when results do not meet expectations is not reasonable.

Distributive Justice
The principle of distributive justice comes from the broader principle of justice, which most Americans hold so dear. The principle of justice is founded on the concept of fairness. The principle of distributive justice then concerns itself with the fair allocation, or distribution, of scarce resources. This principle is especially relevant in the realm of health care, where resources are always scarce. For example, there is a chronic need for transplantable organs, which raises the difficult question of how fair decisions might be made about who receives a transplant and who does not. Furthermore, such difficult decisions must be made to maximize good (beneficence) for the greatest number of people, while minimizing harm (nonmaleficence) to all.

Ethical Philosophies
All people operate from the foundation of one or a combination of ethical philosophies, whether or not they are aware of it. Understanding ethical philosophies and identifying which one feels most true helps individuals understand why they view issues as they do and why they may seem unable to

Paternalism
Paternalism may arise in situations where the ethical principles of autonomy and benecence are in conict with one another. In this setting, a dominant paternal role is taken by a health care provider, judge, or other person or entity who

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understand others who have opposing viewpoints. Understanding ethical philosophies also helps a person understand why she analyzes ethical dilemmas as she does. Two of the most common types of ethical philosophies are deontological and teleological.

the legal system to rob the woman of her autonomy, even temporarily, may be viewed by some as a greater harm to her and to society as well, for in this country the right to self-determination (autonomy) is prized above nearly everything else.

Deontological Philosophies
Deontological philosophies operate from the belief that all human beings are of equal worth. This type of philosophy focuses on individual behaviors, rights, and duties. According to deontological philosophies, ethical principles are absolute and exceptions are rarely, if ever, justied. Thus, some actions are considered intrinsically immoral or wrong, regardless of any good or useful consequences that might result from them. For example, a person who believes it is wrong to kill and views that doctrine in a deontological way will not tolerate exceptions to that rule. So, for example, if a person adheres to this doctrine, he may be opposed to capital punishment, military action, and abortion because each of these can be considered a mode of killing. A person with such a deontological view believes that violating the doctrine in any way will cause greater harm to humanity than any immediate harm that may be caused by adhering to it. On the other hand, some persons may use their deontological perspective to override their usual beliefs about appropriate behavior. For example, they may feel a great obligation to serve their country by joining the military, regardless of their feelings about killing others, or may feel compelled to commit a crime, such as bombing an abortion clinic.

Philosophical Divide
No one ethical philosophy is right or wrong. Each person operates from a philosophical foundation consistent with her own religious beliefs, personal values, and life experiences. Individual actions may be supported or rejected by others based on their different philosophical foundation. If two persons are operating from different ethical philosophies, they may never agree on issues as controversial as abortion or capital punishment and will probably never understand one anothers viewpoints. Sadly, without such understanding social debate commonly deteriorates into name-calling and other unproductive argumentation. Learning about ethical philosophies such as utilitarianism and deontology promotes understanding of why people tend to disagree so heatedly about some issues and may further explain why some social debates never see resolution. Regardless of the ethical philosophy used and the specic decisions made, some situations have the potential for profound, long-term consequences.

Anatomy of an Ethical Dilemma

In many cases, what rst seems to be an ethical dilemma is really just a situation in which miscommunication has occurred or inadequate information is available. Therefore, the rst steps in addressing a potential ethical dilemma are to gather data and seek clarication of all relevant issues. Interested parties must put emotion aside long enough to really communicate and gather the data. When they do so, they are generally able to agree about a course of action. However, if parties are in perpetual disagreement, a true ethical dilemma may exist. How can anyone know for sure? The dening criteria of an ethical dilemma include: 1. A decision must be made. 2. The outcome will have profound consequences. 3. There is disagreement among involved parties about the right course of action.

Teleological Philosophies
Teleological philosophies focus more on the consequences of actions, rather than actions themselves. Utilitarianism is one of the most common teleological philosophies. The name of this philosophy is taken from the idea of utility or usefulness. Developed by two English philosophers, Jeremy Bentham and John Stuart Mill, this philosophy interprets the rightness or wrongness of actions according to their consequences. Similar to deontology, utilitarianism also values duty and obligation and regards all human beings of equal value. However, utilitarianism rarely views particular issues or behaviors as strictly right or wrong; rather, it allows for ambiguity, or a state of uncertainty or vagueness. This emphasis on the shades of gray in a particular issue steers a person to consider the consequences or end result of an action as an integral component in determining its ethical rightness. Examining the end result, then, demands that the needs of many people supersede the needs of a few, and values highly the greater good for humankind as a whole. For example, a person who adheres to utilitarianism may believe that a pregnant womans right to autonomy supersedes whatever rights her unborn fetus may have. For

Ethical Decision Making

In the case of a true ethical dilemma, decision making may be extremely difcult. So how is a reasonable decision nally achieved? Unfortunately, in most cases, a person responds based on emotion and personal beliefs, rather than careful reection. Sometimes a persons response is based on a

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previous experience that has little bearing on the current situation. Making such judgments is known as bias. Sadly, this type of response commonly leads to conict. On the other hand, thoughtful decision making based on a solid understanding of ethical principles and careful reasoning, called the ethical reasoning process, will generally lead to consensus among key parties and result in sound decisions. A person must learn this type of decision making; it does not come naturally to most people. When people follow this process, they are able to think their way through a situation systematically, considering all relevant issues and arriving at a thoughtful conclusion. Use of the ethical reasoning process does not guarantee an easy resolution to any problem. However, careful, thoughtful reasoning supports decision makers in making the best decision possible under difcult circumstances. (See Ethical reasoning process.)

community members. Such education can aid staff members in putting aside personal bias in order to support clients and families most effectively as they navigate difficult situations. An ethics committee serves a consultative role as well. For example, disagreement between family members and health care providers on decisions regarding patient care is common. A member of an ethics committee may act as a guide for interested parties and help them through the decision-making process. Alternatively, the entire committee may meet to conduct a more formal analysis of a case. Recommendations from the committee are not legally binding but can be helpful to staff who are in conflict and to family members who are paralyzed by confusion, grief, or guilt.

Ethical reasoning process

Ethics and the Medical Professional

A solid understanding of health care ethics can help a medical assistant in several ways. It can help her identify and clarify her own personal values, behave in a manner consistent with the values of her profession, and respond to situations in the medical office in a thoughtful, consistent manner.

Ethics Committee
An ethics committee serves several functions within a health care organization and the larger community. Such a committee usually helps formulate institutional policies and provides education for health care staff and, possibly,

Ethical reasoning process

There are many systems that employ an ethical reasoning process to analyze ethical dilemmas. Here are the most common features included in most of them: Identify and clarify the problem(s). Putting the problem(s) in writing is commonly helpful. Gather all relevant data. Avoiding tunnel vision in gathering data will enable the inclusion of data that may initially seem unimportant but may actually be relevant. Identify issues in conict. Beginning with the examination of differing opinions and views may help as well as identifying relevant ethical principles and personal bias. Brainstorm. Allow a free ow of ideas without making judgments about whether ideas are valuable. Identify the most promising choices. Narrow down the options from brainstorming to the most reasonable courses of action and examine the potential consequences of each. Negotiate or recommend a nal course of action. Determine a course that maximizes benet and minimizes harm. Evaluate. Consider the value of the nal outcome as well as the effectiveness of the overall problemsolving process.

Code of Ethics
All health care providers, including medical assistants, must demonstrate behavior that is legal and ethical. The medical assistant should have an understanding of ethical principles and be familiar with codes of ethics that pertain to her profession. The AAMA has adopted a code of ethics that embodies the core values agreed upon by the members of the profession and sets the standards for personal and professional conduct. Not surprisingly, the AAMA Code of Ethics and the related Medical Assistants Creed share themes that are consistent with the American Medical Association code of ethics. (See AAMA Code of Ethics and Medical Assistants Creed.)

Ethical Behavior in the Medical Ofce

Medical assistants are obligated to behave professionally and ethically in the medical office. They must act and respond to all situations in a manner consistent with their own professional code of ethics and with the expectations of their employer. A medical assistant will fulfill this obligation easily if she takes the time to clarify her own values and seeks understanding regarding health care ethics. (See Ethical conflicts.) Issues of importance in the clinical setting are the same as those touched on in the AAMA Code of Ethics, including trust and loyalty, confidentiality, respect and dignity, and commitment to professional development.

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AAMA Code of Ethics and Medical Assistants Creed

The American Association of Medical Assistants (AAMA) Code of Ethics and Medical Assistants Creed* touch on themes of service, trust, loyalty, condentiality, respect for others, desire to benefit others, and commitment to professional development. D. Seek to continually improve the knowledge and skills of medical assistants for the benet of patients and professional colleagues; participate in service activities aimed toward improving the health and well-being of the community.

AAMA Code of Ethics

The Code of Ethics of AAMA shall set forth principles of ethical and moral conduct as they relate to the medical profession and the particular practice of medical assisting. Members of AAMA dedicated to the conscientious pursuit of their profession, and thus desiring to merit the high regard of the entire medical profession and the respect of the general public which they do serve, do pledge themselves to strive always to: A. Render service with full respect for the dignity of humanity. B. Respect condential information obtained through employment unless legally authorized or required by responsible performance of duty to divulge such information. C. Uphold the honor and high principles of the profession and accept its disciplines.

Medical Assistants Creed

The AAMA Medical Assistants Creed reads: I believe in the principles and purposes of the profession of medical assisting. I endeavor to be more effective. I aspire to render greater service. I protect the condence entrusted to me. I am dedicated to the care and well-being of all people. I am loyal to my employer. I am true to the ethics of my profession. I am strengthened by compassion, courage, and faith.
*Copyright by the American Association of Medical Assistants, Inc. Used with permission.

Ethical conicts
Clinical or administrative medical assistants are obligated to provide education and information to patients as directed by their employer on a wide range of subjects. If a medical assistant has religious, moral, or ethical beliefs that prohibit her from providing information about contraception, pregnancy termination, blood transfusion, or other subjects, she should inform her potential employer during the job interview process. Failing to do so is a form of dishonesty and may eventually prove a hardship to the medical assistants coworkers, who may need to cover for her.

developed as a medical assistant demonstrates that she can be trusted with sensitive information and increasing responsibility.

Condentiality
The importance of condentiality in health care is a common theme, because a medical assistant has no more important duty than to protect her patients privacy, keeping all information condential. When tempted to share personal health care information about a patient with another party, a medical assistant must always ask herself these questions rst:

Trust and Loyalty

A person rarely grants another trust automatically. Usually, a person earns the trust of another through behaving in a trustworthy manner, such as by demonstrating loyalty and commitment to high-quality work. A medical assistant should seek to earn the trust of her employer and the physicians and others with whom she works as well as her patients. A medical assistant who is dependable in attendance, punctuality, and work effort as well as respectful in her behavior toward others will quickly earn the trust of most people. Further trust is

Is this party a health care professional directly involved in this patients care? Has legal documentation been provided that grants this party legal access to this information? How would the patient feel about me sharing this information with this party? Will my sharing of this information benet or harm this patient? If I were in this patients shoes, how would I feel about my personal health information being shared in this way and with this party?

Respect and Dignity

Few persons would argue against being treated with respect and dignity, and most would agree that treating others with

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respect and dignity is desirable. Why, then, does disrespectful behavior seem to be so prevalent? Because humans are emotional beings, they commonly act and react based on how they are feeling at the moment without carefully considering the potential ramications of their actions. As a result, their words may be poorly chosen, their behaviors may be interpreted by others as offensive, and the emotions they are feeling may cause them to communicate in an overly aggressive manner. A medical assistant may feel that her patients, coworkers, or even the physicians and supervisors, on occasion, treat her disrespectfully. She may even be tempted to respond in kind. However, the truly professional medical assistant does not let such events inuence her behavior. A medical assistant is never justied in treating a patient or member of the health care team in a disrespectful manner, regardless of how that person behaves. Even so, if the medical assistant really believes her coworkers behavior was out of line, she should nd an appropriate time and place to discuss the issue privately with her coworker. She can let her coworker know that she found that persons words or behavior to be unprofessional and unacceptable. She should then suggest an alternative way in which the person might convey the message in the future. The medical assistant must behave tactfully and professionally throughout the conversation to set an example of professionalism and decrease the risk of causing the person to react defensively.

Commitment to Professional Development

A hallmark of a true professional is the commitment to lifelong learning. Nowhere is this commitment more important than in the health care eld, where the knowledge base changes rapidly, seemingly on a daily basis. A medical assistant must make a commitment to continue her education in some fashion for the duration of her career. Opportunities for continued education are numerous. For example, a medical assistant committed to professional development can attend in-house educational offerings at work; take formal college classes; attend regional, state, or national medical assistant conferences; read medical assistant and other health care journals; and study topics of interest on her own.

Chapter Summary
Morals and ethics are based on values regarding human conduct. Morals are deeply held personal beliefs about what constitutes right or wrong behavior. Ethics involve thoughtful analysis and evaluate human behavior in light of specic ethical principles and look at the impact of such behavior on individuals and society as a whole.

Although a behavior may be deemed unethical by some individuals, it is not necessarily illegal. Conversely, a behavior that has been designated as illegal is not necessarily considered unethical by all. Bioethics is a specialized branch of ethics that concerns itself with human behavior within the context of modern medicine. The number and variety of situations that confront health care providers are limitless. Therefore, health care providers should become educated and be prepared with information and tools that can help them navigate these difcult waters and provide better guidance to their patients. Ethical principles are rules about how people ought to behave. Common ethical principles include nonmalecence, benecence, autonomy, distributive justice, paternalism, veracity, and delity. Understanding ethical philosophies and identifying which one feels most true to them helps individuals understand why they view issues as they do and why they may seem unable to understand others who have opposing viewpoints. The two key ethical philosophies include deontology and utilitarianism. Knowledge of these philosophies helps promote understanding about why people tend to disagree so heatedly about some issues and may further explain why some social debates seem never to be resolved. The dening criteria of an ethical dilemma include the need for a decision, an outcome with profound consequence, and disagreement among interested parties. In the case of a true ethical dilemma, decision making may be extremely difcult. However, thoughtful decision making based on a solid understanding of ethical principles and careful reasoning will generally lead to consensus among key parties and result in sound decisions. The ethical reasoning process includes problem clarication, data gathering, identication of relevant ethical principles, brainstorming, identication of options, negotiation of a course of action, and evaluation. An ethics committee serves as a resource within the health care organization and the larger community. It helps formulate institutional policies, provides education, and may serve as a consultant when a difcult decision must be made. A solid understanding of health care ethics can help a medical assistant identify and clarify her own personal values, behave in a manner consistent with the values of her profession, and respond to situations in the medical ofce in a thoughtful, consistent manner. All health care providers, including medical assistants, must demonstrate behavior that is legal and ethical. The medical assistant should have an understanding of ethical principles and be familiar with codes of ethics that pertain to her profession.

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The AAMA Code of Ethics and Medical Assistants Creed include themes of service, trust, loyalty, condentiality, respect for others, desire to benet others, and commitment to professional development. Medical assistants must demonstrate the qualities of trust, loyalty, condentiality, respect and dignity, and commitment to professional development.

Team Work Exercises

1. Divide into teams of three to ve students. Read the following scenario with the members of your team. Then discuss the ethical issues involved, according to the guidelines that follow the scenario. Madge is an 82-year-old African American female who lies in a coma on life support. She was admitted to the hospital two weeks ago after falling, hitting her head, and suffering a severe intracranial bleed. Initially, her family urged health care providers to do everything possible to keep Madge alive. They stressed that she had recently been living independently in her own home and was an avid gardener. They were hopeful that she could return to a similar quality of life. After many tests and procedures and minimal improvement in Madges condition, the family now faces a heart-wrenching decision. Should they continue to push for aggressive care, knowing that the prognosis is poor yet hoping for the chance of a miracle? Or should they make the difcult decision to withdraw all aggressive forms of care, provide comfort measures only, and allow nature to take its course? a. Discuss this scenario and reach a consensus among team members about what recommendation you think should be made in this case. b. Now picture in place of Madge your own mother or child. Does the choice still seem as simple? Discuss your thoughts and feelings with your teammates. c. Now consider the same scenario with the following changes: Madge is now a 4-year-old, blond-haired, blue-eyed little girl. Madge is now a 32-year-old Asian American widowed nurse with four young children at home. Madge is now a 57-year-old Native American woman who is an alcoholic, has no family, and is on public assistance. Madge is now Miguel, a 33-year-old, unmarried Mexican American man who does seasonal work. Madge is now Michael, a 45-year-old white male who is a stockbroker with good insurance and a wife and two teenagers at home. Madge is now Marvin, a 33-year-old artist who has been diagnosed with HIV and is openly gay.

d. The purpose of changing the patients in this scenario is to help you notice any potential biases you may have. While it may be easy to agree in theory that all humans are of equal worth and deserve equal treatment, we may, in fact, react differently based on personal values, beliefs, and biases when faced with each situation. We commonly dont even realize our biases until confronted with such a scenario. Does your opinion about the right decision change in any of these scenarios? Discuss your thoughts with your teammates. 2. Divide into teams of three to ve students. Over the course of the next week, watch a medical movie or television show, making note of any ethical dilemmas that are presented. Then get together with your team to describe your ndings. Describe the situation presented in the movie or show and identify the ethical principles you believe were upheld or violated and why.

Case Studies
1. A coworker has come to you for advice. She feels that some of the comments that one of the physicians has made to her are demeaning and rude. She didnt say anything at the time because there were other people around, including a patient. However, this has been bothering her and she cannot seem to let it go. What advice do you have to offer her? 2. A coworker comments one day that she just noticed in her patients chart a comment about a history of four pregnancy terminations. She is angry that this patient obviously has such low respect for human life. She is further frustrated that hardworking people like us have to pay for these welfare patients to clean up their mistakes. You are concerned that you coworker is making such comments about a patient and wonder if she is jumping to some possibly inaccurate conclusions. What is most concerning about this persons comments? What assumptions does she seem to be making? How will you respond to her?

Resources
The American Journal of Bioethics: www.bioethics.net Bioethics news and issues: www.bioethics.com Ethical guidelines for conducting research on human subjects at the National Institutes of Health, Ofce of Human Subjects Research: www.nihtraining.com/ohsrsite/ index.html

CHAPTER

Patient Education
Learning Objectives
Upon completion of this chapter, the student will be able to: dene key terms describe the medical assistants role in patient education compare and contrast the three domains of learning list teaching methods that appeal to each of the learning domains describe a plan for assessing the learning needs of a patient differentiate between short- and long-term learning objectives describe the role of self-efcacy in motivating behavior changes create a plan to increase a patients feelings of self-efcacy describe the stages of grief and loss according to theorist Elizabeth Kubler-Ross list at least ten potential barriers to effective patient education and a possible solution to each discuss age-related teaching considerations and list appropriate teaching methods for patients of various ages describe three different teaching strategies that might be used for patient education list at least ve different teaching tools along with considerations for each describe a plan for evaluating medical literature to determine its appropriateness for patient education discuss two methods of evaluating patient learning create a tool to document patient education discuss the patient medical record as a legal document. Motivation to Learn
Locus of Control Self-Efcacy

9
Barriers to Effective Patient Education
Emotional Response to Illness and Disability Physical and Personal Barriers to Learning

CAAHEP Competencies
General Competencies Professional Communications
Recognize and respond to verbal communications Recognize and respond to nonverbal communications

Age-Related Teaching Considerations Teaching Strategies

Verbal Lecture Conversational Group

Patient Instruction
Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention

ABHES Competencies
Communication
Adaptation for individualized needs

Legal Concepts
Use appropriate guidelines when releasing records or information Follow established policy in initiating or terminating medical treatment

Patient Education Literature Evaluation of Learning Legal Implications of Patient Education Chapter Summary Team Work Exercises Case Studies Resources

Instruction
Instruct patients with special needs Teach patients methods of health promotion and disease prevention

Chapter Outline
Medical Assistants Role in Patient Education Learning Styles Learning Domains
Cognitive Domain Affective Domain Psychomotor Domain

Assessing Learning Needs Identifying Learning Objectives Organizing the Teaching Session

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Key Terms
acceptance

Stage of grief and loss when a person acknowledges the reality and permanence of life changes
affective domain

Medical Assistants Role in Patient Education

As important players on the health care team, medical assistants should collaborate with physicians, nurses, and others in the provision of patient education. Because time and resources are usually limited, the medical assistant may nd it a challenge to provide good quality teaching. To make the most of the time available, the medical assistant should view every patient contact as an opportunity for some type of teaching. Receptionists might provide literature on appropriate topics for patients to read while they are waiting. Nurses and medical assistants can provide teaching and encouragement that reinforce the physicians instructions. Other members of the health care team, such as therapists and dietitians, can provide focused teaching in their areas of expertise that is consistent with identied goals. If everyone makes the most of every available teaching moment, patients will receive comprehensive education in a manner that also conveys the message that the health care team is cohesive and unied in their approach. (See Handy literature.)

Thought processes involving emotions, values, and attitudes

anger

Stage of grief and loss when a person experiences feelings of rage

bargaining

Stage of grief and loss when a person makes irrational attempts to negotiate for unlikely or impossible changes
cognitive domain

Thought processes that involve the intellect and include thinking on several levels
compliance

Patients adherence to the plan of care as instructed by the health care provider
denial

Stage of grief and loss when a person refuses to accept the reality of a situation
empathy

Understanding of the emotions and thoughts of another

jargon

Technical, specialized language used by professionals that is generally confusing to other people
learning domains

Learning Styles
Patient education is most effective when teaching methods are adapted to a patients individual learning style. (See Chapter 1, Succeeding as a Student, on page 3 for more information on learning styles.) When possible, a medical assistant should ask the patient how he prefers to learn. Some patients will not know and children will probably not even know what the term learning style means. An adult may or may not know his learning style, but the medical assistant can ask about prior experiences with learning and the patients preferred studying

Modes of learning conducted by different parts of the brain

learning objectives

Goals or outcomes to be achieved in the learning process

locus of control

Persons belief about the degree of control that he has over events in his life
psychomotor domain

Processes that involve physical activity and the senses (sight, sound, touch, smell, and taste)
resolution

Stage of grief and loss when a person expresses emotions more freely and begins to identify changes in life caused by the loss
self-efcacy

Front ofceBack ofce connection

Handy Literature
Administrative and clinical medical assistants should make sure that an assortment of patient teaching literature is available in any areas where patients will be waiting. The administrative medical assistant can make sure that literature racks in the reception area remain fully stocked with appropriate literature. The clinical medical assistant should make sure that appropriate educational literature is available in examination and treatment rooms. Doing so provides patients with multiple opportunities to access this information and read through it while they are waiting to be seen.

Persons perception of how capable and condent he feels about being able to make a specied change or accomplish a goal

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method to determine his style. When the medical assistant is unsure of a patients learning style, she should use methods that address multiple styles. She should also ask the patient about learning or sensory disabilities so she can modify teaching tools and methods appropriately.

role playing, and independent projects. These activities utilize all levels of cognitive function in a way that permits a patient to raise and address her own concerns, learn from others, and participate in active problem solving.

Affective Domain

Learning Domains
A medical assistant will be most effective in helping patients learn if she has a general understanding of the learning process. An important rst step is to learn about the learning domains. Learning domains are the different parts of the brain that are involved in the learning process. Understanding them can help the medical assistant modify her instruction to appeal to these domains. There are three learning domains:

cognitive affective psychomotor. (See Figure 9-1.)

The affective domain involves emotions, values, and attitudes. This domain enables a person to listen and pay attention to what others have to say and to become actively engaged in conversation by responding verbally and behaviorally. The affective domain enables a person to choose behaviors based on her value system. Teaching methods that utilize the affective domain include discussion and role playing with a focus on feelings, beliefs, and values. Private oneon-one discussion is appropriate for personal issues. Group discussion allows group members to exchange ideas, learn from the experiences of others, and feel supported by them.

Psychomotor Domain
The psychomotor domain enables a person to learn skills that require a combination of mental and physical activity. A person uses the sense of sight, sound, touch, smell, and even taste as she learns by manipulating physical objects. Performance of new skills under the guidance of instructors increases the persons condence in her abilities. Further practice allows the beginner to move from minimal competence to a higher degree of prociency. As the person becomes more skilled and condent, she is able to adapt when unexpected problems occur. The most effective teaching strategies for the psychomotor domain include demonstration, practice, and return demonstration. Most people learn best by rst watching the teacher demonstrate the behavior or skill. Doing so allows them to see the steps from start to nish. They can then perform skills with instructor guidance to obtain coaching and feedback in a safe, structured setting. After sufcient practice, a person can then perform a demonstration of the skills she has mastered. Demonstration is the most accurate and effective means of evaluating that learning has occurred. (See Skill demonstration tips, page 98.)

Cognitive Domain
The cognitive domain involves the intellect and includes thinking on several levels. The lowest level involves simple memorization and data recall. Other levels involve understanding, meaningful application to new situations, sorting trivial details from signicant ones, and determining the overall value of an idea or concept. Teaching strategies that utilize the cognitive domain include lecture, active discussion,

Cognitive Intellect

Psychomotor Combination of mental and physical activity Affective Emotions, values, and attitudes

Assessing Learning Needs

One of the most common mistakes that health care providers make when delivering patient education is failing to assess the patients learning needs. In an effort to quickly check patient education off the to-do list, many health care providers quickly recite a brief set of verbal instructions and believe that they have done a good job of teaching. In fact, this type of teaching commonly leaves patients thinking What did she just say? or I already knew all of that. In

FIG 9-1 Three learning domains.

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Patient Education

Skill Demonstration Tips

When the medical assistant is demonstrating a new skill to a patient, she should follow these steps: Assemble the supplies and equipment. Ensure adequate lighting and privacy. Review the purpose and rationale with the patient. Perform the steps of the skill in the same sequence that the patient must perform them. Explain the key rationale for each step without overanalyzing. Adapt the speed, timing, and techniques to the patients abilities. Allow time for questions. Guide the patient as she performs and practices the skill.

how to use a glucometer to check his blood glucose levels. Long-term learning objectives focus on knowledge and skills that a patient may need to adapt to permanent health changes and achieve optimal health and well-being over the long term. An example of long-term learning objectives would be teaching the diabetic patient how to perform daily examination of his feet and how to care for his skin in order to prevent complications of wound infection that could lead to amputation. Learning objectives should be clear and measurable so that the medical assistant and the patient can identify when they have been accomplished. Furthermore, learning objectives must be realistic so that the medical assistant and patient can feel condent about the chances of success. Finally, learning objectives should be stated in terms of what the patient will accomplish, not what the medical assistant will do.

Organizing the Teaching Session

Experienced teachers know that effective learning rarely happens by accident. Careful thought and preparation are necessary. The medical assistant must be clear about the purpose and goal of the teaching session. The session is where the time invested in assessing learning needs and determining learning objectives pays off. When the medical assistant determines the content of the session, she should create an outline to organize the session into a logical sequence, progressing from simple to complex subjects. She can reinforce learning by repeating key points throughout the teaching session and then summarizing all key points again at the end. To hold the patients attention, the medical assistant should infuse energy into the session by varying vocal tone and using culturally appropriate eye contact and gestures. She should engage the patient in the conversation as fully as possible. She might accomplish this task by inviting the patient to ask questions, having him repeat key steps or key points, and having him employ as many senses as possible. She should address all learning domains.

either case, the teaching session was probably much less effective than the teacher thought. To be an effective teacher, a health care provider should rst take time to talk with the patient, ask questions, and listen to determine the patients current level of knowledge and understanding about the issue at hand. Doing so provides opportunities to correct misinformation or misunderstandings and lets the provider know where to begin in the process of providing new information. It also allows the provider to begin identifying the patients concerns and potential barriers to learning or compliance. Compliance is the patients adherence to the plan of care as instructed by the health care provider and is a key goal in good patient education. Other goals throughout the assessment and teaching process include identifying the patients resources. Examples of resources include nances, insurance, living situation, and help from family or friends. Appropriate referrals may be necessary if signicant lack of resources is identied.

Identifying Learning Objectives

Learning objectives identify goals or outcomes to be achieved and help guide the teaching session. The medical assistant should invite the patient to participate in and contribute to goal setting. Doing so will help the medical assistant understand the issues of greatest concern to the patient and help the patient feel included. Short-term learning objectives address immediate survival needsfor example, ensuring that a newly diagnosed diabetic patient knows

Motivation to Learn
While knowledge is helpful in motivating people to make health changes, knowledge alone is not typically enough. If it were, then nearly everyone would achieve and maintain an optimal weight, participate in regular exercise, eat a healthy diet, never use tobacco or drink to excess, and manage stress effectively. However, many people simply are not motivated enough to make lifestyle changes based on information alone, and no amount of lecturing will change the situation.

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Such people are commonly labeled noncompliant. However, health care providers who nd themselves feeling frustrated or angry with such patients should remember that they themselves are rarely 100% compliant in their own recommended health care activities. In reality, virtually everyone could be labeled as noncompliant at one time or another. Therefore, health care providers should remember that such labeling may be unfair to a patient who desires to make changes but who may feel powerless to do so. The health care providers job is to help the patient identify barriers that hinder success and support him in getting the results that he, the patient, wants. In general, a patient can identify barriers, because most people have tried and failed to make health changes in the past. Instead of arguing with the patient, the provider might create a list of obstacles as a starting point. When the patient identifies obstacles, the discussion can center around identifying potential solutions. Some obstacles, such as lack of money or inability to drive, may be very real. However, they can also usually be resolved through identification of community resources or encouraging the patient to utilize his own personal support system. The most effective approach involves gentle prompting by the provider to enable the patient to identify solutions. In many cases, the true obstacles to patient success in making lasting lifestyle changes is the locus of control and a struggle with feelings of low self-efficacy.

likely to adopt lifestyle changes or alter their self-care practices. Those with an external locus also tend to feel more helpless and victimized by God, fate, luck, or even their medication or their health care provider. Health care providers who attempt to inuence these lifelong beliefs and patterns will nd themselves up against a challenge. The development of locus of control happens over a lifetime but is most inuenced during the early formative years. Such inuences include family, culture, religion, and life experiences. Efforts to inuence patients are best aimed at education combined with activities that help foster the patients feelings of self efcacy.

Self-Efcacy
An important factor that determines how likely patients are to successfully institute behavior changes is their feeling of self-efcacy. Self-efcacy is a patients perception of his capability to make changes and his condence in his ability to do so. A number of factors impact a patients feelings of self-efcacy, such as self-esteem and past experiences with success and failure. Helping increase patients self-efcacy is the key to helping them make changes. A medical assistant can do a number of things to help boost a patients feelings of self-efcacy:

Locus of Control
Locus of control describes a persons beliefs about the degree of control (or lack of control) that he has over events in his life. A person who believes that everything that happens to him is up to fate, chance, luck, God, or another external source is said to have an external locus of control. On the other hand, a person who believes that he is in control of the events in his life and that his destiny is largely up to him is said to have an internal locus of control. Of course, many people believe in a mix of the two. Even so, studies have shown that, in general, people whose locus of control is more internal than external are more goal-oriented and get higher-paying jobs. They are more likely to devote the study and work necessary to get ahead and earn promotions because they believe their efforts will pay off. People who believe their success is up to fate or some other external power are less likely to see the value of such efforts. Understanding the concept of locus of control helps health care providers better understand patients. Patients with an internal locus of control are more likely to take charge of their health and demonstrate willingness to invest time and effort into self-care activities because they believe they can alter their own destiny. On the other hand, those with an external locus tend to be more fatalistic and are less

Identify and address the patients beliefs and concerns regarding health issues and needed changes. Determine the patients denitions of health, exercise, healthy eating, or whatever the key issues are. Prompt the patient to identify small steps that he feels sure he can successfully make now. Success with small steps leads to increased feelings of confidence and increased self-efficacy. Future steps will feel easier. Encourage realistic short-term and long-term goals. Losing 50 pounds in 1 month is not realistic or healthy. On the other hand, a short-term goal of losing 5 pounds each month for a total of 50 pounds over the next 10 to 12 months is realistic and healthy. Focus on permanent changes toward a healthier life, rather than quick xes that have little chance of lasting. Help the patient understand the whys. Most people become more enthusiastic about making changes once they truly understand how and why they are beneficial. Ask the patient to identify his own reasons for making changes. For example, the medical assistant might ask a patient, What do you think the value is in taking your blood pressure medicine every day? Notice that this question is not a closed question that permits a yes or no response. The patient will feel obligated to think of a response. If he happens to say, I dont know, then a good follow-up questions is, If you did know an

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answer, what would it be? This sounds like a silly question but it is amazingly effective. When a patient identifies the value himself, he is more likely to buy in to the plan. Design a plan that is exible yet specic. For example, the patient with a hectic schedule may need to vary the days and times that she exercises. A specic goal may be to exercise a minimum of three times each week by briskly walking for 20 minutes. Put the plan into writing and make sure that the patient and health care provider keep a copy. Be sure the patient has made a verbal commitment to the plan. Suggest adding new healthy behaviors to the patients life before eliminating unhealthy ones. For example, many people fail at weight loss because they eliminate food, thus feeling deprived, without bothering to increase physical activity. Success is more likely if exercise is added first with a gradual change in eating patterns to follow. As people begin to experience positive results from exercise, many find they feel more motivated to eat a healthy diet. Work new behaviors into the existing routine. Most people do not want to make drastic lifestyle changes. Review the patients normal daily routine and help her identify where the new behavior will t. Perhaps she watches a favorite television show each evening and could watch it while walking on a treadmill rather than sitting in her recliner. Express concern and caring. A persuasive statement from a professional medical assistant can be influential. For example, the medical assistant might say, I am concerned about you. Your blood pressure and cholesterol levels have been pretty high. I would very much like to see you bring them both down so that you can be healthier, feel better, and live to see your grandchildren grow up. Employ the shotgun approach to teaching by using a variety of strategies and tools to teach and encourage. Consult with physicians about appropriate referrals for professional consultation. Examples include registered dietitians, diabetic educators, physical therapists, and psychologists. (See Total team approach.) Refer the patient to support groups when appropriate where he can meet other people who are dealing with similar issues. Monitor the patients progress through future ofce visits or even by calling him at home. A patient is much more likely to stick with behavior changes when he knows that the health care provider is interested in him enough to follow up. (See Key interventions for self-efcacy.) Small successes build self-efcacy, which leads to permanent changes. (See Figure 9-2.)

Self-efficacy

New habits Improved health Health care provider

Empowerment

educate

encourage

coach

Proficiency

Small steps

Patient

FIG 9-2 Path to self-efcacy.

Front ofceBack ofce connection

Total Team Approach

For the most effective patient education, all members of the ofce staff should get involved using the total team approach. Although everyone in the ofce is busy and no one has a lot of time, everyone can do something to create a positive impact on patient education. The staff should consider creating a committee with representatives from all areas of expertise (physicians, nurses, administrative and clinical medical assistants, and so on) to brainstorm about what each member of the team can do to contribute to effective patient education. They can then create a plan agreeable to all so that everyone knows his or her role.

Patient Education

Key Interventions for Self-Efcacy

Here are the most essential, or key, interventions for increasing a patients feelings of self-efcacy: Invite her to identify her own learning goals. Start with small realistic steps that she believes are achievable. Link new behaviors to old. Ask her for a commitment. Connect her to a support person or support group. Identify a plan for follow-up and let her know that the provider will be monitoring her progress. Express condence in her ability to succeed.

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Barriers to Effective Patient Education

Most patients want to make positive changes in their lives, including changes in their health practices. However, they commonly encounter barriers that impede their ability to do so. To help patients make needed changes, medical assistants must do more than simply dispense information. They must help patients identify barriers and move beyond them. Examples of common barriers include emotions, such as denial and anger; sensory decits, such as hearing loss; or physical issues, such as pain or decreased mobility.

Emotional Response to Illness and Disability

Many people respond to permanent health loss in a manner similar to the way they respond to other signicant losses in their lives. Typical stages of grief and loss as identied by researcher Elizabeth Kubler-Ross include denial, anger, bargaining, resolution, and acceptance. Such a grief reaction is normal and, to a certain extent, even healthy. However, effective patient education may be hindered while patients are in the early stages of grief and may not be possible for patients who get permanently stuck in the grief process. The medical assistant should evaluate the patient for signs of grieving and note which stage the patient is in. The medical assistant must understand that the stages of grief are uid, meaning that a patient may uctuate between stages and even exhibit signs of multiple stages at once. However, over time, the patient should progress to the point of acceptance. The medical assistant can help the patient by noting where the patient is in this process and modifying educational methods accordingly. A patient who is experiencing the initial stage of denial refuses to accept the reality of the changes in his life, health, or situation. He may appear withdrawn and refuse to discuss the health issue. He tends to misunderstand and distort information or ignore it completely. The medical assistant should respond with empathy, which means that she is able to understand and identify with the patients feelings. She should also be available to answer questions. Her attempts to teach the patient should include simple, careful explanations that focus on the present. The medical assistants explanations to family or friends should be aimed at helping them understand the impact of the grieving process on their loved one. As a patient begins to progress though the stages of grief, he may feel and express anger, which is rage that masks the pain and grief hiding behind it. Initially, it manifests in the form of emotional outbursts and statements of blame directed at others. The medical assistant must not take such expressions

personally or argue with the patient. Rather, she should respond with empathetic listening. She should also offer reassurance to family members and signicant others with an explanation that such a response is normal. Bargaining is an irrational attempt to negotiate for unlikely or impossible changes. As the patient displays signs of the bargaining stage, he may offer to make behavior changes in exchange for a promise of better health. The medical assistant must take care not to offer false reassurance in these situations. She should emphasize the reality of the present situation and encourage setting realistic short-term goals. For example, a patient with metastatic lung cancer most likely has a poor long-term prognosis. Therefore, the medical assistant should not promise a remission of the cancer or make guesses at life expectancy. However, after consulting with the physician and nursing staff, it may be realistic for the medical assistant to encourage the patient to plan to attend an upcoming family reunion or grandchilds birthday party. Many patients will enter a period of depression as they face the inevitability of their health loss. During this time, the patient may exhibit typical depressive symptoms, such as fatigue, apathy, loss of interest in usual activities, and insomnia. He may not feel the interest or energy required to learn or make behavior changes. The medical assistant should provide empathetic support and acknowledge the patients feelings as normal, while gently reminding him that he may not feel this way indenitely. In cases of severe depression, the physician may wish to prescribe antidepressant medications or refer the patient for psychological counseling. As the patient enters the resolution phase of the grieving process, he expresses emotions more freely and begins to identify the changes caused by the health loss. As this happens, the medical assistant may acknowledge and validate the patients feelings and begin to share information needed for the near future. Acceptance is the stage in which the patient acknowledges the reality and permanence of the changes and begins to actively move forward. More formal teaching sessions may be scheduled as the patient expresses acceptance of the health change and displays more interest in learning. Patients are commonly motivated by a desire for an optimal degree of independence and normalcy in their daily lives. At that point, the medical assistant may focus on information and skills the patient will need in the short- and long-term future. (See Figure 9-3.)

Physical and Personal Barriers to Learning

A number of physical and personal barriers may hinder effective patient education. Some issues of physical discomfort, such as heat, cold, or pain may be modiable. The medical assistant should address those issues before attempting

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Normal

Return

Age-Related Teaching Considerations

Teaching methods and tools should be appropriate for the age of the patient. A childs ability to learn depends on his developmental maturity. A young child needs information presented in a more concrete manner. Therefore, the use of tangible objects that appeal to the senses will be the most effective. As a child gets older, the medical assistant can present information in a more abstract, less tangible manner, based on concepts that involve thoughts, feelings, and creative components, rather than concrete narration or pictures. Most teenagers have an aversion to being lectured to but enjoy working on computers. Therefore, they are the ideal candidates for programmed computer instruction. This form of instruction involves sequential presentation, interaction, feedback, and correction and allows learners to work at their own pace. In addition, teenagers and adults usually enjoy teaching that includes the use of audiovisual technology, such as CDs, television, or videos. These tools are also useful for patients with reading comprehension or illiteracy problems or those with sensory decits. The medical assistant should ask an adult patient to identify his own learning needs based on the issues he wishes to address. The medical assistant should respond to such issues rst. This approach not only helps to resolve concerns that will distract the patient from other learning but also lets the patient know that the medical assistant genuinely cares about his needs and concerns. Depending on a patients learning style, he may nd visual data in the form of diagrams, graphs, pictures, or illustrations to be helpful. The

Denial Shock Withdrawal Confusion Numbness

Anger Blame Emotion Frustration Guilt Bargaining Offers to change Reaching out

Acceptance Notes reality and permanence of changes Begins creating new plans for life Resolution Expresses feelings of loss and identifies changes Depression Fatigue Apathy Insomnia

FIG 9-3 Stages of grief and loss.

patient education. Other issues may be less readily solved; however, the medical assistant can add modications in the teaching plan to address those issues. For example, a patient has limited energy and tires easily. The administrative medical assistant might schedule the patients appointment for early in the day, when the patients energy level is at its highest, to avoid impacting the patients ability to learn. (See Common barriers to learning.)

Common barriers to learning

This table lists common barriers to learning along with potential solutions the medical assistant and other ofce staff may employ to address them.

Barriers
Physical or environmental Room is too hot, cold, or drafty Environmental noise Poor lighting Uncomfortable seating Poorly arranged furnishings Patient limitations Pain Low energy, fatigue Decreased strength

Solutions
Ask the patient about comfort issues and adjust the thermostat if necessary. Open or close windows. Adjust lighting. Take measures to minimize background noise.

Medicate for pain or anxiety per the physicians order or encourage the patient to take her own medications as appropriate.* Adjust seating for the patients comfort. Limit the length of teaching sessions according to the patients tolerance.

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Common barriers to learningcontd

Barriers
Impaired mobility Impaired coordination or agility Impaired memory Dementia Anxiety

Solutions
End the teaching session or allow a rest period when the patient displays signs of fatigue or loss of concentration (poor eye contact or slumped posture). Schedule teaching for a time when the patients energy is greatest (such as early in the day). Schedule several short sessions, rather than one long one. Help the patient problem-solve physical barrier issues (such as stairs). Use an unhurried approach. Provide frequent encouragement and reassurance. Include family or signicant others in the teaching session (if appropriate and the patient agrees). Write lists or instructions for the patient to take with her. Use multiple strategies that appeal to as many senses as possible. Refer the patient, as appropriate, for specialized information or counseling.

Illiteracy (functional illiteracy is dened as reading comprehension below fth-grade level)

Avoid slang or medical language. Use simple language. Provide material written at fourth-grade level or below. Read instructions to the patient.

Sensory decit: Diminished hearing or deafness

Face the patient so he can see lips and facial expressions. Speak at an adequate volume for the patient to hear but do not shout. Speak in a clear, unhurried manner using a low tone of voice. (Elderly patients commonly have difculty hearing high-pitched vocal tones.) Use visual aids, including illustrations and pictures. Employ a sign language interpreter if appropriate.

Sensory decit: Poor vision or blindness

Speak clearly but do not shout. (Poor vision does not equal deafness.) Use large-print materials for the patient with poor vision. Announce your presence when entering the room and introduce yourself. Evaluate the color use on visual teaching aids if the patient is color-blind.

Language and cultural barriers

Avoid stereotyping. Collaborate with health care providers of other cultures and languages to learn from them. Consider communications patterns, time perception, and gender roles. Adapt the teaching approach to the patients religious or cultural beliefs, as appropriate. Employ an interpreter, if appropriate. Use a courteous, formal approach, addressing the patient by his last name. Use culturally appropriate eye contact, touch, and gestures. Use visual aids, including illustrations and pictures. Monitor the patients facial expression and body language for signs of confusion. Use simple language and wording. Demonstrate procedures and have the patient do a return demonstration to ensure learning. Provide written instructions in the patients primary language.

Lack of privacy

Close doors or install insulated screens to minimize noise and ensure privacy. Avoid discussing condential information within the hearing of others.

Lack of time

Focus on the immediate survival needs rst. Use the team approach, including all members of health care team as appropriate. Provide prehospital education prior to hospital admission (for elective procedures). Integrate teaching with medical care.

* Note that some medications may cause sedation or otherwise impair the patients ability to learn and remember new information.

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medical assistant can use such visual aids to help show relationships between numbers and concepts, summarize and clarify key concepts, and help learners grasp information quickly. Throughout the teaching process, the medical assistant should invite the adult patient to collaborate in identifying goals, topics, and strategies. (See Age-appropriate teaching strategies.)

verbal lecture conversational group.

Verbal Lecture
The verbal lecture format is efficient for giving instructions. The medical assistant may use this format when time is limited and the subject matter is simple. For example, a medical assistant tells a patient to take her antibiotic capsules three times each day with a full glass of water until all the capsules are gone. This format does not encourage discussion but does allow patients to ask questions and seek clarification if needed. This format is more effective if the medical assistant also gives the patient

Teaching Strategies
There are three main teaching strategies, or formats, that a medical assistant can employ when providing patient education:

Age-appropriate teaching strategies

This table lists age appropriate teaching strategies and the tools needed to employ them.

Patient Age
Infant

Strategies
Consistency Secure handling Soft, soothing voice Smile Make eye contact

Tools
N/A

Toddler and preschooler

Play allowing the patient to touch equipment, such as a stethoscope, before using it on him Provide a toy stethoscope and let the patient listen to a dolls heart or even yours Role playing

Pictures Books Blocks Dolls Toys Age-appropriate books Pamphlets Videos Toys

School-age child

Simple explanations Question and answer Demonstration

Teen to middle-age adult

Allowing choice Inviting collaboration and expression of feelings Providing information

Age appropriate books Pamphlets Videos Computer-aided instruction

Older adult

Allowing choice Inviting collaboration Teaching when the patient is rested and mentally alert Limiting the length of teaching sessions Focusing on realistic goals of optimal strength and independence Adapting strategies to sensory decits

Books (considering use of large-print materials for those with poor vision) Pamphlets Videos

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instructions or important information in writing. Simple instructions for taking her pill three times a day could be quickly put into writing. In addition, most medical offices keep a variety of pamphlets, brochures, and booklets on hand that cover various topics of concern for their patient population. Giving these to the patient affords her the opportunity to review the information as many times as necessary after she leaves the office.

Group
The group format can be effective for some teaching situations. It allows discussion and brain storming and encourages general interaction. Patients often nd emotional support in such groups when they realize that they are not alone in dealing with their health issue. Effective group process requires a trained leader who is able to facilitate group discussion and guide the group in a positive and productive direction. (See Analogy and role play.)

Conversational
A conversational approach encourages the patient to participate and collaborate. It also fosters an environment in which the patient feels comfortable asking questions and giving feedback. Such an approach is useful for helping the patient understand a new diagnosis and take ownership of a treatment plan that he has helped design. As the patient becomes more knowledgeable about his health care issue, the medical assistant should encourage him to take more responsibility for managing his own self-care. The medical assistant helps the nurses and physicians in monitoring the patients progress and should be available for consultation. Her role is to clarify information for the patient and reinforce positive behaviors.

Patient Education Literature

The medical assistant should evaluate the patient education literature used in the medical ofce for currency, accuracy, clarity, and appropriate reading level. Research indicates that most literature currently used in health care is above the reading level of most patients. It is recommended that all literature be written below the sixth-grade level. Some sources recommend that it be at fourth-grade level or lower. Medical assistants should avoid using medical terms and jargon, or the technical specialized language of medicine, or translate it into common language to avoid confusing patients.

Patient Education

Analogy and Role Play

When providing patient education, the medical assistant will nd the use of analogy and role play valuable. Insulin is like a tiny key that must unlock tissue cells before glucose can enter.

Analogy
An analogy is a comparison between two partially similar things. It can be used to translate a complex idea into a simpler, more easily understood concept that the patient can understand. However, the medical assistant should be familiar with the patients background, experience, and culture to select an appropriate analogy. Examples of analogies that may be useful include the following: The heart is like a pump. An aneurysm is like an inner tube with a weak, bulging spot. Blood owing through veins and arteries is like water owing through pipes. Skin is like a rubber band, it loses elasticity with age and exposure to sunlight. Having an asthma attack feels like trying to breathe through a straw.

Role play
Role play allows the patient to try out actions, words, and responses to see what works best for him. It gives the patient a chance to consider and practice the most effective means of coping with difcult situations and allows the patient and medical assistant to evaluate the session and try out other variations. Examples of role play that might benet the patient are: The medical assistant pretends to be one of a diabetic teenagers friends and teases him about his dietary practices and insulin use. This scenario gives the teen the chance to think about and practice different responses. The medical assistant pretends to be a pushy friend or relative who keeps trying to get the patient to overeat or to drink too much alcohol. The patient tries out different responses.

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Literature should also be available in other languages and have reputable Internet sites listed for patients who wish to do further research on their own.

Evaluation of Learning
Health care providers commonly make assumptions about patient learning without taking the time to determine if patients really understand specic information or if they are capable of performing certain skills. The medical assistant should always conduct some type of evaluation to determine whether the patient has really achieved the desired learning goals. Evaluation also provides useful feedback about the effectiveness of teaching methods. Furthermore, it provides opportunities to reinforce key points and clarify areas of confusion. Including a tool, such as a checklist, in the patients chart allows various members of the health care team to keep track of what subjects have been covered and what they still must address. It also provides a simple way to track evaluation of learning or skills. Return demonstration performed by the patient is the best method of verifying whether the patient is truly able to perform skills, such as administering their own insulin or using a metered dose inhaler, accurately and safely. (See Figure 9-4.)

To evaluate other forms of learning, the medical assistant may ask the patient to describe or summarize key concepts. The medical assistant may also administer more formal tools, such as simple posttests or questionnaires. She can send such tools home with the patient to help him remember how to perform the skill. She can also le such aids in the patients chart to document learning. In addition, she may ask the patient to provide a self-report in the form of a simple journal.

Legal Implications of Patient Education

Patient education is important for a number of reasons. First and foremost, patients are entitled to information about their health and to understand any issues related to their condition. In addition, the medical record also serves as a legal record. Therefore, documentation about patient education must be thorough, accurate, and timely. The old saying not charted, not done applies to patient education as well. Because medical records are legal documents, from a legal perspective, any care or education that goes undocumented never occurred. Attorneys or insurance personnel may review medical records years after care was provided. After that length of time, it is unlikely that anyone involved in a patients care would remember any of the details. Therefore, the medical record must speak for itself. It is not unusual for litigation to hinge on whether a patient was adequately informed about his diagnosis, prognosis, treatment, medications, or other aspects of care. Therefore, the medical assistant must carefully document all patient education.

Chapter Summary

FIG 9-4 Return demonstration.

As important members of the health care team, medical assistants should collaborate with physicians, nurses, and others in the provision of patient education. Patient education is most effective when the medical assistant adapts her teaching methods to the patients individual learning style. When the medical assistant is unsure of a patients learning style, she should address multiple styles. The medical assistant should ask the patient about learning or sensory disabilities so that she can modify teaching tools and methods appropriately. Medical assistants will be most effective in helping patients learn if they have a general understanding of the learning domains, including cognitive (intellect), affective (emotions, values, and attitudes), and psychomotor

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(senses of sight, sound, touch, smell, and taste). The medical assistant should assess the patient to determine what his learning needs are before beginning teaching. Learning objectives identify goals or outcomes to be achieved and help guide the teaching session. The medical assistant should invite the patient to participate and contribute to goal setting. Learning objectives should involve short-term and long-term goals. The medical assistant must be clear about the purpose and goal of the teaching session. The medical assistant should create an outline to organize the session into a logical sequence that progresses from simple to complex subjects. The medical assistant should infuse energy into the session by varying vocal tone and using culturally appropriate eye contact and gestures. While knowledge is helpful in motivating people to make health changes, knowledge alone is commonly not enough. The medical assistant should help the patient identify barriers that hinder his success and support him in getting results. Self-efcacy is an important factor in determining patient success in instituting changes. Many people respond to permanent health loss in a manner similar to how they respond to other signicant losses in their lives. Typical stages of grief and loss include denial, anger, bargaining, resolution, and acceptance. The medical assistant should evaluate the patient for signs of grieving and note which stage he is in. It is important to understand that the stages of grief are uid, meaning that patients may uctuate between stages and even exhibit signs of multiple stages all at once. A number of physical and personal obstacles may hinder effective patient education. Some issues of physical discomfort may be heat, cold, or pain. The medical assistant should address those issues before attempting patient education. Other issues may be less readily solved; however, the medical assistant can add modications in the teaching plan to address those issues. A childs ability to learn depends on his developmental maturity. A young child needs information presented in a more concrete manner. As a child gets older, the medical assistant can present information in a more abstract manner. Teaching strategies for conveying information include the verbal lecture format, conversational approach, and group format. As a patient becomes more knowledgeable about his health care issue, the medical assistant should encourage him to take more responsibility for managing his own self-care. The medical assistant helps the nurses and physicians in monitoring the patients progress and should be available for consultation. Her role is to clarify informa-

tion for the patient and reinforce positive behaviors. The medical assistant should evaluate patient education literature used in the medical ofce for currency, accuracy, clarity, and appropriate reading level. It is recommended that all literature be written below the sixth-grade level. Some sources recommend that it be at fourth-grade level or lower. Medical assistants should avoid using medical terms and jargon or translate it into common language to avoid confusing patients. The medical assistant should always conduct some type of evaluation to determine whether the patient has met established outcomes. Evaluation also provides useful feedback about the effectiveness of teaching methods. Furthermore, it provides opportunities to reinforce key points and clarify areas of confusion. Return demonstration performed by the patient is the best method of verifying whether patients are truly able to perform skills, such as administering their own insulin or using a metered dose inhaler, accurately and safely. Patient education is important because patients are entitled to information about their health and to understand any issues related to their condition. In addition, the medical record also serves as a legal record. Therefore, documentation about patient education must be thorough, accurate, and timely.

Team Work Exercises

1. Divide into teams of three to ve students. Visit one or more medical ofces in your area. Identify all of the places where patient education literature is kept, and collect at least ve samples of patient education literature. Evaluate this literature for target audience, attractiveness and creativity, and reading level. Report your ndings to the class. 2. Divide into teams of three to ve students. Select one of the following patients and role-play a teaching session where you utilize age-appropriate teaching strategies that appeal to all three learning domains. Incorporate at least one age-appropriate analogy into your teaching session. a. 5-year-old child; teach him about why hand washing will help him keep from getting sick. b. 11-year-old; teach her about why it is important to wear a seatbelt in the car and a helmet when riding her bicycle. c. 16-year-old; teach her about safe, effective use of oral contraceptives. d. 45-year-old; teach him about lifestyle modications to reduce his risk of cardiovascular disease. e. 65-year-old; teach her about smoking cessation. f. 75-year-old; teach him about how to care for the surgical incision on his arm and how to prevent infection.

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Case Studies
1. Anthelia is a clinical medical assistant who works in an allergy clinic. The physician has asked her to teach a 17-year-old boy how to administer his own injection of epinephrine, which comes in his emergency bee sting kit. Describe the approach that Anthelia should take. Include: a. learning domains b. assessment of learning needs c. identication of learning objectives d. how to organize the teaching session e. motivation to learn f. identication of potential barriers g. specic age-appropriate teaching strategies h. evaluation of learning. 2. Kaelee is a medical assistant who works in an internal medicine clinic. She has been asked to teach a 61-yearold man who has recently had his left foot amputated due to complications of a diabetic foot ulcer about lifestyle modications to reduce his blood pressure. He seems

fatigued and apathetic. Describe how Kaelee might design one or more teaching sessions with this patient. Discuss the following: a. potential barriers to learning and how they can be overcome b. self-efcacy issues c. age-appropriate teaching strategies d. how teaching sessions will be organized e. evaluation of learning.

Resources

Extensive list of medical analogies: www.altoonafp.org/ analogies.htm Five stages of grief and loss: www.davidkessler.org/ items-of-interest/5-stages-of-grief Patient education information: www.medicalcenter.osu .edu/patientcare/patient_education Printable patient education information: www .familydoctor.org

UNIT II
Administrative

CHAPTER

10 11 12 13 14 15 16 17 18

The Ofce Environment 111

CHAPTER

Telephone Techniques 121

CHAPTER

Appointment Scheduling 133

CHAPTER

Written Ofce Communications and Mail 151

CHAPTER

Records Management 173

CHAPTER

Ofce Management 187

CHAPTER

Coding and Insurance 203

CHAPTER

Billing and Collections 247

CHAPTER

Accounting and Banking 259

CHAPTER

The Ofce Environment

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms presented in the glossary describe an inviting and comfortable reception area discuss how the facility environment can help ensure patient privacy discuss ofce compliance with the Americans with Disabilities Act list at least ve items to include in an ofce to make patients feel comfortable and at ease describe the personality characteristics of an effective receptionist discuss strategies for managing unexpected delays that cause patients to wait for long periods of time in the reception area
Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention Identify community resources

10
Reception Area
Managing Ofce Space Lighting Colors Reading Materials Music Cleanliness

ABHES Competencies
Professionalism
Project a positive attitude Maintain condentiality at all times Be cognizant of ethical boundaries Project a responsible attitude Be courteous and diplomatic

Educational Resources
Marketing Materials

Ofce Safety
Other Precautions

Communication
Be attentive, listen, and learn Be impartial and show empathy when dealing with patients Adapt what is said to the recipients level of comprehension Use appropriate medical terminology Recognize and respond to verbal and nonverbal communication Use correct grammar, spelling, and formatting techniques in written works Observe principles of verbal and nonverbal communication

Chapter Summary Team Work Exercises Case Studies Resources

CAAHEP Competencies
General Competencies Professional Communications
Recognize and respond to nonverbal communications

Chapter Outline
Welcoming New Patients
Americans with Disabilities Act

Legal Concepts
Identify and respond to issues of condentiality

Ofce Design
Privacy Workow Ergonomics

Patient Instruction
Explain general ofce policies

111

Key Terms
accessibility

Welcoming New Patients

When a patient enters the physicians ofce for the rst time, the impression of the ofce surroundings and staff can welcome or alienate the new patient. A warm, professional, pleasant reception staff and environment will welcome a patient and inspire condence in patients about the care they will receive. An ofce staff s productivity, or their ability to perform their job duties efciently and effectively, will continue that rst impression of capability and patients will feel encouraged to stay with the practice.

Degree of a persons ability to gain entrance to a facility when using a wheelchair or other assistive device
asepsis

State of cleanliness that is free from disease-causing microorganisms

disability

Deciency, especially physical, that prevents or restricts normal performance

ergonomics

Science of equipment or workplace design that aims to minimize operator fatigue

marketing

Americans with Disabilities Act

The design of a clinic, physicians ofce, or hospital must be functional and easy to maintain. In addition, it must be in compliance with the Americans with Disabilities Act (ADA). A disability, which is a physical or mental impairment that may limit an individuals access to or use of facilities, must be considered. The ADA is legislation passed in 1990 to ensure the rights of persons with disabilities in many areas. It provides enforceable standards to ensure accessibility and prohibit discrimination in employment, public services, transportation, public accommodation, communications, and other areas. ADA regulations insist that all persons be able to enter and use the facility, regardless of their physical limitations. Doorways must be wide enough to accommodate wheelchairs, ramps must be available, and bathrooms must be designed so that sinks and toilets are accessible to all. Ensuring easy access to the ofce and examination rooms for such patients will promote ease of use and establish a workow that increases overall productivity.

Process of letting customers or potential customers know of a product or service

productivity

Extent of a persons ability to perform a job function

repetitive motion injury

Physical injury caused by a specic repeated motion

workow

Physical space that facilitates accomplishment of work-related duties

Ofce Design
The layout or design of the office can promote comfort and ease of use for staff, physicians, and patients. A new building or one that was originally designed as a physicians office lends itself better to easy delineation of work areas, reception areas, and treatment rooms than a building that was once a bank or retail store. However, with proper planning, a design team or even medical office personnel can create an appropriate environment for a medical practice from any space.

Privacy
Clinical and ofce staff need areas in which to convey private, personal information to patients. An ofce design that includes adequate space between the reception window and seating area ensures that conversations are not overheard by other patients. The medical assistant at the reception window should be able to receive insurance cards and co-payments,

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answer billing questions, and make follow-up appointments without disturbing patients or other ofce staff. Computer screens should face only the ofce staff and not be visible to patients at the reception window. When speaking on the phone, the reception staff should shut the privacy window so that patients in the waiting room do not hear the exchange. Conversation in the reception area should be limited. The medical assistant should call the patient into the examination room by name and wait to ask medical questions until the patient is in the treatment room. When a patient reaches the examination or treatment room, privacy is vital. A patient is commonly naked under a paper gown and feels vulnerable. Closing doors for privacy and knocking before entering show the patient that he is respected and his dignity is important to the staff. Having a mirror and a hook or hanger in the examination room for patients to hang clothing are thoughtful touches. A physician will commonly speak to a patient in an ofce after the examination. Doing so allows the patient to be fully clothed and discuss treatment options with the physician across a desk, rather than in a paper gown on an examination table.

orderly with a place for all items when not in use. In addition, equipment and supplies that are not properly stored present a danger if re exits are blocked or staff members need to step over items in a hallway. Also, the unorganized ofce appears unprofessional and does not inspire patients condence. The ofce with a successful workow will ensure that each work station is located in an area from which the person working there can easily access the items needed to perform that job. For example, reception staff should be able to answer telephones, retrieve patient charts, create new patient charts, and use the computer and copier without having to run around the ofce. Clinical staff should be able to retrieve examination and treatment items in close, secure storage areas, rather than in a hallway outside of the ofce where clinical staff would have to walk through the reception area to retrieve items. (See Figure 10-1.) The expansion of a practice, hiring more medical assistants or physicians, may disrupt workow. The ofce manager will need to reevaluate storage options and work stations. Staff members feeling cramped and disrupted workflow decrease overall productivity. Anything that decreases productivity can lead to frustration.

Workow
The ofce environment that is designed to allow easy access to work materials and enough space for all workers to perform their tasks greatly increases work productivity. Adequate workow is achieved by providing enough physical space for employees to perform job duties. Ofce and clinical staff must have access to telephones and areas to unpack newly ordered items and place patient charts for later ling. Workow is disrupted when there is inadequate space for one or more staff members or if staff fail to return materials to their proper location due to insufcient space. If a staff member cannot answer the phone because too many patient les are on the desk, that staff member cannot do her job. The ofce staff should always keep the work area neat and A

Ergonomics
Ergonomically designed equipment and work spaces prevent injury, reduce fatigue, and promote productivity. Ergonomics ensure that equipment and work spaces t the needs of individuals. For example, chairs should t the height of the user, and desks, computers, and les should be accessible with comfort. To reduce eyestrain, staff should position the computer screen in an area where glare is minimal. The height of desks and computer tables should allow workers to sit straight with elbows bent on the desk or table. Poorly designed work spaces cause employees to move into awkward positions. If the employee must constantly move into uncomfortable positions, a repetitive motion injury can B

FIG 10-1 Successful workow practices. (A) Successful workow. (B) Insufcient work space.

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occur. Repetitive motion injuries are injuries sustained from constant repeated strain on muscles. For example, a table that is too high will cause wrist strain, such as carpal tunnel syndrome; a table that is too low will cause the worker to look down and can cause neck strain. (See Figure 10-2.) Because staff members in physicians ofces and hospitals commonly retrieve and le many medical reports and other records, step stools for upper shelves should be available. For safety, step stools should have rubber tips. If step stools have rollers, they should have locks for added safety. Employees should never improvise using a chair, bucket, or other object to reach high shelves. Equipment used frequently for clinical purposes should be stored in accessible areas; physicians and medical assistants should be able to comfortably and privately interview patients in examination rooms.

comfortable and adequate for the size of the practice. There should be enough seats for all people and enough space between the seats that patients feel comfortable and have their own space. (See Figure 10-3.) Chairs can also be arranged into groups so that people entering with family members or friends can sit together. Chairs should be supportive and easy to get in and out of. Chairs that are too low may be difficult for elderly patients or patients with lower back problems. Dividing the reception room into two separate areas for healthy people and those who may be sick with a communicable illness is also a way to show consideration to patients. (See Sick child area.)

Managing Ofce Space

Having enough chairs in the reception area and enough examination rooms to accommodate the physicians schedule is only benecial if employees can manage the ow of patients, physicians, and employees within the space. Medical assistants must be able to keep the ow of patients steady and avoid crowding in high-use areas. For example, having patients check in and then enter a hallway to treatment rooms where a scale is located in the hallway can help medical assistants take height and weight measurements prior to showing the patient into the examination room. To avoid crowding in high-trafc areas, the ofce design can include a separate exit in a hallway opposite the entrance for patients coming out of C

Reception Area
A patient enters a medical office through the reception area. While it is commonly referred to as a waiting room, waiting should be minimized as much as possible. Proper scheduling can prevent lengthy waiting. (See Chapter 12, Appointment Scheduling, on page 133.) Because the reception area is the first room that a new patient will see, it should be inviting and comfortable. Seating should be A B

FIG 10-2 Proper and improper ergonomics. (A) Desk at proper height. (B) Desk set too high. (C) Desk set too low.

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FIG 10-3 Acceptable and unacceptable reception areas. (A) Acceptable area that is spacious and clean with comfortable furniture and good lighting. (B) Unacceptable area that is poorly lit, crowded, and dirty.

Front ofceBack ofce connection

Sick Child Area

Pediatric ofces commonly have a separate waiting area for sick children. These children may be contagious and are usually uninterested in playing with toys. A comfortable couch where a caregiver can hold a sick child away from healthy, noisy children is appreciated. Be sure to keep tissues and a wastebasket in the area in case a child becomes ill in the waiting area. The administrative medical assistant should advise the clinical medical assistant that sick children are in the sick child waiting area. The two medical assistants should work together to get such children into treatment rooms quickly to prevent further exposure of healthy children to pathogens in the waiting area.

the examination rooms. This hallway can also include a station for scheduling future appointments. Because checking in and out are on opposite sides of the front desk, patients arent backing up in the hallway creating a bottleneck. (See Figure 10-4.) In addition to providing a ow of patients entering and exiting the treatment areas, medical assistants must be able to act quickly if a patient in the reception area needs immediate attention. If all examination rooms are lled, an emergency patient can be seated in an ofce or the laboratory if the medical assistant determines that the patient should not be left alone. A patient who arrives at the ofce in acute distress must be attended to immediately. (See Chapter 47, Ofce Emergencies, page 967.)

Lighting
Since patients may read in the reception area, lighting should be bright but not glaring. High illumination in the

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Exam 1

Exam 2

Exam 3

Exam 4

Bathroom

Traffic Flow Door Reception Area Door Fax Scale (height and weight) Exam 5

Check-in Window

Copier Billing Office

Chairs

Door

Coat rack
Table with Brochures

Moveable Files X-ray and Lab

Door Exam 6

Door

Exam 9

Exam 8

Exam 7

Bathroom

FIG 10-4 Diagram of a medical ofce designed for efciency and optimal ow.

form of ceiling lights makes the room appear larger and inviting. Low lighting from table lamps can be added for extra light near chairs but should be used in conjunction with ceiling lights. (See Figure 10-5.)

Colors
Neutral tones are a better choice than bright colors in a reception area or examination room. Colors that are too bold or bright might seem aggressive and make patients feel ill at ease. Off-white or cream is a better choice than bright white, and paint should be a at nish rather than a glossy nish to avoid glare. Colors can match or coordinate with chairs, paint, and carpet. Framed artwork, such as paintings

and posters, can complement the furniture and overall look of the room. When updating the paint, carpeting, or furniture of a reception room, the ofce manager or designer should ask, Would I feel comfortable sitting or reading in this room? Although owers and plants are generally an attractive addition to a room, the ofce manager or designer should be careful to choose plants that are nontoxic and not common allergens. Silk owers and plants are a safer choice; however, even these need dusting and regular maintenance.

Reading Materials
The ofce manager or other staff member should make a variety of reading materials available for patients and remove

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FIG 10-5 Effects of correct lighting. (A) Successful lighting plan. (B) Inadequate lighting.

outdated magazines from the reception area. Although it remains unproven, patients commonly associate outdated magazines in the reception area with longer waiting periods. Pediatric ofces should have childrens books and magazines as well as reading material for adults. An orthodontic practice, which will see many teenagers, should offer reading materials for that age group. Reading materials should never include items that could be offensive to patients; sexually explicit or politically charged materials should be avoided.

may want to read or simply relax. If a television is on in the waiting room for entertainment or information, the radio should be turned off to avoid competing with the sound from the television.

Cleanliness
Cleanliness in the clinical areas is vital to maintaining medical asepsis, or a state of cleanliness that is free from diseasecausing microorganisms. It is also vital to maintain cleanliness in the reception area. If the reception area has cobwebs, dust, or dirty carpeting or bathrooms, patients may infer that the clinical areas are also dirty. Most ofces have a cleaning service to clean these areas; however, it is the responsibility of all employees to maintain a clean environment at all times. Although eating and drinking is usually prohibited in

Music
Music can be incorporated into the reception area but should never be intrusive. A radio can be used, but speakers that spread the music throughout the room are preferred. It should never be so loud that it is intrusive to people who

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reception areas, the medical assistant may have to pick up garbage or clean a spill if it occurs.

Educational Resources
Patient education is always important in the clinical setting. The reception area can offer pamphlets that identify specic diseases and disorders and possible treatments offered at the ofce. A rack of educational pamphlets should be kept lled with a variety of offerings. Patients can choose the materials, or staff members can give patients specic pamphlets to read. These educational pamphlets can aid physicians in educating patients about their medical condition. If patients have read about a condition in the reception area, they may already be familiar with its physiology and treatment options. These educational pamphlets may also be available in examination rooms for physicians and patients to review. The office can also use a television in the reception area as an educational resource. A television and DVD player can provide patients with information specific to the practices area of specialty. Because a DVD is viewed by all people in the reception area, it should not contain graphic material (such as surgery or infected wounds). Educational companies that create these DVDs provide a variety of topics depicted in a manner that is appropriate for a reception area. While most of these materials include sound, some are pictures only (or the sound can be turned off ).

the physician, these brochures can be placed in the reception area for patients to read and consider as a possible treatment option. It is important that patients understand that medication decisions are made by physicians and patients, not merely by marketing materials. If a medication is taken off the market for safety concerns, the marketing materials for that drug should be removed immediately.

Ofce Safety
Safety in the ofce should be maintained by attending to possible hazards and avoiding risky behaviors. Some hazards to avoid include:

exposed electrical cords hallways blocked with boxes or equipment defects in carpeting that may cause trips and falls re hazards such as long, ammable curtains broken equipment that may electrocute or cause res spilled liquids that could cause falls broken furniture or sharp edges on tables.

Behaviors to avoid include:

standing on tables or chairs to reach high objects items that are stacked in cabinets or closets and may fall when cabinet doors are opened leaving coffee makers or other appliances on when not in use smoking anywhere inside the building.

Marketing Materials
The receptionist can offer ofce brochures or make them available in the reception area. Because patients may be unaware of all the services offered by the practice, brochures can encourage them to seek additional services or to recommend the practice to others. Patients and staff members can also give ofce brochures to friends or family members. Insurance and billing practices, HMO participation, hours of practice, and scope of services are types of information to include in a brochure. In addition to a brochure for the practice, the ofce might offer marketing materials for other local physicians that accept referrals from the ofce. Services that are not offered in the ofce can be referred and endorsed by the ofce. Marketing materials for services that contribute to improved patient health, such as local health clubs, diet centers, smoking cessation clinics, and health food and vitamin stores, can be presented in the ofce. In addition, pharmaceutical representatives will commonly leave brochures outlining the benefits of specific medications for specific diseases. At the discretion of

Other Precautions
In addition to avoiding hazards and risky behaviors, there are many precautions that will ensure a safe ofce environment, including:

using surge protectors to protect computers and other electrical equipment from power surges that may accompany thunderstorms unplugging televisions and microwaves in the event of a thunderstorm installing smoke detectors and sprinkler systems or asking the landlord to do so (the landlord and tenant benet from the added safety; owners and renters can receive a discount on property insurance for having and maintaining smoke detectors and sprinklers) disposing of broken jars or plastic bottles that may leak clearly marking steps in areas that people may not see with such words as step down or watch your step inspecting the ofce periodically for safety hazards, because the best way to ensure safety is to prevent hazards before they occur.

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Case Studies Chapter Summary

The appearance of the physicians ofce, clinic, or hospital environment can inuence a patients opinion before treatment begins. A professional, pleasant, clean environment inspires patient condence and allows staff to work efciently. Properly chosen colors and lighting, attention to privacy needs, comfortable chairs, and appropriate reading materials show patients that the physicians and staff are interested in patient comfort and delivering quality health care. Attention to workow and ergonomics increases productivity, reduces employee frustration, and prevents repetitive motion injuries, such as carpal tunnel syndrome and neck strain. Ofce staff should immediately address such safety concerns as blocked exits, faulty wiring, or other hazards such as spills to avoid injury to staff, physicians, or patients. Patient education through the use of practice brochures, disease and disorder pamphlets, and DVDs helps patients understand their specic conditions as well as the overall offerings of the practice.

Team Work Exercises

1. With a group of classmates, choose ve appropriate topics for educational materials in each of the following settings: a. obstetrics and gynecology b. pediatrics c. dermatology Research the conditions and select educational materials pamphlets and DVDs. Discuss with the remainder of the class why you chose the materials that you did. Who is your audience for each of the topics? How readable is the material that you chose? 2. With a group of classmates, design an ofce. Be sure to include a reception area, a front desk, examination rooms, a bathroom, and ofces. You may include a break room for employees as well. Think about the ow of patients and staff. Decide on a budget, using local vendors, and choose furniture. Discuss comfort, durability, and maintenance of the furniture. What materials will you use for ooring, walls, countertops, and le storage? Why?

1. The physicians ofce you have been working in for the past 5 years has grown tremendously. Two new medical assistants and a physicians assistant were hired recently to meet the increasing needs of the practice. What was once your desk is now quickly becoming a dumping site for charts in need of ling, x-rays, HMO treatment request forms, and faxes. While you appreciate the new employees, you are beginning to resent the changes in the practice. You ask the physician-owner for a staff meeting to address your concerns. Make a list of items to discuss at the staff meeting and determine possible solutions to the problem. For example, has the practice grown to the point where more space is needed? Are there too many inactive patient medical records in the les that could be moved to a storage area? Can an area be designated for items that need to be led? Should employee hours be expanded to keep up with ling and organizing medical records? Discuss these issues with classmates. Have you experienced changes in your work environment that are similar to the scenario? If so, discuss. 2. Mrs. Chen comes to the ofce for an examination with Dr. Rodriguez. She approaches your desk in the reception area and explains in a loud voice that she experienced chest pain the night before and is quite upset. She does not appear to be in an immediate physical crisis but is emotionally needy. You dont want to have the conversation with her in the reception area, but the examination rooms are all full. How can you help Mrs. Chen? Discuss options with classmates.

Resources

Ergonomics: www.usernomics.com/ergonomics.html The benets of working in a healthy environment: www .ghchealth.com/healthy-ofce-environment.html Ofce environment concerns for obese patients: www .ama-assn.org/ama1/pub/upload/mm/433/ ofceenvironment.pdf

CHAPTER

Telephone Techniques
Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms presented in the glossary discuss why etiquette, tone, speed, and volume are important components in the use of the phone describe the proper procedure for taking incoming calls describe the acceptable way to place someone on hold describe the proper procedure for making outgoing calls describe the types of phone calls that should be taken by the medical assistant, the registered nurse, and the physician list four questions to ask when triaging a phone call and the appropriate action based on the response describe how to contact emergency services by phone and direct them to the callers location describe useful techniques in managing a problem call.
Recognize and respond to nonverbal communications Demonstrate telephone techniques

11
Clarity and speed Multilingual callers Making Outgoing Calls Ending Calls Time Zones

Legal Concepts
Identify and respond to issues of condentiality Perform within legal and ethical boundaries Document appropriately

Call Handling
Taking Messages Triaging Calls Difcult Callers Automated Routing Units

Patient Instruction
Explain general ofce policies Instruct individuals according to their needs

ABHES Competencies
Communication
Be attentive, listen, and learn Adapt what is said to the recipients level of comprehension Serve as a liaison between physician and others Use proper telephone techniques Receive, organize, prioritize, and transmit information expediently

Documentation Answering Service or Machine Chapter Summary Team Work Exercises Case Studies Resources

Administrative Duties
Schedule and monitor appointments Perform telephone and in-person screening

Procedures
Demonstrating telephone techniques

CAAHEP Competencies
Administrative Perform Clerical Functions
Schedule and manage appointments

Chapter Outline
Essential Tool Telephone Etiquette
Answering Incoming Calls Hold Volume and tone

General Professional Communications

Recognize and respond to verbal communications

121

Key Terms
bilingual

Essential Tool
The telephone is the communication tool most used in the clinical setting. New patients who call for information and to make an initial appointment will form an impression of the ofce based on that rst phone call. The medical assistant must be professional, helpful, and clear in communicating over the telephone. Medical assistants also use the telephone to follow up on insurance claims, conrm patient appointments, and order supplies. The medical assistant ensures condentialityor the principle of keeping medical, nancial, and personal information private and avoiding disclosure to unauthorized personsby following the guidelines set by the Health Information Portability and Accountability Act (HIPAA). Regardless of how often the medical assistant uses the telephone, she must always adhere to condentiality rules when conducting telephone communications to ensure that medical, nancial, and personal information remains private. (For more information on HIPAA, see Chapter 7, HIPAA and a Patients Rights, page 71.) Physicians, nurses, and clinical medical assistants use the telephone to give instructions to patients, explain test results, and answer questions. Without the use of the telephone, no physicians ofce could remain open for long.

Capable of conversing in two languages

call forwarding

Technology that enables a telephone call to reach a specic person, department, or desk
condentiality

Principle of keeping personal medical and nancial information private and avoiding divulgence of such information to any unapproved party
empathy

Understanding the emotions and thoughts of another

enunciation

Act of pronouncing words distinctly

etiquette

Rules for socially acceptable behavior

uent

Able to speak and write well

jargon

Abbreviated versions or slang for terms used in a specialized profession or trade

multilingual

Procient in several languages

pronunciation

Generally accepted sound of a spoken word

slang

Unconventional word or phrase used in place of a conventional word that is commonly clinical or complex in some way
triage

Telephone Etiquette
A telephone call should be handled in a professional and courteous manner. Adhering to telephone etiquette, or socially accepted rules for using the telephone, includes saying please and thank you and allowing your caller to speak. The caller may perceive interruptions, abruptness, or discourteous behavior as not only rude but also unprofessional. Enunciation, which is the practice of pronouncing words clearly and at a speed that affords the listener the opportunity to hear and understand the message, is essential for clear communication. Using proper pronunciation, the generally accepted sound of words, also helps the recipient understand the message. Pronouncing words in a way that is appropriate to the region helps the listener understand the message. A medical assistant who moves from Boston to Houston will need to change how she pronounces words to accommodate the difference in regional accents. In addition, the medical assistant should avoid using jargon, which is the use of abbreviations or medical terms that the patient might not be familiar with, so that the patient will understand the message. A medical assistant who uses medical jargon on the telephone may intimidate recipients and cause them to avoid asking questions that might aid in comprehension. As with jargon, the medical assistant should avoid using slang, or unconventional words or phrases to describe clinical conditions, because the patient may not understand the true

Process of screening patients to determine which need immediate medical treatment and in what order each patient must be seen
voice mail

System that enables a caller to leave a recorded message for the recipient

CHAP TER 11

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123

meaning. When answering the phone, the medical assistant should speak clearly, in a pleasant tone, and at a comfortable volume. The patient calling the ofce should never feel that he is interrupting work and that the medical assistant is too busy to answer his questions and concerns. The caller must feel that the medical assistant answering the phone has empathy, which is an understanding of the callers emotions and needs. Telephone communication is an integral part of the job; full attention must be given to the caller.

Answering Incoming Calls

The medical assistant must identify the practice and herself. Examples of telephone greetings include:

Doctor Warners ofce, Louise speaking. How may I help you? Middletown Orthopedics, this is Sharon. Can you hold please?

Stating the practice name helps callers know that they dialed the correct number. Stating the receiving persons name lets them know the name of the person with whom they are speaking and that the medical assistant is listening and ready to help. Using this type of greeting puts the caller at ease and helps ensure a successful call.

and work toward using commonly accepted word pronunciations. Medical assistants for whom English is a second language should list and practice speaking the commonly used terms that are difcult to pronounce. Clear communication also includes using terms that the receiver is familiar with and avoiding terms that are too technical. The medical assistant should be sure to know the caller; if she is speaking to a patient who is a physician, nurse, medical assistant, or other health care provider, the use of technical medical terms or medical jargon is appropriate. If the caller is an attorney, a college president, or an accountant, despite being highly educated, they will most likely be less familiar with medical terminology. The speed of speech should be appropriate to the callers needs. When given directions to the ofce, the caller may be taking notes, so the medical assistant should allow the caller time to catch up. Speaking too slowly, however, will frustrate the caller and he will disengage from the dialogue. Speaking too rapidly causes confusion; the caller may have to ask the medical assistant to repeat her statements. Speaking too fast also conveys the message I am too busy to give my time to you.

Hold
If the medical assistant wants to put a caller on hold to answer another line or to speak to a patient at the reception desk, she should ask the caller if she may put the patient on hold, such as Can you hold, please? Although most people will agree to be put on hold, the medical assistant must wait for the callers response before putting him on hold. A caller may say, No you cant put me on hold, this is an emergency! The medical assistant must then triage the call to assess emergency status. She should never put a caller on hold who tells her there is an emergency.

TIP Language Choice Take cues from the callers use of terms. A caller who says, My last UA showed gram-negative rods has more medical knowledge than the caller who says, Last time the MA tested my pee and I had a bladder infection. Speak to the caller in terms that she will understand.
Multilingual Callers
Because English may not be the callers first language, many physicians offices practice in a multilingual environment. Medical assistants who are bilingual, speaking two languages, or even multilingual, speaking three or more languages, should offer to speak to the caller in the language most comfortable for the caller. However, the medical assistant offering to speak in another language must be fluent in that language, that is, able to speak and write in that language so that the communication is complete. A medical assistant offering to speak in a language that she has limited knowledge of can cause confusion and misinterpretation. If a caller is most comfortable speaking Spanish and the medical assistant is fluent in Spanish, the phone call can be conducted in Spanish. If a Spanishspeaking physician is part of the practice, offering to make an appointment with that physician will be helpful. If no Spanish-speaking physician is available, the medical assistant should tell the caller that she recommends bringing a family member to interpret if the office does not have an interpreter available.

Volume and Tone

When speaking on the telephone, the medical assistant should use a level of volume appropriate to the caller. An elderly patient may have trouble hearing, so speaking more loudly may be helpful. However, speaking too loudly and overemphasizing words can be irritating and perceived as condescending or patronizing. The medical assistants tone, or sound of her voice, should be pleasant and convey a helpful attitude. A monotone voice tells the caller I am bored and dont care about your call. A varied pitch with inection raised at the end of sentences engages the caller.

Clarity and Speed

The medical assistant should speak clearly and distinctly. A medical assistant with a heavy accent should speak slowly

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TIP Avoid Slang The use of slang terms may confuse people. Are you feeling sick? is a clear statement, understood by the recipient. Are you under the weather? is not only unprofessional but can be taken literally by people for whom English is a second language. The receiver may wonder what the weather has to do with her health concern.

Example of an outgoing call

Here is an example of an appropriate outgoing telephone call by a medical assistant. The medical assistant uses all of the rules of telephone etiquette when calling the home phone number for Mr. James OReilly. Recipient: Hello Medical assistant (caller): Hello, Mr. OReilly?

Making Outgoing Calls

When making outgoing calls, the medical assistant should identify herself and the practice name, just as she would when receiving a call. She should then ask to speak to the patient. For example:

Recipient: Yes, this is he. Medical assistant: Hello, Mr. OReilly, this is Janice from Rockridge Endocrinology. Recipient: Oh, hello, I meant to call to make another appointment when I left last Wednesday, but I was running late and had to pick up my son at soccer practice. Medical assistant: Thats ne, Mr. OReilly, I can help you schedule the follow-up right now. When the recipient says, Oh, hello, his response tells the medical assistant that she is speaking to Mr. OReilly and that she can discuss medical or personal information if necessary.

This is Louise from Doctor Warners ofce. May I speak to Greg Ramirez, please? Hello, Mr. Lynch? This is Sharon from Middletown Orthopedics. Hi, Bill? This is Doug from Associated Internists.

The medical assistant may recognize the patient when he answers the phone; however, conrming his identity is vital. Speaking to a person without conrming his identity could result in a breach of condentiality. Discussions of and references to personal or medical information on the telephone are protected under HIPAA mandates. The medical assistant can continue the call only when she is sure of the recipients identity. The recipient of the call will also need the identity of the caller (the medical assistant) and the ofce that she represents. When the recipient acknowledges the medical assistant and identies himself, the medical assistant can give the reason for the callfor example, I am calling to conrm your 10 a.m. appointment with Dr. Wilson for tomorrow, April 7th, at 3:30. (See Example of an outgoing call.) By clearly identifying herself, conrming the identity of the recipient, and identifying the ofce and the reason for the call, the medical assistant sets the tone for a successful call.

Time Zones
Patients will live in the same time zone as the office, but vendors of office and clinical supplies, insurance companies, or HMO accrediting agencies may be located several states away, so the medical assistant should be aware of different time zones and take into account office hours in those areas. For example, a New York office should not expect to reach a California office until noon Eastern Standard Time (9 a.m. Pacific time). (See North American time zones, page 126.)

Example of an outgoing call

Ending Calls
At the conclusion of a phone call, the medical assistant should repeat important information from the phone call, such as confirmation of appointment date and time or patient instructions. For example, the medical assistant could say, Mrs. Martin, so you understand that if Cindys fever or rash returns, you need to call the office and bring her in for Dr. Wilson to examine her again. If the patient is unsure of instructions, the medical assistant must try to explain further. Patient understanding of the results of the phone call will ensure proper follow-up care. (See Procedure 11-1: Demonstrating telephone techniques.)

Call Handling
Appointment scheduling, driving directions, and insurance and billing questions can be answered by the medical assistant. Medical questions regarding diagnosis and treatment should be handled by a physician or registered nurse. Because the medical assistant is usually the person who answers the phone, deciding who needs to speak with the patient will be her responsibility. (See Incoming calls and actions, page 127.)

TIP ID the Caller To conrm the identity of a caller and therefore establish need to know, caller ID technology can be helpful. If the

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PROCEDURE 11-1

Demonstrating telephone techniques

Task Demonstrate proper telephone answering, screening, and message-taking techniques. Conditions Telephone Message pad Appointment schedule Appropriate patient chart Pen or pencil Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully demonstrate proper telephone techniques by answering incoming calls, performing patient screening, and taking messages in an efcient, professional manner. Performance Standards 1. Gather all necessary supplies and have them handy near the telephone area. Being organized before answering the telephone allows you to take a message accurately and efciently. 2. Promptly answer the telephone on the third ring or sooner to avoid causing anxiety or annoyance to the caller waiting on the line. 3. Greet the caller by identifying your ofce and yourself to assure the caller that he has dialed the correct number. 4. Listen to the caller and obtain the callers name and reason for the call to assist the caller appropriately and efciently. 5. If necessary, place the caller on hold and obtain the medical record to access necessary patient information in the medical record or to pass along to the appropriate staff member who can assist the caller. 6. If you need to transfer the caller to another staff member, let the caller know the name and occupation of the person to whom you will be transferring him so the caller can get connected to the person quickly in the event that there is an error in transferring the call. 7. If the caller wishes to speak with a person who is unavailable, take a message, being sure to include: a. person or patients name and contact phone numbers b. date and time of the call c. detailed message d. your name or initials as the person taking the call.
For: Phone Message

Dr. Greer

Date:

12-4-09

Time: 11:13

am

Name: Tammy Connery Contact information Phone: 564-860-4321 Fax: Email: Message:

home

work

X cell

Tammy missed two doses of her birth control pills and wants to know what she should do?

Call taken by: Ann Date: 12/04/09

Chapin, CMA
Time :

11:15 am

8. Tell the caller that you will be giving the message to the appropriate person and explain the ofces policy for return calls, if appropriate. Some ofces have special times of the day in which return calls are made to patients. 9. If the call is appropriate for a medical assistant to take, perform a screening, asking appropriate questions to determine if the call is an emergency situation. 10. If you must put the caller on hold to get an answer to his question, ask the the caller if he can hold. Be sure to wait for the callers answer to avoid offending the caller who does not wish to wait on hold. 11. When you take the caller off hold, be sure to conrm the identity of the caller to avoid a breach of condentiality and identify yourself again to avoid causing confusion and then provide the caller with the requested information. 12. Be sure to identify and respond professionally to issues of condentiality during the conversation because some callers may be providing sensitive information or results. 13. Perform within all legal and ethical boundaries during the conversation. Medical assistants and all health care providers must avoid taking phone calls that are not within their scope of practice. 14. If the call is related to a patient, document the phone call in the patients chart as necessary to maintain an accurate medical record.

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North American time zones

When calling a different time zone, the medical assistant must determine if it is too early or late to make the call by adding one hour for each zone change to the east (right) and subtracting one hour for each time zone to the west (left). The map below shows the time zones for the United States and Canada.

Newfoundland Time Zone Atlantic Time Zone Eastern Time Zone Central Time Zone Mountain Time Zone Pacific Time Zone Alaskan Time Zone Hawaiian Time Zone

AK YU NT

NU

BC

AB

SK

MB QC ON NB VT WI NH PE

NF

WA OR HI ID

MT WY CO NM

ND SD

MN

NV UT CA AZ

ME NS NY MI MA NE IA RI IL IN OH PA KS MO CT KY TN NJ NC OK AR VA AL GA WV TX SC DE FL LA MS MD

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Incoming calls and actions

The medical assistant can help many patients who call the ofce. However, she must ask the physician or registered nurse (RN) to handle some situations. The table below outlines possible phone requests from patients and who should handle the call.

Type of call
Patient calls to make or change an appointment Patient calls to conrm an appointment Patient calls for a prescription rell

Action taken by MA
Schedule a nonemergency appointment or reschedule appointments as needed. Conrm the time and date of the appointment.

Who handles the call?

Medical assistant

Medical assistant

Take a message for the physician, including the patients name, pharmacy name, and prescription number. Put the patients chart and message on the physicians desk.

Physician calls the pharmacy to order the rell. Medical assistant calls the patient to indicate that the rell has been ordered. If no rell is granted, the medical assistant or physician calls the patient to explain.

Patient calls seeking medical advice Patient calls with a question about billing or insurance Patient calls with a complaint

Take a message and put it and the patients chart on the physicians or RNs desk. Identify the caller as a patient or guardian and then answer billing or insurance questions. Ask Is there anything I can help with? If the complaint is medical, take a message for the physician or RN. If the problem is related to scheduling, attempt to reschedule and better accommodate the patients schedule. If it is a billing problem, record the information, call the insurance company, and get information to the patient as soon as possible.

Physician or RN

Medical assistant

Physician or RN for medical complaints Medical assistant for administrative (scheduling or billing) complaints

Patient asks to speak to the physician

Ask the patient Is there something I can help with? If the patient says no, the medical assistant should ask if the nurse or physician can help and give the message to the RN or physician as appropriate.

Medical assistant, RN, or physician, based on information needed

Patient calls with a question about medication, illness, or injury

Take information from the patient, including the patients name, the nature of the injury or illness, and the patients question and put the message and the patients chart on the RNs or physicians desk.

RN or physician

Patient calls for test results

Identify the caller as the patient or guardian of the patient and then take a message and put it and the patients chart on the physicians or RNs desk.

RN or physician

Outside laboratory calls with patient test results

Write down the laboratory test results as dictated over the phone or give the phone to a clinical medical assistant or another designated person and conrm the laboratory fax number if results must be faxed.

Medical assistant or RN

Continued

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Incoming calls and actionscontd

Type of call
Insurance company calls for information to process a claim on a patient Attorneys ofce calls for information regarding a patients claim, such as workers compensation or an auto accident Another physician calls to speak to the physician

Action taken by MA
Identify the caller and give the required information about the patient (only the information needed to process the claim). Identify the caller and check to see that the patient has signed an authorization to release the information to the attorneys ofce (releasing only the information related to the claim). Ask if the call is regarding a specic patient, retrieve the patients chart, and transfer the call to the physician.

Who handles the call?

Medical assistant

Medical assistant

Physician

Pharmaceutical sales representative calls to talk to the physician or RN about new medications or how existing medications are working for patients Ofce or clinical supply sales representative calls to ask if the ofce needs products or to notify the ofce about sales and special products Person calls to speak with a staff member about a personal matter

Make appointment for the sales representative to see the physician or RN (scheduled as ofce policy dictates).

Medical assistant

Take message for appropriate staff member.

Medical assistant or ofce manager

Direct the call to the appropriate staff member, following ofce guidelines regarding personal calls during ofce hours.

Staff member

phone shows the telephone number of the caller, check that number, for example, against the letterhead of the attorneys ofce or a list of insurance company numbers kept at the desk for quick reference. If you cannot conrm the identity of the caller, offer to call the caller back at her ofce. Other methods that are considered a legitimate conrmation of a caller are having spoken with the individual in past conversations and recognizing her voice or the caller referring to a previous conversation.

action requested (such as if the caller wants a call back or if the caller will call again later) message, including the patients question with reference to specics, such as medication and dosage initial or signature of the medical assistant taking the message.

Triaging Calls
Triaging a call is deciding if immediate medical attention is required and assisting the caller in getting the appropriate attention. Many patients who call the ofce feel that their situation demands immediate attention through speaking to a physician or getting an immediate appointment. The medical assistant must accurately assess the priority of the situation. Having a list of questions by the telephone will guide the medical assistant in assessing the urgency of the call. (See Emergency dialogue.) If a phone call is an immediate emergency, the medical assistant can assist the caller by taking the following actions:

Taking Messages
When taking messages for physicians, nurses, or fellow medical assistants, the medical assistant should try to include as much information as possible, including:

name of the caller date and time of the call return phone number and when the person can be reached

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Emergency dialogue
While all calls are not emergencies, the medical assistants job is made easier when she has these questions and associated actions at hand by the phone when calls arrive. (Keep in mind, not all questions will be appropriate in a given situation.)

Question
What happened?

Reason
It is most important to nd out the nature of the injury rst.

Follow-up Questions
When did the injury take place?

What is the patients name? How old is the patient?

If the patient is a child, it is necessary to determine if the caller is a parent or guardian who has the legal right to make medical decisions for the child.

If the caller is a parent, the call can continue with specic questions as outlined below. If the caller is not a parent or guardian, the parent should get on the phone. If the parent is not available, the medical assistant is able to provide only emergency care without the consent of a parent or guardian.

Is the patient breathing?

Difculty breathing is a life-threatening emergency. Direct the caller to use an inhaler (if available) and to call 911.

If caller answers Yes to the question, Do you want me to call 911? then the medical assistant should use another telephone line to call 911, give the location of the caller, and stay on the line until emergency medical services arrive.

Is there bleeding? From where? How much?

Arterial bleeding requires immediate medical attention, but venous or capillary bleeding does not.

If the caller answers Yes, to the question, Can you stop the bleeding? then the medical assistant should instruct the caller to put pressure on the wound to control bleeding. If the caller cannot stop the bleeding, the medical assistant should instruct the caller to continue applying pressure and call 911.

What is the patients temperature?

Fevers of 100F or higher in adults and 101F in children should be seen in the ofce immediately.

How long has the patient had the fever? If the patient has had a high fever for more than 12 hours, the medical assistant should ask the caller to bring the patient to the ofce immediately.

Did the patient take a medication? What is the name and how much?

Overdoses of some medications are life-threatening and require a 911 call.

Are there instructions on the bottle for overdose? If there are not instructions on the bottle, the medical assistant should instruct the caller to call the Poison Control Center at 1-800-222-1222.

1. Establish the nature of the emergency, such as breathing difculty, injury, heart attack, seizure, or diabetic coma. 2. Stay on the line with the caller and get the exact location of the caller. 3. From another telephone line, call emergency medical services (EMS) or have another medical assistant or employee make the call.

4. Give EMS the location of the caller and the nature of the injury or illness. 5. Stay on the line with the caller until EMS arrives. 6. Document the phone call and actions taken. In nonemergency situations, asking questions on the phone is used to determine the action to be taken. Patients calling for

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an appointment should be asked some questions to determine when they should be seen. These questions include:

How long have you had the pain or symptoms? Are you taking any medications? Are you in need of rells? Do you need a blood sugar (glucose), thyroid, or lipid (cholesterol) panel? (Patients who are taking maintenance medications will be familiar with the blood tests that are monitored for their condition.)

using voice mail to leave a recorded message for the department or individual. For example, Hello this is Joanne, the operator. No one is available in the billing department. Would you like to leave a message for them? The operator can then connect the caller to a voice mail box that can hold messages to be returned later.

Documentation
Proper documentation of phone calls in a patients chart can clarify questions that may occur later. (See Examples of phone call documentation.) Documenting phone calls can help physicians when speaking with patients in the ofce. If a patient calls with questions regarding medication, the medical assistant or nurse can document the call and any instructions given, such as blood glucose testing and insulin levels. At the patient examination, the physician can refer to the chart and say, So, you had some questions on the use of the blood glucose meter? Are you comfortable with the machine and managing your blood sugar? The physician can conrm that patient education is established or that the patient needs more help using the machine. Abusive phone calls made by angry patients should be documented in the patients chart as well. Physicians and staff need to know if a patient might be unruly in the ofce during the visit or abusive on the phone in the future. Documenting angry and abusive phone calls can also prompt a physician to refuse to continue to see a patient, severing the doctor-patient relationship.

If the medical assistant determines that no immediate emergency exists, an appointment can be made at the patients earliest convenience.

Difcult Callers
Not all callers to the physicians ofce will be pleasant and cooperative. Patients with complaints regarding billing and insurance or the progress of their medical condition may be angry or even abusive. The medical assistant must always remain calm and professional and never argue with a patient or return abusive comments. She should be careful never to yell at the patient, even if the patient is yelling at her. Asking questions of the caller for clarication of the complaint can help to calm the patient and show that the medical assistant is attentive to his needs. If the physician, nurse, or ofce manager must handle the call, the medical assistant should take a complete message from the caller. When giving the message to the recipient, she should be sure to include that the caller was upset, abusive, or angry. The medical assistant should give the message and the patients chart to the physician, nurse, or ofce manager in person, rather than leaving it on the desk. If a caller is so abusive that no constructive outcome of the phone call is possible, the medical assistant should tell the patient that she will hang up if the abuse (such as swearing, screaming, or threatening) continues. She should hang up on the caller only after she has made it clear that she will do so if they do not calm down. She should then immediately report any abusive behavior to the physician or ofce manager and document abusive language in the patients chart.

Answering Service or Machine

Many practices use an answering service to answer incoming calls when the ofce is closed. The practice should give the answering service instructions on directing calls to on-call physicians in the case of emergency, taking messages for the ofce, and telling the caller the ofce hours. Answering services do not answer questions or make patient appointments. If the physician practice does not want to hire an answering service, call forwarding is an option. With this technology, when a patient calls the ofce phone, the call is forwarded to the on-call physicians cellular phone. The medical assistant may be required to change the on-call number as the physicians rotate their on-call duty. The practice may also elect to designate one cellular phone for the on-call service and the physicians will take turns keeping the phone. In either scenario, the medical assistant can assist the physicians by charging the cellular phone and reminding the physicians of the on-call schedule.

Automated Routing Units

Large practices, clinics, and hospitals commonly use automated systems for directing calls. When a caller is connected, a recorded voice gives a greeting and options for connecting to specic departments or staff members. With the use of a touch-tone phone, the caller is directed to the appropriate recipient. When calls are directed to individual phones, the receiver should answer and identify the department and give her name. For example, Scheduling, this is Shannon. How may I help? If the phone rings and goes unanswered, the calls go back to an operator. The operator can give the caller the option of

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Examples of phone call documentation

Occasionally, notations made in a patients chart regarding a phone call can be useful at a later date when questions arise. For example, why did Mrs. Wilson wait two years for
Date 12/10/05; 9:45 a.m.
Patient called. Canceled appt. of 12/19. Will call to reschedule. ---------------------------------------------------------------- A. Chapin, CMA

her checkup? Looking in the chart might show that the patient had an appointment last year but called to cancel it. The administrative medical assistant would have written:

This piece of information can be useful if Mrs. Wilson were to claim that she was not told to make an appointment or that lack of attention to her needs caused her harm (such as a late diagnosis of cancer). Documentation of the cancelled appointment can show that the physician
Date 12/19/05; 2:45 a.m.

was not negligent in offering care, but that the patient refused care. In addition, the physician will document phone calls in the patients chart if medication dosages are changed or if he instructs the patient to discontinue a medication.

Spoke to patient. She says she no longer feels nauseated, medication makes her constipated. I told to discontinue use of compazine. ------------------------------------------- A. Wilson, MD

When opening the office in the morning, the medical assistant should call the answering service to get messages and tell the service that the office is open and will be answering the phone. When closing the office, the medical assistant will call the answering service and alert them to answer incoming calls and the physician who will be receiving any emergency calls that arise. Ofces that might not offer 24-hour phone coverage, such as optometrists, chiropractors, physical and occupational therapists, and radiology groups, may use an answering machine when the ofce is closed. The answering machine message should include the name of the ofce and when the ofce will reopen. The message may also include instructions for emergency care. Emergencies may be referred to 911 or the nearest emergency roomfor example, You have reached Middleeld Chiropractic Associates. The ofce is now closed. Our ofce hours are Monday through Thursday 8:30 a.m. to 7:00 p.m. and Friday and Saturdays from 8:30 a.m. to 2:00 p.m. If this is a medical emergency, please call 911 or go to the nearest emergency room. To leave a message for the ofce, please wait for the tone. Thank you for calling Middleeld Chiropractic Associates. Alternatively, the message may provide a physicians cell phone numberfor example, You have reached Middleeld Chiropractic Associates. The ofce is now closed. Our ofce hours are Monday through Thursday 8:30 a.m. to 7:00 p.m. and Friday and Saturdays from 8:30 a.m. to 2:00 p.m. If this is an emergency, please call 911. To speak to the on-call physician, please dial 123-555-9708. To leave

a nonemergency message for the ofce, please wait for the tone. Thank you for calling Middleeld Chiropractic Associates.

Chapter Summary

Using courteous, clear communication on the telephone helps promote understanding and good relationships with patients, insurance companies, and vendors. Accurate appointment scheduling, driving directions, and billing questions are the responsibility of the medical assistant; medical questions should be directed to the physician or registered nurse. The medical assistant must assess emergency versus routine patient needs on the phone in a methodical, calm manner and take appropriate actions. Taking accurate and complete messages for physicians and coworkers allows patient questions and concerns to be addressed properly and shows patients that their needs are important to staff and physicians. Proper documentation of phone calls ensures complete, accurate records of telephone exchanges. The use of answering services or machines allows access to the ofce when it is closed. Understanding the telephone system and protocols will help the medical assistant perform her job duties.

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Team Work Exercises

1. Assume that your class is in charge of answering the phones at a busy pediatric ofce. Create roles for class members, including: a. administrative medical assistants b. clinical medical assistants c. registered nurses d. physicians e. billing staff f. ofce manager g. parent or guardian Take turns playing the part of the parent or guardian who calls with a request, including: a. scheduling an appointment b. asking about an emergency medical situation c. changing the time of an existing appointment d. parent new to the area scheduling an appointment for a child (new patient) and needing directions to the ofce Discuss as a group what the appropriate responses are to the various calls. 2. In groups of three to ve, create lists of medical jargon and slang that could be confusing to patients when spoken over the phone. Create a dialogue using these terms and try to confuse the other groups with your use of jargon and slang.

billed Mr. Kraft, but he tells you, You had better not bill me for that visit, or Ill sue you. Mr. Kraft does not want to hear that you can appeal the denial if he is willing to ll out the form that was sent to him. He tells you, Paperwork is your *&$*& job, not mine! What should you do? Should you alert the physician or the ofce manager? Discuss the scenario with your classmates. 2. Sadie Collins calls to cancel her follow-up appointment for her clavicle fracture of 10 weeks ago. She states that she feels ne and does not need to come in. What documentation should you write in Sadies chart? Why?

Resources

Revamping your telephone technique: www.nb.com/ object/IO_27174.html Telephone technique self-test: www.ompersonal.com.ar/ selftests/telephonetechnique.htm Belding, S.: Winning with the Caller from Hell: A Survival Guide for Doing Business on the Telephone. Toronto: ECW Press, 2006. Evenson, R.: Customer Service Training 101: Quick and Easy Techniques That Get Great Results. Albany, N.Y.: AMACOM Publishing, 2005.

Case Studies
1. Mr. Kraft calls the ofce and is very angry. His insurance denied a claim for an ofce visit saying that the visit was not medically necessary. The physicians ofce has not yet

CHAPTER

Appointment Scheduling
Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell key terms related to appointment scheduling compare and contrast the various types of scheduling create an appointment matrix for a practice prepare a daily appointment sheet describe six considerations in scheduling appointments discuss the importance of triage in scheduling patient appointments create proper cancellation documentation and describe its importance create a reminder system and discuss the three types of reminder systems discuss how practice policies regarding appointments can be applied schedule and monitor appointments schedule inpatient and outpatient hospital procedures triage phone calls, giving priority to patients who need immediate care maintain condentiality in appointments on a computerized or manual system communicate effectively with patients, giving directions and instructions when needed.
Schedule inpatient and outpatient admissions and procedures

12
Chapter Outline
Challenges in Appointment Scheduling Types of Scheduling Systems
Practice-Based Scheduling Stream Scheduling Cluster Booking Double Booking Wave Scheduling Open Hours Catch-up Time

Clinical Patient Care

Perform telephone and in-person screening

General Professional Communications

Recognize and respond to verbal communications Demonstrate telephone techniques

Operational Functions
Utilize computer software to maintain ofce systems

Patient scheduling
Scheduling Patients by Phone New patient Established patient Scheduling Patients During In-ofce Checkout Appointment Matrix Computerized appointment systems Manual appointment book system Daily worksheet Appointment Changes and Cancellations Computerized changes and cancellations Charging for cancelled visits or denying future visits Triage for Setting Appointments

ABHES Competencies
Communication
Use proper telephone techniques Interview effectively Use appropriate medical terminology Recognize and respond to verbal and nonverbal communication

Administrative Duties
Apply computer concepts for ofce procedures Schedule and maintain medical records Schedule inpatient and outpatient admissions

Procedures
Creating appointment cards Creating an appointment matrix and scheduling appointments using the rules of triage Documenting appointment cancellations and no-shows and rescheduling appointments Scheduling inpatient and outpatient procedures

Referral Procedures Termination of Services Chapter Summary Team Work Exercises Case Studies Resources

CAAHEP Competencies
Administrative Perform Clerical Functions
Schedule and manage appointments

133

Key Terms
appointment matrix

Grid or schedule (computerized or manual) that shows the times available for scheduling patients and the days and hours the practice is open (excluding lunches and breaks)
catch-up time

Challenges in Appointment Scheduling

The success of an ofce and quality of care depend on consistent scheduling to create a workow. If scheduling is done haphazardly, patients will be required to wait for long periods of time or be rushed through an appointment, which may compromise the quality of care. To allow protable use of the physicians and staff s time, matching the scheduling system to the type of practice and ability of the staff is vital. Imagine a psychologist having ve patients arrive at the same time! However, a general practitioner with several clinical medical assistants may consider ve patients at once an easily workable schedule. Proper planning ensures that equipment in specic rooms is not needed for more than one patient at the same time. If the practice has one x-ray machine, ve patients cannot be scheduled for an x-ray at the same time. The most common complaint among patients is the amount of time spent in the waiting room. Patients appreciate when the staff recognizes that their time is valuable and works to reduce waiting time. Overall patient satisfaction is increased when attention to scheduling prevents long waiting.

Time in the schedule that is not booked with appointments to let doctors and staff catch up on paperwork, return phone calls, or catch up with appointments if patient visits take longer than anticipated
cluster booking

Scheduling technique that involves consecutive booking of patients who have similar problems or are undergoing similar procedures
double booking

Scheduling technique in which several patients are scheduled for the same appointment time and are attended to at the same time in different rooms
established patient

Patient who has previously received care at the ofce

modied wave

Scheduling technique in which two or three patients are scheduled at the beginning of each hour and then one patient is scheduled every 10 to 20 minutes into the hour
new patient

Patient who has not previously received care at the ofce

no-show

Patient who has a scheduled appointment but fails to appear

open hours

Types of Scheduling Systems

The type of patient scheduling used in the ambulatory care ofce depends on many factors. How many doctors, nurses and clinical medical assistants are available to care for patients? How many treatment rooms are available? What type of equipment is used and what procedures are performed in the treatment rooms? Because all of these issues must be considered, there are several scheduling systems an ofce can choose as the best for that practice.

Block of time in which patients are seen by the physician on a rst-come, rst-served basis
practice-based

Scheduling technique that designates special days for common treatments based on time limits and staff and equipment availability
stream

Most common scheduling technique in which patients are seen in a steady stream at set appointment times of 15-, 30-, 45-, or 60-minute intervals
triage

Practice-Based Scheduling
Most specialty groups develop their own method for scheduling patients based on time limits and staff and equipment availability. Such a system is called practice-based scheduling. For example, an orthopedist might schedule a recheck in the morning on a patient who needs physical therapy (PT) so that the patient can go to PT immediately after the appointment. An obstetricians ofce may schedule all ultrasounds on Thursdays, when the technician is scheduled to work; an orthodontist may restrict scheduling ttings for new braces to Monday and Wednesday mornings to cluster the times that she will be unavailable to see other patients.

Process of determining if a patient has an emergency and needs to go to the emergency room or if he can be worked into the physicians schedule for the day
wave

Scheduling technique in which patients are scheduled in the rst half-hour of each hour

Stream Scheduling
If equipment is portable or available in all treatment rooms, a simpler system to utilize would be the stream system.

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Ofces using this system see patients in a steady stream at set appointment times of 15-, 30-, 45-, or 60-minute intervals. The type of appointment dictates how much time is reserved for each patientfor example, 60 minutes for a new patient (someone who has never been seen at the ofce before), 45 minutes for a stress test, and 15 minutes for a checkup.

get current with paperwork or return phone calls. After an ofce surgery, the room must be thoroughly cleaned, taking up the clinical medical assistants time and attention. This time also allows the schedule to run on-time if patient visits take longer than anticipated. Short breaks in the schedule can also allow doctors and staff to take a break, make a personal phone call, or use the restroom.

Cluster Booking
When patients with similar problems or procedures are booked consecutively, it is called cluster booking. Examples of cluster booking include pediatric vaccines and routine gynecologic appointments, which might be booked on a specic day or only in the afternoon to allow equipment and supplies to be prepared ahead in anticipation of these patients.

Patient Scheduling
Scheduling appointments with patients can happen over the telephone or when the patient checks out of the ofce after an appointment. When scheduling a patient over the phone or in person, the medical assistant should be sure to include all necessary information to avoid confusion on the part of the patient or the ofce staff.

Double Booking
Sometimes, several patients are scheduled for the same appointment time and are attended to at the same time in different rooms. This technique is called double booking. Large and small practices can double book; however, in a small ofce, juggling patients can get hectic. Double booking works best for short visits. For example, a chiropractic ofce may schedule several patients for the same time who need a maintenance adjustment and no therapy at the time of the visit.

Scheduling Patients by Phone

When scheduling a patient for an appointment over the telephone, the medical assistant must rst determine if the patient is a new patient or an established patient (someone who has been seen in the ofce previously and whose medical record is kept at the ofce).

Wave Scheduling
In the wave scheduling system, patients are scheduled in the rst half-hour of each hour. Because there will be some early, some late, and some no-show patients (patients who do not cancel but simply fail to appear for their appointments), the hour will ll. This system works best in a larger practice; a small ofce runs the risk of doctors waiting with no patients to be seen. A variation of this system is called the modied wave system. In this system, two or three patients are scheduled at the beginning of each hour and then one patient is scheduled every 10 to 20 minutes into the hour. This modication to the wave system may ensure a more consistent patient ow.

New Patient
When scheduling a new patient, the medical assistant will need to gather information from the patient prior to the visit. This information will include the patients:

name address and phone number insurance carrier and policy number reason for the appointment.

Open Hours
Emergency rooms and clinics commonly use the open hours scheduling method. Patients are seen by the physician on a rst-come, rst-served basis. This system may cause patients to wait several hours to be seen, but no appointment is necessary. Of course, any life-threatening or urgent condition is treated immediately.

The medical assistant may also ask the patient to bring copies of previous medical records, recent x-rays, or laboratory results. The medical assistant should always remind a new patient to bring her insurance card to the visit so that a copy can be made. A new patient may need information from the medical assistant regarding insurance coverage, office hours, and copayment fee policies as well as directions to the office. It may be the policy of an office to mail an informational brochure to a new patient prior to her appointment. (See Informational office brochure, page 136.)

TIP New Patient, More Time

A new patient must complete Condential Patient Information and HIPAA forms. Thus, the administrative medical assistant should be sure to schedule extra time for the patient to ll out paperwork before the examination.

Catch-up Time
No matter the scheduling system, catch-up time, when no patients are scheduled, should be incorporated to let doctors

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Patient Education

Informational Ofce Brochure

The informational ofce brochure is an opportunity for the medical ofce staff to assist a new patient in achieving a smooth transition to a new health care provider and ensuring continuity of care for that patient. Brochures can be given to patients in the ofce or mailed to them upon making their rst appointment. Such a brochure could include: hours of practice scheduling and cancellation procedures insurance participation services offered.

Brochure as referral
The ofce brochure can also act as a patient referral tool. Specialty practices can send copies of the brochure to primary care providers to indicate what services the ofce can provide to their patients.

Services Include: Blueville Family Medicine

15 Main Street Blueville, CT 860-555-3212 Routine physicals, including well-child, well-adult, and sports physicals All childhood immunizations, including HPV In-office x-ray and physical therapy departments Acupuncture Nutritional counseling, including weight loss and diabetes management Robert Greer, MD Family Medicine Hector Rodriguez, MD Family Medicine Anne Wilson, MD School and Sports Physicals Sharon Piecek, APRN Nutritional Counseling and Weight Loss, Diabetes Management Henry Lee, MD Acupuncture Ample parking at side of building Conveniently located next to Johnson Auto Body
nS hn Jo so

Emergency, 24-hour on-call service Affiliated with Hartell Memorial Hospital Most insurance accepted

Main

St.

Established Patient
Scheduling an appointment for an established patient by phone will be shorter because less information is needed. However, the medical assistant should ask a patient who has not been seen for a while if any personal information, such

as address, phone number, and insurance carrier, has changed. If the patient has changed insurance, the medical assistant should explain differences in coverage or copayment and ask that the patient bring the insurance card at the time of the visit.

W es

tD

r.

t.

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TIP Conrm, Conrm, Conrm The medical assistant should conclude all appointment phone calls by conrming the information. For example, she should say, Okay, Mrs. Jones, we will see you on Wednesday, February 4th, at 3:30 p.m.

Appointment Matrix
An appointment matrix is a grid or schedule of appointments that shows time slots for scheduling patients and the practices days and hours of operation. The matrix is organized to show rooms, doctors and other personnel, and hours of use. The matrix can be created in advance and show blocked time for holidays, vacation time, lunches, and breaks. Scheduled machine maintenance can be included to reflect rooms that may be unavailable at a given time. (See Procedure 12-2: Creating an appointment matrix and scheduling appointments using the rules of triage, page 138.) The appointment matrix may be computerized or in a book form.

Scheduling Patients During In-Ofce Checkout

After patients see the physician, they must check out and schedule a follow-up appointment, if necessary. Scheduling a follow-up appointment should include offering an appointment card. An appointment card is a courtesy to the patient, and many ofces create them on the computer. (See Procedure 12-1: Creating appointment cards, page 138.) It helps them remember the date and time of the appointment and provides the ofce telephone number if the patient needs to reschedule. (See Figure 12-1.) The copayment may be taken before or after the patient visit, based on ofce policy. Also, remember to offer a receipt based on ofce policy.

Computerized Appointment Systems

Most ofces are fully computerized and patient appointments are made using a computer. The system will allow the user to jump from various days and times while viewing the other appointments that have already been scheduled. (See Figure 12-2.) If the system is not working, the medical assistant can make tentative appointments for patients and then call them back with changes (if necessary) when the system is working again. The new administrative medical assistant may be familiar with the software from school or will need to be trained on the specic software program. The differences among the various programs are minor and the student who is procient in one software program should easily adapt to the ofce software.

TIP Offer All Options When offering an appointment to patients on the phone or in person in the ofce, ask them if they would like a morning or afternoon appointment and then offer specic times. For example:
Medical Assistant: Is the morning of the 17th better or the afternoon? Patient: Afternoon, please. Medical Assistant: I have a 3 p.m. or a 4:30 p.m. on the 17th. Rather than asking, What time is good on the 17th? prompting the patient with specific times will expedite the scheduling process by offering only available appointments.

TIP Appointment Analysis An ofce may generate appointment reports by day, week, month, or specic doctor to track trends and identify busy times. Analysis of the appointment trends can be used to adjust staff scheduling to meet the needs of the practice. For example, if Wednesdays after school are particularly popular

Blueville Family Medicine

15 Main Street Blueville CT 860-555-3212 Name Date Time

Patricia Leitch April 14, 2008 3:00 pm

A. Wilson, MD

If you are unable to keep your appointment, please call the office 24 hours in advance. R. Greer, MD H. Rodriguez, MD H. Lee, MD

S. Piecek, APRN

FIG 12-1 Appointment card given to patients making follow-up appointments in the ofce.

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Administrative

PROCEDURE 12-1

Creating appointment cards

Task Create appointment cards and give to ve patients at the front desk after scheduling. Conditions Computer Card stock Scissors or paper cutter Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully create appointment cards to give to patients during appointment scheduling. Performance Standards 1. Using your computer, card stock, and scissors, create appointment cards that are the size of a business card so that it can t into the patients wallet. 2. Be sure to include the following information when creating cards: a. name and telephone number of the practice so patients can easily call the ofce if they need to reschedule the appointment. b. line for the patients name so that the family member with the appointment is identied for the patient. c. line to write in the date and time of the appointment for patient reference. 3. Print appointment cards. 4. During the front-desk appointment role-play procedure, write out an appointment card and give it to the patient.

PROCEDURE 12-2

Creating an appointment matrix and scheduling appointments using the rules of triage
Task Create an appointment matrix and manage appointments. Conditions Computer and printer Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully create an appointment matrix and perform scheduling procedures as instructed. Performance Standards 1. Using your computer, create an appointment matrix for Drs. Greer, Rodriguez, Wilson, Lee, and Sharon Piecek, APRN, for the week of September 15, 2008 through September 19, 2008. Use the following information when creating the matrix: a. The ofce is open from 8:30 a.m. to 7 p.m. on Monday, Tuesday, and Thursday. b. The ofce is open from 8:30 a.m. to 4:30 p.m. on Wednesday and Friday. c. Create the matrix in 15-minute intervals. Appointments are based on 15-, 30-, 45-, and 60-minute intervals. d. The providers hours are: Dr. GreerMonday from 8:30 a.m. to 3 p.m., Tuesday none, Wednesday from 8:30 a.m. to 4:30 p.m., Thursday from 1 p.m. to 7 p.m., Friday from 8:30 a.m. to 1 p.m.; Dr. RodriguezMonday from 12:30 p.m. to 7 p.m., Tuesday from 8:30 a.m. to 4 p.m., Wednesday none, Thursday from 8:30 a.m. to 4 p.m., Friday from 8:30 a.m. to 1 p.m.; Dr. WilsonMonday none, Tuesday from 11 a.m. to 7 p.m., Wednesday from 8:30 a.m. to 3 p.m., Thursday from 8:30 a.m. to 4 p.m., Friday from 10 a.m. to 4:30 p.m.; Dr. Lee Monday from 8:30 a.m. to 4 p.m., Tuesday from 12:30 p.m. to 7 p.m., Wednesday from 8:30 a.m. to 4:30 p.m., Thursday from 1 p.m. to 7 p.m., Friday from 8:30 a.m. to 4:30 p.m.; Ms. PiecekMonday from 8:30 a.m. to 4:30 p.m., Tuesday from 8:30 a.m. to 1 p.m., Wednesday from 8:30 a.m. to 4:30 p.m., Thursday none, Friday from 8:30 a.m. to 4:30 p.m. 2. Block time for lunches for each provider. Providers working a late shift should be given a break later in the day. Blocking provider times for lunch and breaks allows them to respond to phone messages, eat, and catch up if they get behind schedule. 3. Print the appointment matrix to use at the front desk.

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PROCEDURE 12-2contd

4. Practice telephone procedures by taking ve appointments on the phone (role-play with other students). 5. Two of the patients are new patients (NPs). To ensure complete records, obtain the appropriate information from these patients on the telephone: a. full name b. date of birth to check insurance coverage c. daytime phone number to contact them in case you need to change appointment or they are a no-show d. complete address to send practice information to the patient e. source of referral for marketing purposes f. insurance coverage to check insurance eligibility prior to patient visit g. reason for appointment to schedule the appropriate amount of time for the visit.

6. Role-play the remaining ve appointments with students at the front desk to practice face-to-face appointment scheduling. 7. Schedule the following appointments: a. Candace Burnsu b. John HowardNP c. Lynn Littelsore throat d. Gary ONeilNP smoking cessation e. Jeff Ramirezsuture removal f. Cindy Pantarellaadult PE g. Hannah CollinsBP check h. Sadie Hernandezcast removal i. Christopher Evanssports PE j. Jill Evanssports PE.

Appointment Sheet Friday, January 22nd 9:00 9:15 11:15 11:30 11:45 12:00 1:30 1:45 2:15 2:30 3:00 3:15 3:30 4:00 Hannah Collins Les Collins Sarah Goren Jessica Vente Nora Williams Mike Williams Chris OConnell Joe Hart Maria Ortiz Joe Kramer Susan Howard Tara Olsen Walter Sims Room 1 Room 2 Room 1 Room 2 Room 1 30 minutes 45 minutes 30 minutes 45 minutes 30 minutes Sports physical New patient URI New patient BP & heart check

LUNCH Room 2 Room 1 Room 1 Room 2 Room 1 Room 2 Room 1 Room 2 45 minutes 15 minutes 45 minutes 30 minutes 30 minutes 30 minutes 15 minutes 45 minutes PE/Laboratory work BP check New patient Sports physical Sports physical Sports physical BP check New patient

FIG 12-2 Computerized appointment system day sheet.

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with patients, an extra assistant can be added to accommodate school physicals or vaccinations.

Manual Appointment Book System

A manual appointment book serves as a written record of patient appointments for each day. Books are organized by time, room, or physician as in a computerized system. Although most offices are computerized, the manual appointment book system is always available and can be the primary schedule or used as a backup to a computerized system. As in a computerized system, the manual daily appointment sheet, which is generally a photocopy of that days page of the appointment book, shows the names of patients scheduled for the day, the treatment room for each, and the length and purpose of the appointment. Each day, the medical assistant should make copies of the sheet and post them in the administrative and clinical areas so that staff can anticipate the schedule. In addition, an appointment sheet can be used as a legal record of patient appointments. (See Figure 12-3.)

change. The appointment is removed from the system to accommodate a new appointment in that time slot. The recording of the appointment change in the patients chart is, therefore, the only record of the cancelled appointment. No-show appointments, also called failed appointments, may be noted in the computerized system because that time slot cannot be used for another patient.

Charging for Cancelled Visits or Denying Future Visits

Because revenue is lost when a patients time slot is not lled, some ofces have charge policies for no-show or cancelled appointments. If a patient is a no-show or cancels within 24 hours of the appointment time, the ofce may choose to charge the patient for the copayment amount. The charge policy of the ofce must be in accordance with state and insurance guidelines. The ofce may also deny future appointments to a patient who chronically cancels or fails to appear for appointments. When dealing with this type of patient, it is imperative that the medical assistant be clear about the policy of the ofce regarding charges or denials of visits. (See Why do some patients cancel?)

Daily Worksheet
In a manual or computerized system, the medical assistant may use a daily worksheet to show patient appointments as well as meetings with pharmaceutical representatives, physician or assistant time out of the ofce, staff meetings, and equipment maintenance. Although computerized appointment systems allow the medical assistant to input patient appointments and block time for other purposes, they will rarely allow her to add other notes without specic modications to the software package. In any case, the medical assistant should print a hard copy of the computerized worksheet or photocopy the appointment book and add notes for the staff. Such a worksheet provides a complete picture of staff activities for the day. (See Figure 12-4.)

Triage for Setting Appointments

When a patient calls the ofce for an appointment, the medical assistant must conduct triage, or an evaluation of the urgency of the patients condition. A patient calling for a routine checkup or physical is not an emergency and the medical assistant can schedule this patient at any time that

Why do some patients cancel?

Some patients may have chronic cancelitis; that is, they repeatedly cancel their appointments. A patient may repeatedly cancel appointments because of: fear of a diagnosis or bad news nancial constraints fear of needles or pain shame about mental illness or sexually transmitted disease fear that the ofce staff will mock or judge him.

Appointment Changes and Cancellations

Patients are commonly busy people who may need to cancel or reschedule appointments to t their work schedule and various commitments. When a patient cancels an appointment, it must be noted in the patients chart. In the event that the patient does not come in for follow-up care and her health suffers, the cancelled appointment can show that the physicians ofce was not negligent in scheduling follow-up visits. If applicable, it is also wise to indicate that the ofce offered the patient a new appointment, but that she failed to reschedule. (See Procedure 12-3: Documenting appointment cancellations and no-shows and rescheduling appointments, page 144.)

Treating chronic cancelitis

Patients who chronically cancel may benet from a conversation with a staff member about payment plans or sliding-scale fees as well as the physicians obligation to keep information condential and educate patients as needed. The medical assistant plays an important role in ensuring that patients understand the professional obligations of the medical staff.

Computerized Changes and Cancellations

Rescheduling or cancelling appointments in the computerized system commonly does not leave a record of the appointment

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Appointment Sheet Friday, January 22nd 9:00 9:15 9:30 9:45 10:00 10:15 10:30 10:45 11:00 11:15 11:30 11:45 12:00 12:15 12:30 12:45 1:00 1:15 1:30 1:45 2:00 2:15 2:30 2:45 3:00 3:15 3:30 3:45 4:00

Maria Ortiz Joe Kramer

Room 1 Room 2

30 minutes 45 minutes

Sports physical New patient

Susan Howard Tara Olsen Walter Sims LUNCH LUNCH LUNCH LUNCH LUNCH LUNCH Hannah Collins Les Collins

Room 1 Room 2 Room 1

30 minutes 45 minutes 30 minutes

URI New patient BP & heart check

Room 2 Room 1

45 minutes 15 minutes

PE/Laboratory work BP check

Sarah Goren Jessica Vente

Room 1 Room 2

45 minutes 30 minutes

New patient Sports physical

Nora Williams Mike Williams Chris OConnell

Room 1 Room 2 Room 1

30 minutes 30 minutes 15 minutes

Sports physical Sports physical BP check

Joe Hart

Room 2

45 minutes

New patient

FIG 12-3 Manual appointment sheet.

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is convenient for the ofce and the patient. If, however, the medical assistant determines that the patient needs immediate attention, she can direct the patient to come in immediately or go to the emergency room. When questioning patients on the phone, the medical assistant must be careful to get the needed information without panicking the patient or trivializing the situation. Asking clear, concise, openended questions will elicit the information needed. Examples of items to ask include:

This type of appointment triage is for phone appointment requests only. If a patient appears in the ofce without an appointment but is a possible emergency situation, it is considered an ofce emergency. (See Chapter 47, Ofce Emergencies, page 967, for more information.)

How long have you had the symptoms? Where is the pain? How intense is the pain? Does it radiate? Where is the origin of the bleeding or discharge? How profuse? If fever, how high? (See Phone triage notes, page 145.)

TIP Tele-Triage Each medical ofce should have a triage what-to-do sheet near every phone. The list should contain questions to ask if the call is a medical emergency; for example:
Who is the patient? Is the patient conscious? Is the patient breathing? Where are you calling from?

Daily Worksheet Friday, January 22nd 9:00 9:15 10:00 11:15 11:30 11:45 12:00 1:30 1:45 2:00 2:15 2:30 2:45 3:00 3:15 3:30 3:45 4:00 Maria Ortiz Joe Kramer Room 1 Room 2 30 minutes 45 minutes Sports physical New patient

Dr. Greer out of office dentist appointment Susan Howard Tara Olsen Walter Sims Room 1 Room 2 Room 1 30 minutes 45 minutes 30 minutes URI New patient BP & heart check

Meet with pharmaceutical rep regarding new lipid-lowering drug Hannah Collins Les Collins Room 2 Room 1 45 minutes 15 minutes PE/Laboratory work BP check

Centrifuge calibration call ABC Electronics to confirm Sarah Goren Jessica Vente Room 1 Room 2 45 minutes 30 minutes New patient Sports physical

UPS pickup for broken hemocytometer Nora Williams Mike Williams Room 1 Room 2 30 minutes 30 minutes 15 minutes Sports physical Sports physical BP check

Chris OConnell Room 1

Sarahs husband is coming in to change light fixture in room 1 Joe Hart Room 2 45 minutes New patient

FIG 12-4 Daily worksheet. (A) Computerized daily worksheet.

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Daily Worksheet Friday, January 22nd 9:00 9:15 9:30 9:45 10:00 10:15 10:30 10:45 11:00 11:15 11:30 11:45 12:00 12:15 12:30 12:45 1:00 1:15 1:30 1:45 2:00 2:15 2:30 2:45 3:00 3:15 3:30 3:45 4:00

Maria Ortiz Joe Kramer

Room 1 30 minutes Sports physical Room 2 45 minutes New patient

Dr. Greer out of office dentist appointment

Susan Howard Tara Olsen Walter Sims LUNCH LUNCH LUNCH LUNCH LUNCH

Room 1 30 minutes URI Room 2 45 minutes New patient Room 1 30 minutes BP & heart check

Meet with pharmaceutical rep regarding new lipid-lowering drug

Hannah Collins Room 2 45 minutes PE/Laboratory work Les Collins Sarah Goren Jessica Vente Nora Williams Mike Williams Room 1 15 minutes BP check Room 1 45 minutes New patient Room 2 30 minutes Sports physical Room 1 30 minutes Sports physical Room 2 30 minutes Sports physical
Centrifuge calibration call ABC Electronics to confirm

UPS pickup for broken hemocytometer

Chris OConnell Room 1 15 minutes BP check

Sarahs husband is coming in to change light fixture in room 1

Joe Hart

Room 2 45 minutes New patient

(B) Manual daily worksheet.

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PROCEDURE 12-3

Documenting appointmet cancellations and no-shows and rescheduling appointments

Task Document cancellations and no-shows and reschedule appointments. Conditions Appointment matrix created in Procedure 12-1 on page 138 Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully document three cancelled appointments and reschedule these appointments and document a no-show appointment in the appointment matrix and call the no-show patient to reschedule. Performance Standards Telephone role-play several scenarios with a classmate. Scenario 1 1. Lynn Littel has a sore throat and needs to reschedule her appointment for Wednesday after 3:30 p.m. 2. Mark Ms. Littels appointment as cancelled in the appointment matrix to allow that time slot to be used by another patient and reschedule her appointment. 3. Repeat the new date and time of the appointment to Ms. Littel to ensure that the patient has the correct date and time. Scenario 2 1. Mrs. Evans calls regarding Christopher and Jills appointments. She needs to bring Jill on Tuesday (any time) and Christopher on Thursday or Friday when he is home from soccer camp. 2. Mark Christopher and Jills appointments as cancelled and reschedule their appointments. Repeat the new dates and times to Mrs. Evans to ensure communication. Scenario 3 1. John Howard did not show up for his appointment with the nurse practitioner (NP). Call Mr. Howard and identify yourself and the practice to ensure that the patient knows who is calling. 2. Tell him that he had an appointment on the date and at the time specied in your appointment matrix to inform him of the purpose of your call. 3. Ask him to reschedule. If he chooses to do so, reschedule the appointment. 4. Inform him of the no-show policy of the ofce (if a charge applies to no-show appointments) so that he will be less inclined to fail to appear for another appointment. 5. If he chooses not to reschedule, tell him to call in the future if he needs care from the ofce. Remaining pleasant and professional may result in a future appointment. 6. Mark the no-show appointment in the matrix to ensure a complete record. 7. Mark the new appointment for Mr. Howard (if necessary) and add the new patient information for the new appointment to ensure a complete record.

Referral Procedures
A specialty ofce may require a referral from the patients primary care provider for insurance reimbursement. When the medical assistant is scheduling an appointment over the phone, she must tell patients if they are required to bring a referral form at the time of the visit or if their primary care practitioner will be faxing a referral form. When working for a primary care practitioner, faxing referral forms or handing the referral form to the patient for specialty care happens during the ofce checkout procedure. The medical assistant may need to schedule appointments for hospital services

for patients and should remember to include referral information to ensure eligibility for medical insurance payment. (See Procedure 12-4: Scheduling inpatient and outpatient procedures.)

TIP HIPAA TIP Because faxing a referral form is considered a transmission of patient identiable information, the record of each transmission must include a conrmation that the fax was received by the correct fax machine. The medical assistant should print the receipt and keep it in a designated fax transmission le for future reference.

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Phone triage notes

Each ofce will have specic phone triage guidelines; the table below shows what scenarios need immediate attention and if the patient should go to the emergency room or call 911.

Scenario
Difculty breathing Chest pain Bleeding

Action
Patient calls 911* or goes immediately to the emergency room.** Patient calls 911* or goes immediately to the emergency room.** Depending on the extent of bleeding: patient comes to the ofce immediately. for arterial bleeding, patient calls 911* or goes to the emergency room.**

Rash or fever Possible allergic reaction

Patient comes in to the ofce (work-in patient appointment). Medical assistant evaluates the reactions severity on the phone: patient with breathing difculty goes to the emergency room.** patient with minor allergic reaction (such as swelling or rash) comes to ofce immediately.

Wounds or possible fractures

Patient comes to the ofce if the medical assistant determines that the wound or fracture is minor. (An orthopedic ofce may see a possible fracture in the ofce or direct the patient to the emergency room** and send the on-call physician to meet them.)

* When directing a patient to call 911, the ofce policy may be to stay on the line with the patient while another employee calls 911 and reports the emergency and the address. A child or hysterical adult would never be directed to place the 911 call without help. Discussing these potential situations with all staff members ensures that policies for emergency phone calls will be consistent. ** Only direct people to drive to the emergency room if there is a driver other than the patient available.

PROCEDURE 12-4

Scheduling inpatient and outpatient procedures

Task Schedule a patient for one inpatient and two outpatient procedures using the physicians orders and obtain proper precertication and referrals. Conditions Physicians orders Two copies of a blank referral form Hospital precertication form Patients medical record (ofce notes) Reminder card Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully complete a referral form for hospital admission precertication and outpatient specialty referrals and schedule related procedures. Performance Standards 1. Make an extra copy of the blank referral form provided on page 148. 2. Refer to the physicians order for MRI, arthroscopic surgery, and physical therapy for Lynn Olsen. Carefully read the physicians orders to avoid errors or confusion. Role-play the following steps with another student. MRI referral 3. Call the patients insurance carrier for referral approval and a referral number to ensure that the insurance carrier will pay for the procedure. 4. Using the information gathered from the order, the photocopy of the insurance card, Ms. Olsens ofce notes, and the insurance phone call, complete the referral form for an MRI scan, according to managed care policies and procedures to ensure third-party guidelines are followed and reimbursement is not compromised. 5. Check the referral for spelling and completeness to ensure accuracy. 6. Call the MRI scheduler with Ms. Olsen at the desk and coordinate between the hospitals schedule and the patient to avoid scheduling conicts.
Continued

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7. Give Ms. Olsen a reminder card with the scheduled appointment to remind the patient of the date and time of the scan. 8. Ask Ms. Olsen if she needs directions to the MRI facility and provide them as needed. Arthroscopic surgery precertication 9. Refer to treatment notes from 10/03/08. 10. Call the patients insurance carrier for precertication to ensure payment for the procedure. 11. Using the necessary documentation, complete the hospital precertication for surgery according to thirdparty guidelines, being sure to include a precertication number to ensure payment. 12. Check the precertication for completeness and accuracy to ensure proper documentation and payment.

13. Schedule the surgery with the patient and the hospital scheduler to avoid scheduling conicts for the patient. Physical therapy referral 14. Refer to the patients ofce notes from 10/14/08, postsurgical checkup. 15. Refer to the second outpatient services referral form for Lynn Olsens postsurgical care. 16. Using the physicians orders, operative notes, and treatment notes, complete the referral form for physical therapy (according to the managed care policy), being sure to check for completeness and accuracy. 17. Call the PT ofce to schedule the rst PT visit while the patient is present to avoid scheduling conicts. 18. Submit all forms to your instructor for approval.

Physicians Orders Blueville Family Medicine 15 Main Street Blueville CT 860-555-3212 Patient: Robert Greer, MD Hector Rodriguez, MD Anne Wilson, MD Sharon Piecek, APRN Henry Lee, MD

Lynn Olsen Date of Birth: 05/01/88 Arthroscopic repair of meniscal tear right knee. Patient to be seen in office 3 days postop. Arrange physical therapy to begin after postop check. CBC Preop Labs: Torn right medial meniscus; suspected lateral Diagnosis: meniscal tear Hector Rodriguez, MD

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PROCEDURE 12-4contd

Patient treatment notes (from patient file) 09/28/08 Patient presents with knee pain, limping favoring right leg. She states she was playing soccer yesterday and felt something move inside my knee. Patient complains that after soccer game, the knee locked. Pain is intermittent, sharp, and sometimes debilitating. Positive orthopedic findings: palpable click upon extension, + McMurrays test, pain upon compression and rotation, negative anterior draw test. Order MRI to confirm tear. H. Rodriguez, MD 10/03/08 MRI of right knee 10/01/08 confirms medical meniscal tear; suspected lateral tear, cannot be confirmed. Order arthroscopic repair. H. Rodriguez, MD 10/14/08 Postop check arthroscopic procedure to right knee of 10/09/08. Repair of medial meniscal tear; no lateral tear was noted. Healing well, no postop swelling, no fever, no infection at scope sites. Schedule PT - 3X per week for 2 weeks, active ROM and strengthening. Return in 2 weeks for check. H. Rodriguez, MD Photocopy of patients insurance ID card:
IELD OSS AND BLUE SH ANTHEM BLUE CR

Lynn Olsen

: XJF0099888888 IDENTIFICATION NO Care POE, $10.00 State Blue iguez, MD PCP: Hector Rodr Group Number: 8089 933X

Continued

Termination of Services
In addition to a verbal denial of appointments to a patient who chronically fails to appear for or cancels appointments, written communication is also necessary. Such a letter should indicate that the physician will no longer care for the patient. (For more information on such a letter, see Chapter 6, Legal Considerations, page 53.)

Chapter Summary

Appointment scheduling can impact quality of care and should follow a consistent system that creates an efcient workow. Scheduling patients to t the type of practice, space constraints, and availability of staff and equipment enables the best use of resources and protable use of physician and staff time.

Patients appreciate when scheduling decreases waiting time but does not require patients to be rushed through appointments. The medical assistant must obtain such standard information as the patients name, telephone number, insurance carrier, and insurance ID number (as determined by the practice) to prepare adequately for patient visits. Patients should be scheduled by phone in a clear, concise, courteous manner. Phone calls should end with the medical assistant repeating the appointment time and date for extra clarication. Appointments scheduled in the ofce should include issuing a reminder card, collecting a copayment, and answering administrative questions as needed.

Team Work Exercises

1. Discuss which form of scheduling will be most efcient for the following types of practices: a. pediatrician (two physicians, two medical assistants, and one RN)

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PROCEDURE 12-4contd

Outpatient Services Referral

Blueville Family Medicine 15 Main Street Blueville CT 860-555-3212

Robert Greer, MD Hector Rodriguez, MD Anne Wilson, MD Sharon Piecek, APRN Henry Lee, MD

Patient: Date of Birth: Insurance Carrier: ID #: Referred to Facility address Facility phone First appointment date Reason for referral Physician orders Gender: Group #: Referral #:

b. ophthalmologist (one physician and two medical assistants) c. psychologist (one therapist and one medical assistant) d. chiropractor (one physician and one medical assistant). 2. You work at a busy multiphysician ofce that is fully computerized. The schedule for the day has been printed and posted at the front desk and in the clinical area. At 3:00 p.m., the computer system stops working. Technical support has been called but the problem will not be resolved until at least 5:00 p.m. Discuss as a group solutions to your scheduling dilemma.

Case Studies
1. Kevin Donohue is scheduled for a stress test and heart checkup with Dr. Greer. He calls to cancel the appointment and says that he doesnt want to reschedule since he is feeling great, and doesnt want to waste the 10-dollar copayment. What should the medical assistant say to Kevin? What documentation should she send as a follow-up to the phone call? Should she speak to Dr. Greer? 2. Wendy OLeary has just failed to appear for the fourth appointment in a row. The medical assistant calls her

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PROCEDURE 12-4contd

Hospital Precertification Verification for Admission

Blueville Family Medicine 15 Main Street Blueville CT 860-555-3212

Robert Greer, MD Hector Rodriguez, MD Anne Wilson, MD Sharon Piecek, APRN Henry Lee, MD

Patient: Date of Birth: Insurance Carrier: ID #: Referred to Facility address Facility phone Date of admission Diagnosis Approved length of stay Surgical procedure(s) Other procedure(s) Copayment Gender: Group #: Referral #:

house but only the answering machine answers. What type of message (if any) should the medical assistant leave? What should she say to Wendy if she calls for another appointment? Discuss with classmates and the instructor the various reasons patients fail to appear for or cancel multiple appointments.

Appointment Quest: www.appointmentquest.com/scheduling/ healthcare Leonardo MD Online Medicine: www.LeonardoMD.com Schedule View: www.scheduleview.com/medicalschedulingsoftware.htm

Resources
These web sites are vendors for medical ofce scheduling software and include demonstration software:

CHAPTER

Written Ofce Communications and Mail

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms as presented in the glossary describe the functions of written communications in the ambulatory care setting identify the various types of letters, notes, faxes, and e-mails that may be written by the medical assistant identify the parts of a letter in the four major letter styles compose business letters to patients, attorneys, and insurance companies identify the various types of incoming mail to the ofce proofread documents for grammar, spelling, and content address envelopes consistent with postal regulations transcribe medical documents from audiotapes and written notes.
Perform within legal and ethical boundaries Establish and maintain the medical record

13
Faxed Documents Preparing an Envelope Internal Marketing
Reminder Notes Birthdays and Holidays Generating Referrals

ABHES Competencies
Communication
Receive, organize, prioritize, and transmit information expediently Use correct grammar, spelling, and formatting techniques in written works Apply electronic technology Master fundamental writing skills

Administrative Duties
Perform basic secretarial skills Locate resources and information for patients and employers

E-mail Guidelines Incoming Mail Transcription of Medical Documents Chapter Summary Teamwork Exercises Case Studies Resources

Legal Concepts
Follow established policy in initiating or terminating medical treatment

Procedures
Responding to written communications Initiating written communications

CAAHEP Competencies
General Competencies Professional Communications
Respond to and initiate written communications

Chapter Outline
Communications and the Medical Ofce Business Letters
Four Styles for Letters Letters to Patients Letters to Physicians Letters to Attorneys

Legal Concepts
Identify and respond to issues of condentiality

151

Key Terms
business letter

Formal document sent by mail that contains information related to business, rather than personal, affairs
dictation

Communications and the Medical Ofce

Written communication in the medical office is an important responsibility of the administrative medical assistant. Clear, concise, professional communications reflect the professionalism of the medical assistant and the medical office. Correspondence to patients, referring physicians, attorneys, and insurance carriers should be thoughtfully composed and mailed in a timely and cost-effective manner. To ensure professionalism, the medical assistant should proofread these communications, which involves checking for accuracy in spelling, punctuation, grammar, word choice, and sentence structure. Health Information Portability and Acountability Act (HIPAA) guidelines must be considered when choosing letters, faxes, and e-mail as the appropriate form of written communication. Confidentiality of written communications is important to safeguard a patients medical and financial information.

Creation of a tape or computer voice le to be transcribed

internal marketing

Method used to stimulate business with existing patients through mailings and other means
proofread

Check of a written document for accuracy in spelling, punctuation, grammar, word choice, and sentence structure
summary of care

Written description of assessment, services (procedures), and outcomes of care provided to a patient
transcription

Creation of a written document from dictated tapes or computer voice les

Business Letters
The business letter is used when a formal document is needed. Copies of letters to patients, referring physicians, or attorneys should be placed in the patient le. Electronic backup on USB drives or CD-ROM ensures that the correspondence is recorded. Business letters include:

datedate on which the letter is written (Position the date according to the style of letter used.) inside addressname, address, and zip code of the letters recipient attention linespecic person to whom the letter should be delivered (If the recipients name is not known, a title or specic department can be used.) Example: MEDICAL DIRECTOR BILLING DEPARTMENT salutationgreeting that begins the letter by addressing the recipient (Capitalize the rst letter of each word. Use Miss or Ms., as preferred by recipient, if known; use To Whom it May Concern if name is not known.) Example: Dear Mrs. Smith subject or regarding linebrief explanation of the purpose of the letter Examples: ACCOUNT OVERDUE PHYSICAL THERAPY SERVICES bodymessage of the letter closingending of the letter

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signature linename and title of the person who signs the letter reference notationabbreviation at the bottom of the last page of the letter that is used to identify the person who typed the letter

enclosure notationindication for the reader of any materials enclosed with the letter copy notationlist of the people that received the letter in addition to the addressee. (See Elements of a business letter.)

Elements of a business letter

The following letter includes the different elements that can be included in a business letter.
DATE POSITION THE DATE ACCORDING TO THE STYLE OF LETTER USED. August 27, 2008 Gottlieb and Associates 654 Draden Court Regency, NV 30948 ATTN: Ms. Jane Devere Dear Ms. Devere: Re: First office visit INSIDE ADDRESS ATTENTION LINE IF THE RECIPIENTS NAME IS NOT KNOWN, A TITLE (SUCH AS MEDICAL DIRECTOR) OR SPECIFIC DEPARTMENT (SUCH AS BILLING DEPARTMENT) CAN BE USED. SALUTATION CAPITALIZE THE FIRST LETTER OF EACH WORD. USE MISS OR MS., AS PREFERRED BY RECIPIENT IF KNOWN; USE TO WHOM IT MAY CONCERN IF NAME IS NOT KNOWN. SUBJECT OR REGARDING LINE

Welcome to Associated Dermatologists! The staff and I are happy that you chose us for your dermatology needs. Enclosed please find a new patient registration form, HIPAA privacy practices, and an office brochure. Please complete the registration form and sign the HIPAA form. Please bring these documents with you on your first visit, which is scheduled for Wednesday, September 17, at 9:30 am. The enclosed office brochure has a map to our office for your convenience. Please note that cell phones must be turned off and we do not permit eating, drinking, or smoking in our office. If you have any questions, please feel free to call and talk to a member of my staff. BODY I look forward to seeing you on Wednesday, September 17, at 9:30 am. Sincerely, CLOSING SIGNATURE LINE ENCLOSURE NOTATION

Rachel James, MD

Rachel James

ccd enc: HIPAA privacy policy form, new patient registration form, office policies and procedures brochure COPY NOTATION cc: Patient file

REFERENCE NOTATION

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Four Styles for Letters

Letters can be written in four basic styles:

full-blockmost common format for business letters, with all lines in standard letter format, ush left modied-blocktyped with all lines beginning at the left margin, with the exception of the date line, complimentary closing, and the keyed signature, all of which are

aligned with each other, ush left with the left margin set in the center of the document indentedtyped with the rst line of each paragraph indented 5 spaces simpliedtyped with all lines ush with the left margin but omitting the salutation and complimentary closing. (See Four basic letter styles.)

Four basic letter styles

Following are examples, using the same letter, of the four basic letter styles.
FULL-BLOCK LETTER

April 28, 2008 John Taylor 123 Main Street Abraham, ME 54321 Dear Mr. Taylor, Re: Lions Club Meeting ALL LINES FLUSH LEFT

Thank you for inviting me to speak at the Willington Lions Club Meeting on July 14 at 7 pm as requested. My topic will be the use of statin drugs versus alternative methods of lowering cholesterol. I will discuss with the group what cholesterol is (both good and bad), how it affects the body, and how it is assessed. I will explain to the group the role of the liver in cholesterol production and alternatives to statins and other medications. Since the Lions were very active in the town basketball tournament to raise money for the school, I will include some statistics on exercise and cholesterol that I hope the group finds interesting. I will need a projector and a screen. I can bring my laptop, as my PowerPoint presentation is on a USB drive. I will provide handouts. I look forward to seeing you on July 14th. Sincerely, FOUR LINE SPACES TO LEAVE ROOM FOR SIGNATURE

Wendy Janick, ND

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Four basic letter stylescontd

MODIFIED-BLOCK LETTER

April 28, 2008 John Taylor 123 Main Street Abraham, ME 54321 Dear Mr. Taylor, Re: Lions Club Meeting Thank you for inviting me to speak at the Willington Lions Club Meeting on July 14 at 7 pm as requested. My topic will be the use of statin drugs versus alternative methods of lowering cholesterol. I will discuss with the group what cholesterol is (both good and bad), how it affects the body, and how it is assessed. I will explain to the group the role of the liver in cholesterol production and alternatives to statins and other medications. Since the Lions were very active in the town basketball tournament to raise money for the school, I will include some statistics on exercise and cholesterol that I hope the group finds interesting. I will need a projector and a screen. I can bring my laptop, as my PowerPoint presentation is on a USB drive. I will provide handouts. I look forward to seeing you on July 14th. Sincerely, CLOSING AND SIGNATURE CENTERED

DATE LINE FLUSH RIGHT

Wendy Janick, ND

Continued

Letters to Patients
Written correspondence to patients is common and can serve many functions. The administrative medical assistant can send bills, medical information, or discontinuance of care notication. Here are the different types of letters sent to patients:

FinancialThe medical assistant may bill a patient monthly for outstanding copayments or unpaid portions of insurance billings. (See Chapter 17 for a full

discussion of this form of written communication to patients.) Medical informationThe medical assistant may send written documentation of a patients condition to him in a letterbut only after the physician has spoken to the patient and explained his condition. The letter serves as conrmation of the conversation with the patient and is never used alone to convey medical information. (See Procedure 13-1: Responding to written communications, pages 157 and 158.)

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Four basic letter stylescontd

INDENTED LETTER

April 28, 2008 John Taylor 123 Main Street Abraham, ME 54321 Dear Mr. Taylor, Re: Lions Club Meeting PARAGRAPHS INDENTED 5 SPACES

Thank you for inviting me to speak at the Willington Lions Club Meeting on July 14 at 7 pm as requested. My topic will be the use of statin drugs versus alternative methods of lowering cholesterol. I will discuss with the group what cholesterol is (both good and bad), how it affects the body, and how it is assessed. I will explain to the group the role of the liver in cholesterol production and alternatives to statins and other medications. Since the Lions were very active in the town basketball tournament to raise money for the school, I will include some statistics on exercise and cholesterol that I hope the group finds interesting. I will need a projector and a screen. I can bring my laptop, as my PowerPoint presentation is on a USB drive. I will provide handouts. I look forward to seeing you on July 14th. Sincerely,

Wendy Janick, ND

Discontinuance of carePatients who dont comply with treatment recommendations can be released from care if notice is given in writing. A certified letter ensures that the patient has received notification and that the doctor is no longer responsible for caring for the patient. (See Letter to discontinue care, page 159.) Be sure to place a copy of the release of care letter in the patients file for permanent record keeping. (See Chapter 6 for a full discussion of the physicians legal obligations of care to the patient and how to suspend such obligation if necessary.)

Letters to Physicians
A physician may write to another physician to thank her for referrals, convey patient information, or inform her of new procedures offered at his ofce in order to solicit referrals. (See Procedure 13-2: Initiating written communications, page 160.)

Letters to Attorneys
Attorneys will correspond with a physicians office if the patients injuries were the result of an accident or a

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Four basic letter stylescontd

SIMPLIFIED

April 28, 2008 John Taylor 123 Main Street Abraham, ME 54321 Re: Lions Club Meeting Thank you for inviting me to speak at the Willington Lions Club Meeting on July 14 at 7 pm as requested. My topic will be the use of statin drugs versus alternative methods of lowering cholesterol. I will discuss with the group what cholesterol is (both good and bad), how it affects the body, and how it is assessed. I will explain to the group the role of the liver in cholesterol production and alternatives to statins and other medications. Since the Lions were very active in the town basketball tournament to raise money for the school, I will include some statistics on exercise and cholesterol that I hope the group finds interesting. I will need a projector and a screen. I can bring my laptop, as my PowerPoint presentation is on a USB drive. I will provide handouts. I look forward to seeing you on July 14th. Wendy Janick, ND OMIT CLOSING SIGNATURE (TYPED OR HANDWRITTEN)

OMIT SALUTATION

PROCEDURE 13-1

Responding to written communications

Task Respond to a written communication. Conditions Correspondence from an outside party Patient chart Paper Computer Standards In the time specied and within scoring parameters determined by the instructor, the student will successfully respond to written correspondence by creating a response letter. Performance Standards 1. Read the correspondence received by the ofce from an outside party to determine what kind of response is required.
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PROCEDURE 13-1contd

Law Offices of Mark Gesmond, JD 27 Crandon Way Blueville CT 06000

May 19, 2008 Dr. Hector Rodriguez Blueville Family Medicine 15 Main Street Blueville, CT 06000 RE: David Swartz DOI: January 13, 2008 Dear Dr. Rodriguez, Please be advised that this office represents Mr. David Swartz for injuries sustained in an automobile accident on 01/13/08. Please send reports and notes related to Mr. Swartzs treatment at your office. If you have any questions, please call my office at 555-0989. Thank you,

Tina Sawyer
Paralegal

2. Choose the appropriate letter style for the required response. 3. Construct a response letter. Use information from the patients chart to ensure accuracy as well as appropriate language, grammar, and spelling to convey professionalism in the letter.
Date 01/17/08; 9:40 a.m. Patient entered with sharp, stabbing pain in the neck and left shoulder. He states that he was in an auto accident on 01/13/08 where he was hit from the right front and collided with a guard rail on the opposite side. He states that the pain has gotten progressively worse over the past few days. He has been unable to sleep; Tylenol and hot packs give minimal relief. X-rays at ED are negative for fracture or pathology. Rx - Motrin 800 mg PRN for pain. ------------------------------------------------------ C. Smith, CMA

Date 01/22/08; 10:05 a.m. Patient states that the pain is less, continuing Motrin allows him to sleep. He will return if necessary. ------Released from care. ------------------------- C. Smith, CMA

4. Proofread the letter so you can catch errors before sending it. 5. Place the letter on the physicians (instructors) desk for her review and signature. 6. Photocopy the signed letter and put a copy in the patients chart. 7. Using the computer and printer, address the envelope and indicate on the envelope the amount of postage that you would afx in the correct area for postage.

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Letter to discontinue care

The following is an example of a letter written to a patient to discontinue providing medical care for that patient. The medical assistant should be sure to place a copy of the letter in the patients le.

May 5, 2008 Mr. Hank Thomas 10 Elm Street Hartford, CT 06100 Dear Mr. Thomas, Due to your continued lack of concern for your high blood pressure, diabetes, and obesity, I am withdrawing my services as your physician. You have consistently cancelled appointments, failed to take prescribed medications, and refused to follow the weight-loss diet that was outlined for you in the office on January 14, 2008. I will forward your medical records to another physician upon your request. Sincerely,

Michael Jones, MD
Michael Jones, MD MJ: cb

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PROCEDURE 13-2

Initiating written communications

Task Initiate a written letter thanking a physician for a patient referral. Conditions Patient chart Paper Computer Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully initiate written correspondence relating to patient care. Performance Standards 1. Refer to the patients chart, as needed, to obtain accurate information about the referral. 2. Choose the appropriate letter style for the required correspondence. 3. Construct a letter thanking a physician for a patient referral using appropriate language, grammar, and spelling to convey professionalism in the letter. 4. Proofread the letter so you can catch errors before sending it. 5. Place the letter on the physicians (instructors) desk for her review and signature.

Dr. Daniel Greenberg 198 Ferguson Drive Blueville, CT 06000

Name Date

Amanda Combs 10/14/08

Acupuncture for chronic neck pain 5 weeks

workers compensation injury. The physicians office is required to release information to attorneys only with the written authorization of the patient. Attorneys may request a physician to write a summary of care and perform a disability examination. (See Summary of care letter.)

before sending it to prevent embarrassment. (See Commonly misspelled words, page 162.)

Faxed Documents
Faxing documents that contain protected health information poses a risk of inappropriate disclosure. While it is permissible to transfer data via fax, the medical assistant should: 1. recheck the fax number before hitting send 2. recheck for authorization to release the information (See the Authorization to Release Protected Health

TIP Misspelling = Unprofessional

Misspelled words in written correspondence appear unprofessional and sloppy. The medical assistant should use the spellcheck function on the computer or a dictionary when unsure of a words correct spelling. The medical assistant may also want to ask a coworker to proofread the letter

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Summary of care letter

The following is an example of a summary of care letter written by a physician for use by the patients attorney.

Collins Medical Associates 123 Main Street Lovely, CT 06111 Phone 860-555-8389 August 19, 2008 Walter Simmons Attorney at Law 14 Main Street Lovely, CT 06111 RE: My Patient, Your Client, David Kowalski Date of Injury: 08/15/08 History: The patient entered this office on 08/18/08 stating that he had been in an auto accident on 08/15/08 where he struck another vehicle in the front right side. He relates the following complaints: neck pain and stiffness, headaches, dizziness, and intermittent numbness about the head. He reports that the symptoms have progressively worsened since the accident on 08/15/08. After reviewing x-rays taken at the emergency room on 08/15/08, I note the following radiographic findings: No fracture or dislocation of the cervical and upper thoracic spine. Loss of cervical lordosis; no osseous pathology is noted. Examination: The patients movements about the neck and upper body appear to be slow, stiff, and guarded. There is loss of cervical lordosis, with a slight head tilt to the right and the right shoulder is held higher than the left. Spasm and active tender trigger points are noted in the trapezius, levator, rhomboids, and posterior cervical musculature, most noted on the patients right side. The patients upper extremity deep tendon reflexes and dermatomes appear to be symmetrical and intact. Range of motion about the cervical spine is as follows: flexion, 25 degrees with pain and dizziness; extension, 10 degrees with pain at end range; right rotation, 50 degrees with pain and dizziness; left rotation, 60 degrees with mild discomfort; right lateral flexion, 15 degrees with pain; and left lateral flexion, 20 degrees with pain on the right side. Foraminal compression, Jacksons cervical compression to the right, and Soto Halls test all exacerbate the patients complaints. Clinical Impression: The patient is suffering from acute whiplash syndrome, myofascitis, radiculitis, and cephalgia as a result of the motor vehicle accident of 08/15/08. Treatment Plan: The patient will be treated with acupuncture, myofascial release, and range of motion exercises. He will be treated in this office 3 times per week for 3 weeks and then reevaluated. Updates to follow. Sincerely,

Carol Jennings, D.O. CJ:sg

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Commonly misspelled words

The following list includes some of the most commonly misspelled words in medical correspondence. Knowing the abscess aerobic aneurysm asepsis asthma benign capillary chancre debrillator desiccation dissect epididymis correct spelling of these words will help ensure that correspondence from your ofce is clear and professional. humerus ischium occlusion osseus parenteral parietal perineum peritoneum specimen surgeon vaccine

ssure glaucoma hemorrhoid homeostasis

Information in Chapter 7, HIPAA and a Patients Rights, page 71.) 3. always use a cover sheet with an attention line. (See Fax cover sheet.) Incoming faxes that contain protected health information should be taken from the fax machine and led or covered as soon as possible. Leaving protected health information in a fax machine violates HIPAA regulations and increases the chance that the documents will be lost.

Preparing an Envelope
Envelopes should be printed on the computer. The printer paper tray can be adjusted to accommodate envelopes. (See the printer instructions for specic information.) The envelope should include a return address as well as a send-to address. Addresses should be keyed in all uppercase letters. (See Addressing an envelope and Abbreviations for mailing addresses.)

Fax cover sheet

Following is an example of a typical fax cover sheet used when sending health information via fax.

Collins Medical Associates 123 Main Street Lovely, CT 06111 Phone 860-555-8389

Fax Cover Sheet

ATTENTION LINE PAGE NUMBERING Fill in the total number of pages in the fax.

TO: Page 1 of

Privacy Notice: This fax transmission contains information that is confidential. This information is intended solely for the intended recipient. Be aware that disclosure, copying, distribution, or use of the contents of this information is prohibited. If you have received this transmission in error, please notify us immediately by telephone at 860-555-8389 or by electronic mail at CollinsMedical@carrier.net. Thank you.

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Addressing an envelope
The following illustration shows how to address an envelope according to United States Postal Service regulations.

COLLINS MEDICAL ASSOCIATES 123 MAIN STREET LOVELY, CT 06111

RETURN ADDRESS AREA Should be in the upper one-third of the envelope and the left half of the envelope.

POSTAGE AREA

WALTER SIMMONS ATTORNEY AT LAW 14 MAIN STREET LOVELY, CT 06111

SEND-TO ADDRESS Should be centered in the OCR area, starting 1/3 from top to 1/2 from bottom, right, and left edges of the envelope.

BAR CODE CLEAR ZONE Should be a minimum of 5/8 high and a minimum of 43/4 long.

Abbreviations for mailing addresses

The table lists the states and provinces in the United States along with their postal abbreviations.

State or Province
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia

Abbreviation
AL AK AZ AR CA CO CT DE DC

State or Province
Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota

Abbreviation
MT NE NV NH NJ NM NY NC ND

Continued

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Abbreviations for mailing addressescontd

State or Province
Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri

Abbreviation
FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO

State or Province
Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Abbreviation
OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

Internal Marketing
Internal marketing is a way to remind patients to come into the ofce for care. For example, patients who are busy may forget to schedule routine appointments. Also, patients may be unaware of a new doctor in the practice, and internal marketing is a way to tell them about the services she will offer as well as other new services that the practice is offering. If the physicians purchase a new piece of equipment, such as an x-ray machine, patients can have their x-rays taken at the ofce, rather than having to go to a separate imaging facility. New HMO afliations may enable patients to come back to the practice if they had previously left due to noncoverage of services. Specic medical updates, new medications, or procedures offered at the ofce can encourage patients to make an appointment. Having the patient receive information from the practice puts the practice name and phone number in the patients hands, which can increase appointments. A gentle, friendly reminder helps patients make time for health care.

Birthdays and Holidays

Birthday and holiday greetings will also remind patients of their relationship to the ofce and may prompt them to make an appointment. Receiving birthday cards or holiday cards promotes a friendly relationship with the patient and the gesture is generally appreciated. Patients may refer friends and family to the nice doctor who always remembers my birthday. (see Figure 13-2.)

TIP Holiday Marketing If the office decides to send holiday cards, be sure to send the appropriate religious card (such as for Christmas, Hanukkah, or Ramadan). Some offices opt to send Thanksgiving cards because most Americans celebrate Thanksgiving and fewer cards are received at that time. Thus, the card stands out in the patients mail. (See Figure 13-3.)

Generating Referrals
In addition to internal marketing to the ofces existing patients, the ofce may receive referrals from other health care professionals. When new services, new equipment, or new providers are added to the practice, letters to fellow professionals can stimulate referrals from those ofces. (See Letter to solicit referrals, page 167.) After receiving a referral, a letter of thanks to the referring physician shows appreciation and good will.

Reminder Notes
Written reminders tell busy patients that it is time to call the ofce to schedule their teeth cleaning, yearly physical, Pap smear, or other routine care appointments. These reminders are usually postcards. The postcards can reect the upbeat atmosphere of the ofce by using cartoons and pictures. (See Figure 13-1.)

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Blueville Family Medicine 15 Main Street Blueville, CT 06000 8605553212

First-Class

Dear Lamar, This is to remind you of your physical exam. If you are unable to keep this appointment, please give the office at least 24 hours notice.

Lamar Shatner 15 Spellings Lane Blueville, CT 06000

Lamar - 092208 at 3:30 pm

Time for your checkup!

FIG 13-1 Reminder postcard.

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E-mail Guidelines
Electronic mail (e-mail) is an informal type of correspondence. E-mail outside of an intranet system in an ofce cannot be considered private. No protected patient information should be disclosed in an e-mail message outside of the hospital or physicians ofce because the identity of the recipient cannot be conrmed. E-mail within a hospital or physicians ofce from one department to another can be considered private. Here are some other guidelines for using e-mail:

Dear Jacob, Wishing you health and happiness on your birthday.

Sincerely, The Doctors and Staff at Blueville Family Medicine

LanguageE-mail messages that are written by a medical assistant are a reection of the medical ofce. The language should be friendly yet professional. FormalityWhen sending e-mail messages to coworkers or familiar personnel at other ofces, you can use the recipients rst name. When sending messages to unfamiliar recipients, always use a more formal address (such as Ms., Mr., or Dr.). PunctuationProfessional e-mail messages should read professionally. E-mail slang (such as LOL for laugh out loud) doesnt belong in a professional e-mail message. Other e-mail conventions, such as omitting punctuation or writing in all capital letters, may be perceived as sloppy or rude. If the medical assistant has a friendly relationship with the recipient, she should use her personal e-mail account for nonbusiness correspondence. Professional e-mail accounts should be used for professional correspondence only.

FIG 13-2 Birthday card from ofce to patient.

TIP Professional E-Mail Address

Some people pick a goofy, funny, or suggestive e-mail address. If you send a resume to an ofce for a job opening, dont send it from an e-mail account with such an address. How can an ofce take you seriously if you call yourself GiveMeChocolate or SexyGuy?

Incoming Mail
The medical ofce will receive mail from patients, vendors, attorneys, and various businesses. (See Types of mail, page 169.) The administrative medical assistant may be responsible for opening the mail each day and directing it to the appropriate person or department within the ofce. This list explains the various types of mail the ofce may receive:

Dear Angela, Wishing you health and happiness for Thanksgiving. Best of Health, The Doctors and Staff at Blueville Family Medicine

FIG 13-3 Thanksgiving card from ofce to patient.

Insurance reimbursementsChecks to physicians from insurance companies for medical services should be recorded on the patients nancial records in a computerized system or on a manual ledger card system. Explanation of benets documentation that accompanies a payment explains

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which services provided by the physician are included in the reimbursement. The administrative medical assistant should post the checks or forward them to the billing department for posting. Patient correspondencePatients may write to the physician to thank her for care or communicate other information of a personal nature. Mail that looks like personal correspondence, such as a greeting card or personal letter, should not be opened by the medical assistant but given unopened to the physician.

PaymentsPatients may not make a copayment at the time of their visit and instead mail the copayment to the ofce. Also, patients may send checks to pay for charges for services that were not paid in full. As in the case of insurance checks, the administrative medical assistant should post the checks or forward them to the billing department for posting. Medical recordsOther medical providers, such as doctors ofces, hospitals, and rehabilitation centers, may forward patient medical records to the ofce at the request of

Letter to solicit referrals

The rst example is a letter written to a physician to introduce a new colleague in the practice in order to solicit referrals for new services offered.
LETTER TO SOLICIT REFERRALS

The second example is a letter thanking a physician for referring a patient to the practice.

October 1, 2008 Dr. Susan Spencer Main Street Rheumatology 1212 Main Street Townington, UT 98098 Dear Susan, PHYSICAL THERAPY SERVICES INTRODUCTION OF NEW SERVICES IN SUBJECT OR REGARDING LINE

I am pleased to announce the addition of Michelle Garner, RPT, to our staff. Michelle is a graduate of UCONN school of physical therapy and has years of experience in the care of patients with chronic joint pain from her tenure at the Madison Pain Clinic. Michelle is available to come meet with you and discuss treatment options and modalities that will benefit your patients. She has had great success with reflex sympathetic dystrophy and chronic neuralgia. Enclosed is a brochure from the Pain Clinic highlighting Michelles success with chronic neuralgia as well as her resum. If you need therapy for your RA patients, please consider referring them to Michelle for physical therapy. Our office participates with BC/BS, Healthnet, and Mediplan, so services for physical therapy are covered under these plans. I hope to hear from you soon. Sincerely,

Michael Jones
Michael Jones, MD MJ:cb Enc:2

MICHAEL JONES IS THE AUTHOR OF THE LETTER; CINDY BROWN, CMA, TYPED THE LETTER. REFERS TO THE NUMBER OF ENCLOSURES IN THE LETTER

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Letter to solicit referrals

(Cont.)

LETTER OF THANKS FOR REFERRALS

November 11, 2008 Dr. Susan Spencer Main Street Rheumatology 1212 Main Street Townington, UT 98098 Dear Susan, Thank you for your referral of RA patients this past month. Michelle, our PT, has had some good progress with several of the patients; they are delighted with their care. I am sure they will convey to you their happiness with their therapy programs. Sincerely,

Michael Jones
Michael Jones, MD

the patient or physician. These materials should be led in the patients chart and given to the physician. Because medical records are protected information, you must follow HIPAA privacy procedures when opening this type of mail. Patient medical records should be placed out of view of other patients entering the ofce and should be viewed only by personnel who need to access the information for treatment, payment, or operations (TPO). Continuing educationAdvertisements for seminars and classes for continuing education for physicians, nurses, medical assistants, therapists, and ofce personnel should be forwarded to the appropriate personnel. FinancialBills for equipment leases, ofce or medical supplies, rent of ofce space, and state and federal tax information should be forwarded to the personnel who handle the ofce nances. Bank statements should be forwarded unopened to the nancial department or the physician. AdvertisingMedical ofces receive mail from vendors of ofce supplies, medical supplies, x-ray supplies, and even magazines. This mail should be forwarded to the person responsible for ordering such supplies. Personal and CondentialAny mail marked personal and condential should be given unopened to the addressee.

Transcription of Medical Documents

Medical reports can be transcribed from dictation tapes or computer voice les. The administrative medical assistant working in the hospital setting may be required to transcribe various medical documents, including history and physical examinations, consults, operative reports, pathology reports, radiology reports, and discharge summaries. The medical assistant in the ambulatory care center may be asked to transcribe letters, memos, history and physical reports, or disability ratings. Transcribing equipment consists of a tape player or voice recognition computer software. When using a tape player, the transcriptionist operates a pedal to hear the dictation at a speed that is comfortable. The machine allows the transcriptionist to rewind the tape, increase or decrease the volume, and adjust the tone, or pitch, higher or lower to ensure that all words are heard and transcribed accurately. In the case of voice recognition software, a transcriptionist or proofreader must review the document for errors. Because transcribed documents contain patient identiable information, HIPAA privacy guidelines must be maintained. The contents

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Types of mail
The table denes various types of mail and some examples of situations where these types of mail would be used. Where applicable, examples of correspondence both sent and received are included.

Type
Certied mail

Denition
Proof of receipt of mail through a return receipt signed by the recipient to verify delivery

Example
Send: Letter of discontinuation of care sent to patient Receive: Letters from attorneys requesting patient records Send: Medical equipment, vitamins/herbal supplements, or other items not covered by insurance can be sent COD to patients from the ofce Receive: Merchandise ordered by ofce

Collect on delivery (COD)

Collection of payment for merchandise or postage from the recipient upon delivery of mail

Express mail

Guaranteed overnight delivery within the U.S.

Send: Summary of care or other documentation to the patients attorney for court proceedings Receive: Documentation from another physician regarding a patient

First class mail

Sealed and unsealed letters (up to and including 11 oz), statements, bills, and business letters

Send: Statements to patients, letters to patients, attorneys, insurance carriers, other physicians Receive: Correspondence from attorneys and other physicians, checks from insurance companies and patients

Second class mail

Newspapers, journals, magazines

Receive: Newspapers and magazines for the waiting room, journals for the medical staff or coding department

Third class mail Fourth class mail

Circulars and advertising materials that weigh less than 16 oz Packages weighing 1 to 70 lb with a combined girth of 108"

Receive: Advertising for medical and ofce supplies Receive: Medical and ofce supplies ordered online or by phone Receive: Patient medical records sent by referring physician Send: Patient medical records to physician upon request of patient, documents sent to attorneys

Priority mail

First class mail weighing more than 11 oz and up to 70 lb; fastest method of delivering heavier mail within 2 to 3 days

Registered mail

Method for shipping items with a declared monetary value that are sent rst class; can be insured for a maximum amount of $25,000

Send: Equipment to manufacturer for repair or maintenance Receive: Equipment from vendor such as small laboratory machinesglucometers, hemocytometers, or medical equipment such as stethoscopes, reex hammers, otoscopes ordered online or by phone

Restricted delivery

Mail delivered to a specic addressee or someone authorized in writing to receive the mail for the addressee

Send: Protected health information sent to physician, patient, or attorney Receive: Protected health information from any source may be sent to the ofce to the specic care of a staff member

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of transcribed documents are not to be shared with anyone who does not demonstrate the need to know. (see Figure 13-4.)

TIP Professionalism and Privacy Protection The medical assistant can emphasize to patients that she will always protect their confidential medical and personal information by presenting professional documentation and adhering to HIPAA guidelines that protect information. The medical assistant can demonstrate the professional tone and attitude of the office via these written communications. Patients will understand that the office

personnel take the responsibility of guardianship of medical records, legal correspondence, and personal information seriously not only by the restrictions of disclosure but by the voice and professional tone of written office correspondence.

TIP What She Said: Transcribing Accuracy Use the physicians words when transcribing documents. While it is acceptable to correct minor grammatical errors, never change the MEANING of the document. If a document seems incomplete or does not seem clear, ask the dictating physician for clarication.

Elm Street Orthopedics 134 Main Street Anytown, USA

July 14, 2008 Patient Name: Patricia Wilson Date of Birth: 06/16/1964 Date of Evaluation: 07/11/2008 SUBJECTIVE: Mrs. Wilson is a 44-year-old white female who slipped and fell at home on 05/12/2008, landing on her right wrist. She was seen at Thomaston Walk-in Clinic on 05/12/2008 where x-rays of the right wrist, forearm, and elbow were negative for fracture or pathology. The patient was placed in a volar splint in the position of function and sent to this office for followup. Today she presents with minimal pain. Pain and range of motion is much improved in the right wrist. Review of x-rays from 05/12/2008 confirms no fracture, pathology or structural abnormality. OBJECTIVE: The splint was removed and the wrist examined. No swelling or discoloration is noted. No tenderness to palpation in the anatomical snuffbox was noted. There was no pain with axial pressure on the thumb. No tenderness over the scaphoid tubercle was noted. There was slight tenderness of the radial styloid. No ulnar styloid tenderness was noted, and there was full ROM of the elbow. The wrist had a decreased ROM of flexion and extension secondary to slight pain. ASSESSMENT: Contusion of the right wrist. PLAN: The plan is to discontinue the splint and range of motion with resumption of normal activities. The patient may resume lifting and/or working on a prn basis. She is instructed to return if symptoms return. Michael Jones, MD MJ: cb D: 07/12/2008 T: 07/14/2008

FIG 13-4 Transcribed document.

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Chapter Summary

The medical assistant must recognize the importance of professionalism and condentiality when communicating with patients, insurance carriers, attorneys, and other physicians ofces. Letters, e-mails, and faxes must always be written in a professional and accurate manner that represents the ofce. All written communications must be clear and concise and use language that is appropriate to the recipient. Spelling, grammar, and punctuation should be checked before sending written documentation or correspondence. Adherence to HIPAA condentiality laws and conrmation of authorization to release protected information is vital.

Team Work Exercises

1. Role-play faxing protected health information with a classmate. Create a fax cover sheet and ll it out appropriately. Conrm the identity of the recipient before you fax the information. 2. Create a business letter and envelope. Exchange business letters with classmates. Read each others letters for clarity and proofread them for errors. Check each others business envelopes for completeness and accuracy.

vacation. Brenda has always been a professional worker and has made the transition from patient to staff and back to patient with ease. She has asked you for a letter of recommendation for a permanent job with another physician. While you are disappointed that Brenda will no longer be available to ll in, you understand her need for a full-time position. Draft a letter to a prospective employer on Brendas behalf. What items would you consider important to include in the letter? 2. Attorney Michael Liebowitz has handled many workers compensation cases involving the ofce. Mr. Liebowitz is a professional who always adheres to the rules of condentiality. However, his new assistant, Jayne, does not seem to understand the importance of condentiality. She yelled at you on the phone for not forwarding a medical record even after you explained that you cannot disclose such records without permission. When you ask to speak to Mr. Liebowitz, Jayne gets defensive and hangs up on you. Write a letter to Mr. Liebowitz outlining the problem. Remember that you are friendly with Mr. Liebowitz, but be rm in your objections to his new assistant.

Resources

Case Studies
1. Brenda Nunez is a patient who has been with the practice for many years. She has lled in as a receptionist on several occasions when one of the ofce staff is ill or on

How to write a business letter: owl.english.purdue.edu/ handouts/pw/p_basicbusletter.html and www.wisc.edu/ writing/Handbook/BusinessLetter.html Examples of reminder cards (dental): www.bracesinfo .com/cards/ Examples of holiday cards and internal marketing: www.medicalartspress.com.

CHAPTER

Medical Records Management

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms presented in the glossary list and discuss the equipment and supplies necessary for a ling system discuss and have an understanding of the four basic ling systems create a paper medical record using appropriate supplies and systems use indexing rules to arrange a list of patient names alphabetically arrange a group of patient numbers in ling sequence for consecutive-, middle-, and terminal-digit ling systems assign correct color tabs to a list of patient names discuss the pros and cons of color, alphabetical, numeric, and accession log ling in a physicians ofce and a hospital discuss the advantages of electronic health records discuss the process of converting from paper-based records to electronic health records discuss the appropriate procedure and documentation for release of a medical record or information contained in the medical record.

14
Consecutive ling Nonconsecutive ling Accession log ling

CAAHEP Competencies
Administrative Perform Clerical Functions
Organize a patients medical record File medical records

ABHES Competencies
Administrative Duties
File medical records

Other Information on the File Folder Locating and Tracking Medical Records
Tracking Medical Records Cross-Referencing Medical Records

Legal Concepts
Use appropriate guidelines when releasing records or information

Electronic Health Record

Increased Access Cost Reduction Reduced Medical Errors Barriers to EHR Conversion

Procedures
Creating a medical record Filing a medical record using the alphabetical system

Medical Record Maintenance

Medical Records Archives Medical Records Purging Release of Medical Records

Chapter Outline
Importance of Medical Records Management File Storage
Vertical Files Open-Shelf Lateral Files Moveable Files

Chapter Summary Team Work Exercises Case Studies Resources

File Folders
Fasteners Tabs Units

Filing Systems
Alphabetical System Simple alphabetical ling Color-coded alphabetical ling Numeric Filing

173

Key Terms
accession log

Record of numbers assigned to each new patient record

active les

Importance of Medical Records Management

Medical records must be organized in a way that makes them retrievable and accessible to health care workers who need them. A well organized, easy-to-use records management system includes rules for:

Medical les of patients who are currently seen in the ofce

alphabetical ling

Organizing system based on the alphabet, usually using the patients last name
archives

Storage place for records that are no longer in use but are kept for legal purposes
closed records

Medical records of patients who no longer seek treatment in the ofce

color coding

creation of the medical record or patient record where it is stored, or led how it is maintained how medical information within the medical record is released.

Alphabetical ling system that adds colored stickers to the open end of a le to facilitate a visual maintenance of les.
consecutive ling

Filing system that uses sequential numbers to order medical records

cross-reference

Guide placed where a medical record could be misled to indicate the correct location of the le
inactive records

Maintaining the integrity of the ling system is necessary to ensure privacy and accessibility to patient information. All health care workers who access les must understand and utilize the system correctly. When a ling system is misused, valuable time is wasted searching for important information and the information could be permanently lost. Because a physicians medical decisions can be based on data in the patients le, the well-being of a patient depends on appropriate access to his le.

Records of patients who have not been seen for an extended period of time (usually 1 to 6 years) but who may return for care
middle-digit ling

File Storage
There are three primary types of ling cabinets that can be used in medical ofces. Depending on availability of storage space, the size of the practice, and the need for access, an ofce may choose to use vertical les, open-shelf lateral les, or moveable les, or a combination of those types.

Numeric system that uses the middle digits of an identication number as the primary indexing unit
nonconsecutive ling

Numeric system that does not use consecutive ordering for medical records
numeric ling

Vertical Files
File cabinets that have pull-out drawers and stand vertically can be used to store restricted access les. Restricted access les may include psychiatric notes or information on treatment of substance abuse and human immunodeciency virus (HIV). Cabinets can be locked for extra security. Some ofces may store nancial documents, such as bank statements, and legal documents, such as rental agreements and malpractice insurance policies, in the locked les to ensure that they will not be lost.

System that assigns an identication number to each patient le

out guide

Marker used to indicate that a medical record has been taken from the ling system
purge

Permanent removal of medical records that are no longer in use

terminal-digit ling

System that uses the last digits of an identication number as the primary indexing unit
unit

Open-Shelf Lateral Files

Open-shelf lateral les are most commonly used for colorcoded les because they enable easy viewing of the right side of each le (with color-coded labels). Because the side of the folder is visible, these shelves should not be in an area where patients can see them. Although no medically sensitive information is written on the outside of the le, the patients name could be read by unauthorized individuals.

Each part of a patients name or identication number used in a ling system

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The open-shelf le system would, therefore, be inappropriate for clinics that treat patients with acquired immune deciency syndrome (AIDS), sexually transmitted diseases (STDs), or substance abuse.

Interview, on page 307, for information on organizing items within the medical record.) The makeup of a le folder varies slightly from practice to practice. However, most folders contain several elements, including:

Moveable Files
Moveable shelving allows access to a large number of medical records without taking up a lot of space. Moveable shelving can be rolled on rollers, moved with a crank handle, or operated electronically. (See Figure 14-1.) Hospitals commonly use moveable le storage because of the large number of patient records and the infrequent access to individual records.

fasteners tabs units.

Fasteners
Fasteners allow the medical assistant to secure papers (such as charting notes and laboratory results) to the le folder. Fasteners are usually long strips of metal that are bent around the back of the le folder and through holes punched near the edge of the le. Corresponding holes punched in the pages to be inserted in the medical record enable the medical assistant to thread the pages through the long metal prongs of the fastener. After threading the pages on, the medical assistant must bend the prongs so that they lie ush with the pages in the record, thus keeping them fastened in place in the le. (See Figure 14-2.) A le folder may contain fasteners on one or both sides of the folder.

File Folders
File folders are designed for different types of labels and organizational systems. (See Chapter 20, The Patient

FIG 14-1 Movable shelving with crank handles.

FIG 14-2 File folder with fasteners and a tab.

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Tabs
Tabs are a small section of the folder that projects beyond the other side of the folder. On the tab, the medical assistant can place color-coded or printed letter labels. A tab commonly extends along the top edge of the le folder. Such tabs vary in position and size to facilitate easy viewing of les in a pull-out drawer. Tabs that extend along the entire right edge of folders accommodate color-coded stickers for use in open-shelf systems. (See Figure 14-3.)

be sure to use the system consistently to ensure that les can be found easily. Disregarding ling rules will lead to inefciency and may compromise the quality of patient care.

Alphabetical System
Files in an alphabetical system are organized using the patients name. One alphabetical system simply les folders in alphabetical order by the patients last name. Another system uses color-coded labels with letters of the patients name.

Units
Rules for ling medical records follow the unit system. Units are any portion of a patients name, accession number, or other numerical ling designation that is used to order and identify the medical record. The medical assistant who creates a new medical record le must attach labels to the le tab to identify the patient using the units designated by that ling system.

Simple Alphabetical Filing

Although the simple alphabetical ling system is easy to use, it does not afford patients anonymity because their names must be prominently displayed on the le folder. This system depends on some simple rules:

Filing Systems
There are two main types of ling systems:

Use the units in order: last name (For hyphenated last names, omit the hyphen and le as if one name.) rst name middle name or initial title (if applicable). Follow the basic alphabetical ordering rule of nothing before something. (For example, R. Dailey is led before Robert Dailey and Smith is led before Smith-Diaz.) Prexes are treated as part of the name. Omit the punctuation and le accordingly. (For example St. Michel is led as Saintmichel and McDonald is led as Mcdonald.) Titles without a surname are considered the rst indexing unit. (For example, Sister Angela is led alphabetically by Sister.) Seniority units are led alphabetically. (For example, Gary Henderson, Jr., is led before Gary Henderson, Sr.)

alphabetical systems by patients last name color coded by patients last name numerical systems consecutive middle digit terminal digit accession log.

Regardless of the system used, ling rules must be easy to follow. In addition, personnel who have access to les must

Color-coded Alphabetical Filing

Color-coded alphabetical systems can be designed for open lateral les or vertical le drawers. In this system, each letter of the alphabet is assigned a colored label that is placed on the side or top of the le folder for ease of use. (See Alpha-Z color-coding system.) The labels are placed down the right side of the le in a lateral system and on the top of the le for a vertical drawer system. (See Figure 14-4.) Adding colors to the side or top of the le does not affect the alphabetical ling rules. The color coding helps keep les in alphabetical order and prevents misled records by creating a visual block of color when les are correctly placed. If a le is misplaced, the colors will not match, easily identifying the misled record. (See Figure 14-5.) A commonly used system includes three stickers, one for each of the rst two letters of the patients last name and one for the rst letter of their rst name. Other systems use the rst three letters of the last name. (See Figure 14-6.) The three labels should be placed along the top or side of the

FIG 14-3 File folders with tabs. (A) Top tabs for drawer ling. (B) Side tabs for open-shelf ling.

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FIG 14-4 Color-coded alphabetical ling. (A) Labels on right side for lateral system. (B) Labels across top for vertical drawer system.

Alpha-Z color-coding system

The Alpha-Z system is one system for color-coded alphabetical ling. This system uses a combination of 13 colors with white letters for the rst half of the alphabet and the same colors with white stripes and white letters for the remaining 13 letters of the alphabet. Because letters next to each other in the alphabet are assigned very different colors, ling errors are easily identied. The accompanying photograph shows the labels used in the Alpha-Z color-coding system.

folder in a uniform fashion. (See Procedure 14-1: Creating a medical record, page 179.)

Numeric Filing
Numeric ling is a system of organizing medical records by number. While the numeric ling system affords greater

condentiality, a record of the chart number for each patient must be maintained. The increased privacy afforded by using a numeric system makes it a good choice for psychiatric ofces, drug rehabilitation clinics, and social services agencies. However, when a computer system is not functioning, medical record retrieval is difcult. If an ofce uses a

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FIG 14-5 Misled medical record with colored labels for easy identication.

numeric ling system, the ofce staff must establish backup systems to nd patient records. There are three types of numeric ling systems:

consecutive nonconsecutive accession log.

Consecutive Filing
Also called straight numerical ling or serial ling, consecutive ling is a system of ling records that uses six digits, broken down into three two-digit segments. The records are led in ascending order from smaller to larger numbersfor example, record number 849932 is led before record number 849942. (See Figure 14-7.)

Nonconsecutive Filing
A nonconsecutive ling system is another numerical ling system that uses six digits, broken down into three two-digit segments. Ofces will commonly use numbers for these
FIG 14-6 Three-sticker systems. (A) File using rst two letters of last name and rst letter of rst name. (B) File using rst three letters of last name.

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PROCEDURE 14-1

Creating a medical record

Task Create a medical record. Conditions File folder Colored letter labels Patient intake form Signed HIPAA statement Pen Other stickers (provided by the instructor, such as allergy indicators) Standard In the time specied and within scoring parameters determined by the instructor, the student will successfully create a medical record. Performance Standards 1. Fill out the patient intake form. (You can use your name or make up a patient as directed by your instructor.) 2. Explain the HIPAA information to a patient (by role playing with a classmate) and have the patient sign the HIPAA form to indicate that the patient has received, read, and understood the document. 3. Insert the patient intake form into the medical record by using the fastener to attach it to the right inside of the medical record. (Note: Each medical ofce has its own guidelines for how to le a signed HIPAA statement in the medical record.) 4. Place the correct colored letter labels on the outside right edge of the folder, folding the label over the edge so that the letter is visible from both sides. 5. Place the allergy alert, insurance, or physician labels on the outside of the folder (as indicated by your instructor).

FIG 14-7 Medical record led using consecutive ling system.

filing may be used for files where the last two digits indicate the patients year of birth. In a pediatric office, these files could then be easily accessed to send reminders for vaccinations or school physicals (See Consecutive and nonconsecutive filing systems, page 180.)

Accession Log Filing

Accession log ling assigns the next number in a sequence to each medical record created. The records are led consecutively by accession number and the ofce staff keeps a log of all patient names and number assignments in a book or computer database. However the log is maintained, it is condential information, so the ofce staff must ensure that only those persons who need to use the log for treatment, payment, or operations (as dictated by HIPAA guidelines) have access to it. Although the system ensures condentiality, it can create problems when searching for a le because the medical assistant must look up the patients accession number in the log every time the patient visits the ofce. In addition, because the accession number is the only number used in this ling system, the only information that the accession log provides is how old the medical record is in relationship to other medical records. Thus, the number is not helpful for sending reminders or organizing other patient demographic information. A computerized database that searches for the le number by the patients name will allow

units from patient information, such as telephone numbers, dates of birth, or the treating physician. However, use of Social Security numbers as le numbers is not recommended for privacy reasons and the risk of identity theft. The two basic forms of nonconsecutive filing are middle-digit and terminal-digit filing. In a middle-digit nonconsecutive filing system, the medical assistant must use the numbers designated as the middle unit as the primary unit used to le the medical record. In terminal-digit ling, she must use the unit designated as the terminal unit. Middle- and terminal-digit ling may be used to group les by common characteristics. For example, terminal-digit

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Consecutive and nonconsecutive ling systems

The table shows the order of medical records led using the consecutive ling system, the middle-digit nonconsecutive ling system, and the terminal-digit nonconsecutive ling system. In consecutive ling, the rst digit is the primary unit used for ling, then the middle digit, then the terminal digit. In middle-digit ling, the middle digit is the primary ling unit, then the rst digit, then the terminal digit. In terminal-digit ling, the terminal digit is the primary ling unit, then the middle digit, and then the rst digit.

Consecutive (1, 2, 3)
01 07 09 02 01 11 02 04 10 02 06 10 03 01 08 03 04 01 04 02 10 04 02 12
KEY: primary ling unit secondary ling unit tertiary ling unit

Middle digit (2, 1, 3)

02 01 11 03 01 08 04 02 10 02 04 10 03 04 01 04 05 12 04 05 13 01 07 09

Terminal digit (3, 2, 1)

03 04 01 03 01 08 01 07 09 04 02 10 02 04 10 03 04 10 02 01 11 04 05 12

location of the medical record. The accession log gives the patients name and the date of the rst visit along with the accession number needed to nd the medical record. If a manual log book is used, an alphabetical log by patients name may also be maintained for cross-reference. It is imperative to keep such a log locked securely in a drawer or ling cabinet and a computerized database must have password protection. (See Figure 14-8.) The accession log number can also be used as the patients nancial account record. Because the accession number gives an idea of how old the le is, outstanding balances of nancial records with lower accession numbers can be identied to pursue payment.

Accession # 503 504 505 506

Patient Name Cheryl White Julia Wells Hector Ramirez Alison Andrews

Date of F Visit irst 8/5/04 8/5/04 8/5/04 8/6/04

507

John Phelps

8/6/04

Other Information on the File Folder

In addition to labeling a folder according to a specific filing system, the outside of the medical record can also be used to display other important information. For example, the file may have a colored label that indicates the primary care practitioner for each patient or a numbered label that indicates medical insurance coverage. Drug and

FIG 14-8 Accession log book.

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must be familiar with methods used to avoid common misfiling errors.

Tracking Medical Records

Regardless of the ling method used, a system must indicate that a medical record has been taken from the ling system. When taking a medical record from a ling system, the medical assistant must put an out guide in its place, which indicates that the medical record has been removed as well as the present location of that record. When the record is replaced, the out guide is removed. The medical assistant can cross out the previous entry and reuse the out guide. Out guides are usually made of lightweight cardboard or stiff paper. (See Figure 14-10.)

Cross-Referencing Medical Records

Locating medical records can become a bit confusing when patients change names. When a patient changes her name, the medical assistant must make a new folder and le the medical record according to the new name. Marriage, divorce, adoption, or taking religious vows are some reasons a patient may change names. In addition, differentiating the last name from the rst may also be difcultfor example, John James, Jim Paul, or Mei Le Huan. As a result, a staff person may search for or le the record in the wrong place. A cross-reference guide is a good way to remedy such a situation. A cross-reference guide is similar to an out guide,

FIG 14-9 Important information indicated on the exterior of the medical record.

significant food allergies are commonly indicated by a red sticker on the outside of a patients file. (See Figure 14-9.) If a patient changes insurance carriers or primary care practitioners, the medical assistant can easily replace the labels. No medically sensitive information such as disease status or treatments received can be written on the outside of a medical record. This information is confidential and protected and must be retained within the interior of the medical record.

Locating and Tracking Medical Records

In addition to following the filing system in place in a medical office, the medical assistant must be familiar with the ways in which the office keeps track of medical records that are in use. In addition, the medical assistant

FIG 14-10 Out guide.

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but is placed where a medical record may be misled. When a staff member attempts to le the record in the incorrect spot, the cross-reference guide will point out the error immediately and will also indicate the correct location for the record. (See Figure 14-11.) One of the most common reasons for name changes is marriage. When a patient changes her name, the medical assistant should ask her what legal name she will use. For example, if Ann Jones married Hector Ramirez, the medical assistant should ask Ms. Jones if she plans to take her husbands name. If Ms. Jones does take her husbands name, the medical assistant should make necessary changes to her medical record, file the record according to the name Ramirez, and create a cross-reference guide to insert where the record would have been filed under Jones. It is common practice to ask patients at each visit if there are any changes in their address, insurance coverage, or name. (See Procedure 14-2: Filing a medical record using the alphabetical system.)

PROCEDURE 14-2

Filing a medical record using the alphabetical system

Task File a medical record using the alphabetical ling system. Conditions Set of mock patient charts File storage unit Out guide, if needed Standard In the time specified and within scoring parameters determined by the instructor, the student will successfully file a medical record using the alphabetical filing system. Performance Standards 1. Gather charts to be led. 2. File each chart by placing it between les in the correct alphabetical order. 3. Cross-reference names if necessary to ensure accuracy. 4. Place the charts in the proper storage unit with color-coded tabs facing forward so that the letter is visible from both sides. 5. Review charts and observe for color-coded tabs that may be out of order and, if detected, rele the chart in the correct order. 6. If removing a patients chart, put an out guide in place of the le to help staff nd missing charts.

Electronic Health Record

An electronic health record (EHR) is a comprehensive computerized health record for a patient that includes data from multiple providers who have diagnosed and treated the patient. The data can be stored and updated throughout the patients life. The advantages of an EHR rather than a traditional paper medical or health record include:

increased access to medical data cost reductions reduction in medical errors.

Increased Access
Most patients receive health care services from multiple providers. During a patients lifetime, he may see many providers. For example, a patient may see the following providers for the conditions listed:

FIG 14-11 Cross-reference guide.

cardiologistfor high blood pressure and arrhythmia endocrinologistfor diabetes or a thyroid dysfunction

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chiropractorfor lower back or neck pain orthopedic surgeonfor carpal tunnel syndrome and athletic injuries physical therapistfor rehabilitation of athletic injuries primary care providerfor routine physicals.

In this scenario, the patient may be taking multiple medications and having multiple therapy sessions with a chiropractor and a physical therapist and progress toward the resolution of each problem may vary. When using EHR, each of the patients providers can access medication records, examination notes, and treatment records from all the providers. The cardiologist, who recommends to the patient that he exercise to lose weight, can see that the orthopedic surgeon has requested that the patient not stress a hip or knee joint. The chiropractor can see that the orthopedic surgeon has prescribed a narcotic pain killer for the knee pain and that explains the patients decreased neck or back pain. The providers can also access imaging studies, x-rays, and blood test results in the EHR and discuss these results with the patient during an ofce visit. In addition, the information stored within the EHR can be accessed by multiple people simultaneously. For example, the billing department can access treatment notes for insurance carrier requests while the physician is simultaneously accessing the EHR during a patient visit. The billing department does not have to wait to access a paper le after the physician has seen the patient.

Prescribing a medication that the patient is allergic to or that is contraindicated based on the patients concurrent medications can cause injury or even death. Surgical errors are caused when the wrong procedure is performed or the wrong surgical site is chosen, such as amputating the wrong leg. Most medical errors are caused by a failure of communication among the many providers caring for the patient. Communication failures can include:

Misled or lost paper medical records. Medical assistants, nurses, and physicians cannot provide adequate care without a complete history of the patients allergies, previous surgeries, or past diagnoses. Trying to provide care without this information can impact medical decision making. Unreadable information. Poorly written charts or prescriptions may lead to medical errors, such as the wrong medication or dosage. Mishandled or mislabeled laboratory specimens. If the testing order is illegible, the laboratory cannot conduct the test. Because the EHR system submits electronic testing orders, the information is typed into the patients record, thus ensuring readability.

Barriers to EHR Conversion

Although the reasons to convert paper-based medical records to EHR are compelling, there are many barriers to the conversion process. Many ofces use paper-based medical records because the conversion process is expensive and timeconsuming. (See EHR conversion methods, page 184.) In addition to the expense of converting old les, it is expensive to purchase an EHR system and train personnel to use it. At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR would cost over $32,000 per physician, with ongoing monthly maintenance costs of around $1,200. These costs make EHR systems unattainable for some practices. Thus, the medical assistant must be prepared to work in a paper-based or electronic environment.

Cost Reduction
Patients in the United States spend 2 trillion dollars per year on health care; approximately 30% of that money is spent on administrative costs. In a paper-based system, referrals to specialists, requests for further information, copies of medical records, and copies of x-rays and other imaging studies incur the costs of copying and mailing. Storage space for paper medical records, climate control for le rooms, security measures, and personnel costs for le management add to the overall cost of doing business. Treatment and diagnostic testing costs are also increased in a paper-based system because lack of access to data leads to repeated procedures. The endocrinologist does not have the blood chemistry panel that the cardiologist ordered 2 weeks ago. The patients blood must be retested and additional costs to the insurer and the patient are incurred. The orthopedic surgeon must x-ray the patients hip because the low back and hip x-rays taken by the chiropractor last week are not accessible. The patient is exposed to unnecessary radiation as well as unnecessary costs.

TIP Terminology Tip Electronic records are new and the terms to describe them are commonly confused. EHR and EMR (electronic medical record) are used interchangeably to describe the patient care records or les. EHR, however, is typically used to describe the concept and EMR is generally used to describe a specic record. In addition, a reference to an EHR system is also commonly abbreviated as EHR or EMR.

Reduced Medical Errors

Medical errors, the eighth leading cause of death in the United States, are dened as adverse events that could have been prevented based on current medical knowledge.

Medical Record Maintenance

When an ofce develops a ling system, it must be sure to safeguard the medical records in that system. Files should

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EHR conversion methods

In converting paper medical records to electronic health records (EHRs), an ofce must choose one of several conversion methods, each having problems and considerations.

Method
Key all data into EHR

Advantages
No handwritten material is used, reducing errors

Potential Problems
Errors introduced while inputting information into EHR Increased cost of inputting all information from lengthy medical records

Use optical character reader (OCR) to convert les Scan paper medical record

Possibly cheaper than hand keying documents Cheaper and faster than other methods

Generally only 90% to 95% accurate Continued illegibility of poorly written charts Compared to new EHR, inconsistency in appearance and organization, which can cause confusion, frustration, and inefciency

never be stored in areas that provide public access. Paper medical records must be stored behind a reception area or in separate le rooms. EHR must be stored in a passwordprotected environment that includes logs to record the individuals who are accessing the record and which portions in order to ensure that medical personnel access records only for necessary functions of treatment, payment, and operations (TPO). In addition, staff using computers should make sure that the computer screens are not in view of patients in front ofce areas and computer screens in treatment rooms show the EHR of the patient being seen, not the previous patient that was treated in that room. The ofce staff should also ensure that the ofce is locked whenever it is empty, including during lunch and coffee breaks. Locking les, if feasible, is an excellent added security measure.

coverage), or died. An inactive record indicates a patient who has not been seen for a given period of time but may return for future care. Closed and inactive paper medical records should be archived in a safe location that is not accessed frequently, such as a locked back storage room, basement, or off-site storage facility, to protect the condentiality of the records. Closed and inactive EHR can be saved on compact discs (CDs) and locked in a secure area of the ofce.

Medical Records Purging

The Medical Practice Act of each individual state determines record-keeping requirements in that state. Most states require medical offices to purge their paper records, which is the permanent removal of medical records that are no longer in use. When purging paper medical records, an office must destroy them by shredding or burning them in order to ensure that they cannot be accessed by unauthorized personnel. Some offices will opt to maintain large numbers of inactive files in order to reduce the risk of inappropriately destroying medical records. However, some offices may opt to transfer paperbased medical records to CDs to reduce storage space needs. Because EHRs do not require much storage space, office staff can maintain such records on CDs and store them in a secure location, rather than dealing with the expense and security risks of destroying medical records. As more providers convert to EHR and become accustomed to its use, archiving EHR will become more common than purging.

Medical Records Archives

Medical les of patients who are currently being seen in the ofce are called active les. These les should be accessible for use and cover patients who have been seen within the past 1 to 6 years, depending on ofce policy and availability of storage space. EHRs of patients who have not been seen in the ofce within 6 years may be removed from the active system and transferred to electronic storage and kept in a secure, locked area. Records of patients who have not been seen for over 6 years may be designated as closed or inactive. A closed medical record indicates a patient who no longer seeks treatment in the ofce, including a patient who has moved from the area, changed doctors (commonly for insurance

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Release of Medical Records

A medical record or a portion of it can be released to persons who demonstrate a need to know. Examples of a legitimate need to know include consultation by another physician, legal action, or insurance processing. (See Chapter 7, HIPAA and a Patients Rights, on page 71, for a release of records procedure.) Physicians, attorneys, insurance companies, government agencies, and the patient may request copies of medical records. In general, the medical assistant will release copies of a medical record. However, she can release original x-rays and magnetic resonance imaging (MRI) scans with the stipulation that they be returned to the original medical record. As the guardians of sensitive personal health information, medical assistants and other health care providers are responsible for maintaining patient condentiality. Remember the rule, when in doubt, do not give it out. (See Special circumstances for records release.)

EHR systems are being introduced into many ofces and can reduce errors and costs due to increased accessibility and readability. Color coding of records may also be used to provide added protection against misling records. Consistently applying the rules for creation, storage, and release of medical records will ensure that records are accessible when needed and released only when appropriate.

Team Work Exercises

1. Discuss with your instructor and classmates converting from paper-based medical records to EMR. Research some software that can be used to create medical records. Should your practice scan the old records? Key the old records? Create a timeline for training the ofce personnel and converting records. How should you design a system that will allow the conversion to take place without interrupting the physicians and billing staff s access to the medical records? 2. Using the paper medical records created by the class in Procedure 14-1, discuss the ling system and storage requirements for your medical records. Create a storage area in the classroom or clinical laboratory. Create out guides and cross-reference guides for medical records (if necessary).

pecial circumstances

Chapter Summary

The medical assistant is responsible for the creation, ling, storage, and appropriate release of medical records. Depending on the needs of the ofce or hospital, an alphabetical or numeric ling system will dictate how medical records are kept.

Special circumstances for records release

In general, a patient has a right to privacy for his health records. The medical assistant will be required to obtain the patients consent to release information in the record before doing so. However, there are some special circumstances in which consent requirements vary from the normal requirements. obtain specic permission from the patient to release these types of information: references to diagnosis and treatment of HIV or AIDS sexually transmitted diseases psychiatric disorders and mental health records drug and alcohol abuse history.

Court cases
When a medical record is subpoenaed by a court of law, the medical assistant may release those medical records without the patients consent. The medical assistant must release original documents (photocopied documents are not acceptable in court) unless the judge species that copies are acceptable. The medical assistant should release the original documents with the stipulation that the court return all the documents after use. She should also note the absence of the documents in the patient le, including the date they were taken and the date the court returned the records.

Guardianship
Custodial and noncustodial parents, foster care providers, and guardians must sign a release form authorizing transfer of medical records for children under age 18.

Emancipated minors
Children who are under the age of 18 and living on their own, married, a parent, or in the armed services can become emancipated by a judge. These persons have exclusive access to their medical records, and a parent cannot request the record without the patients consent.

Specic consent
Because release of some medical information could impact a patients ability to lead his life, the medical assistant must

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Case Studies
1. Which of the following ling systems would be appropriate for a pediatric ofce? A mental health clinic? A substance abuse center? Support your answer. a. Alphabetical b. Alphabetical with color coding c. Numeric d. Accession log 2. You are working in an ofce that uses an alphabetical color-coded system. Sally Jenkins has recently married Henry OLeary. Sally has decided to hyphenate her name. Where should you le Sallys medical record? Will you need to make a new le folder for her? Where should a cross-reference guide be placed? How would you change the record if Sally were to take her new husbands name? Where would you le her medical record? Do you need to le a cross-reference guide? If so, where?

Resources

Health and Human Services discussion of EHR adoption: www.hhs.gov/healthit/ahic/healthrecords Electronic medical records software: www.actimedical.com, http://www.edgemed.com/, www.purkinje.com/ehr/home.cfm, and www.lighthousemd.com Medical ling supply vendors: megastarsystems.com/docs/ ofceprod/,www.ancom-ling.com/medical_page.html?source= overture, and oilingsystems.reachlocal.com Adam, A.: Implementing Electronic Document and Record Management Systems. Philadelphia: CRC Press, 2007. Hamilton, B., and Hamilton, L.: Electronic Health Records. New York: McGraw-Hill, 2008. Lehmann, H. P., et al.: Aspects of Electronic Health Record Systems, 2nd ed. New York: Springer-Verlag, 2006.

CHAPTER

Ofce Management
Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms as presented in the glossary discuss the roles and responsibilities of an ofce manager and a human resources director describe at least three key qualities of an effective ofce manager or human resources director list at least three benets of teamwork describe the purpose of staff meetings, brainstorming, and employee participation in decision making discuss the uses of a policies and procedures manual describe the purpose of marketing and tracking describe the various forms of internal and external marketing and their uses.
Perform routine maintenance of administrative and clinical equipment Utilize computer software to maintain ofce systems

15
Ofce Management Roles and Responsibilities Dealing with Employees
Conducting an Interview New Employee Orientation Policies and procedures manual Conducting a Staff Meeting Conducting an Employee Evaluation Disciplinary actions and terminations

ABHES Competencies
Professionalism
Project a positive attitude Be a team player Exhibit initiative Evidence a responsible attitude

Taking an Inventory and Ordering Supplies

Maintaining laboratory equipment and supplies inventory Selecting Computer Hardware and Software Using computers in the medical ofce

Communication
Be attentive, listen, and learn Interview effectively

Administrative Duties
Manage physicians professional schedule and travel

Ofce Management
Maintain physical plant Operate and maintain facilities and equipment safely Inventory equipment and supplies Evaluate and recommend equipment and supplies for the practice Maintain liability coverage Exercise efcient time management

Assisting with Physician Travel Arrangements Marketing in the Medical Ofce

Internal Marketing External Marketing Tracking Marketing

Chapter Summary Team Work Exercises Case Studies Resources

Instruction
Orient and train personnel

CAAHEP Competencies
General Competencies Professional Communications
Recognize and respond to verbal communications

Procedures
Training new personnel using the policies and procedures manual Taking and reordering inventory, performing maintenance, and checking safety Preparing physician travel

Legal Concepts
Identify and respond to issues of condentiality Perform within legal and ethical boundaries

Operational Functions
Perform an inventory of supplies and equipment

Chapter Outline
Qualities of Leadership
Praising While Problem Solving

187

Key Terms
agenda

Qualities of Leadership
An effective manager possesses qualities of leadership that help her lead her team effectively and efciently. Such leadership qualities include the ability to empower others, gain experience in a multitude of tasks, have enthusiasm for her job, and work hard. The ofce manager of a medical practice can empower her employees by respecting their skills and abilities and trusting their judgment in their areas of expertise. She can also use her varied experience to support the ofce staff with whatever help is necessary. A willingness to do so not only creates an efcient workplace but also fosters a spirit of teamwork. The group that feels appreciated and connected as a team will work together toward common goals. Such strategies as brainstorming, in which a group of people think of possible solutions to problems and discuss them, promote an open dialogue between the ofce manager and ofce staff and show employees that the manager values their opinions. When supervising medical assistants, the ofce manager must remember that medical assistants are educated professionals who take their jobs seriously. In general, an employee appreciates a manager who understands the employees job responsibilities and role in the organization. A manager who worked her way up is commonly in touch with the employee because she once performed the tasks of that employee. An enthusiastic, hardworking manager will help out when a department is busy and does not consider any job beneath her. If the manager has not done the work of the employee, she should ask the employee to teach her how to perform each of her job functions in order to gain an understanding of the responsibilities of all of the personnel that she supervises.

Items of business to be addressed at a staff meeting

brainstorming

Process in which individuals in a group offer ideas to solve a specied problem

constructive criticism

Method of instruction that focuses on actions that can improve an employees job performance rather than focusing on the negative aspects of the persons performance
external marketing

Methods of informing people who have not been patients of the practice about the practice and its services
internal marketing

Method used to stimulate business with existing patients through mailings and other means
job description

Written description of the qualications and duties of a position

policies and procedures manual

Handbook that provides detailed information about regulations regarding tasks and how to perform the tasks

TIP Know What They Do A medical assistant who would like to become a supervisor should learn the responsibilities of a clinical and administrative medical assistant. Although she may never want to work at the front desk or work as a clinical medical assistant, she may supervise both positions. Having an understanding of all of the jobs in the ofce will make her more effective as a supervisor.

Praising While Problem Solving

An effective manager is also able to express appreciation for her employees successes and does not merely focus on solving problems. For example, if the front desk runs smoothly except for copayment collections, the effective supervisor will discuss the good points as well as the problem. The manager can express her appreciation for the jobs that are well done, such as smooth appointment scheduling, accurate record

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keeping and ling, and professional telephone techniques. The employees feel appreciated, not threatened, when the manager then asks for input on the copayment problem. When the manager voices appreciation and praise for the employees good work, they are more willing to accept some constructive criticism on problem issues. (See Attributes of a quality manager.)

Ofce Management Roles and Responsibilities

Physicians spend most of their time and energy caring for their patients. They will, in turn, rely on the expertise of an ofce manager (OM) to ensure that the ofce operations run smoothly and effectively. The OM will commonly serve as the HIPAA compliance ofcer as well as function as the supervisor of personnel. In general, the role of the OM includes:

creating and updating the ofces policies and procedures manual supervising ofce personnel supervising externship students conducting regular staff meetings supervising the purchase of equipment and supplies arranging for maintenance and calibration of equipment supervising the purchase and locked storage of controlled substances ensuring that Material Safety Data Sheets are kept on all necessary chemicals, cleaning solutions, and supplies approving nancial transactions, including payroll and accounts payable and receivable, and creating nancial reports as needed maintaining malpractice insurance and developing risk management strategies reattesting and maintaining physician participation in managed care.

Some larger medical practices and all hospitals employ a human resources director and HIPAA compliance ofcer in

Attributes of a quality manager

The table below lists common attributes of a quality manager along with questions that the medical assistant can ask herself to determine if she already possesses these attributes or should seek to obtain them.

Attribute
Appreciative Approachable

Question
Do I thank and respect others for their hard work? Am I easy to talk to? Am I willing to listen to others? Can I set a friendly and professional tone in the ofce?

Detail-oriented Effective communicator Flexibile Honest and truthful Objective Organized Skilled in dealing with people Optimistic Perceptive Realistic Knowledgeable in the eld

Do I recheck my work for errors? Do I pay attention to small details? Can I communicate effectively in oral and written form? Am I willing to try new ideas and seek solutions to problems? Do I admit my errors? Will I give honest feedback to employees? Will I treat all employees equally and fairly? Will I try to nd solutions to problems that benet everyone? Can I lead by example by being organized in my work? Do I prioritize tasks? Do I enjoy working with people? Can I build the condence and self-esteem in others to bring out the best in them? Am I generally an optimistic person? Do I assume things will go right or wrong? Can I understand nonverbal cues that give me insight into a person? Do I know when someone needs my help? Will I demand too much or too little from employees? Do I have an understanding of the job descriptions for the people I will supervise?

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addition to the OM. At a large facility, such as a hospital, an OM could not perform all of the duties required of all three positions. In general, the role of the HR director includes:

manager should conduct the interview in a private ofce and ask not to be disturbed during the interview. The OM should ask the applicant about:

creating and updating the ofce policies and procedures manual recruiting and hiring ofce personnel orienting and training new personnel and externship students providing continuing education for employees as needed performing evaluations and salary reviews dismissing employees and conducting exit interviews maintaining condential personnel records complying with state and federal regulations regarding employees.

ability to perform the job functions transportation to work availability of hours last job duties of the previous job clinical and administrative skills strengths and weaknesses.

Because the job duties of the OM and the HR director overlap, an individual ofce will delineate the roles of the personnel. As with any position in the physicians ofce or hospital, a job description is necessary so that employees know what their responsibilities are and no functions of the ofce are unattended to.

Dealing with Employees

As a supervisor, you will have to interact with different people with varying personalities. It will be your job to get everyone working toward common goals. Employees must communicate with each other and cooperate in getting tasks accomplished. An effective leader leads by example. Communicate and work with each employee to delineate roles in the tasks of the ofce. Through training, make sure that employees have an understanding of the roles of other members of the team and their jobs. When employees know who performs tasks in the ofce, they can troubleshoot and ask for help if necessary.

TIP Getting Rid of Gossip Gossip can be a destructive force in an ofce. If people are developing personal animosity towards one another, take steps to end the negative comments. Never take sides or participate in the gossiping. Treat all employees with respect and they will in turn treat each other with respect. If you feel that you cannot get people to work together in a positive fashion, you may need to re an employee or ask the advice of the physician owner.

Conducting an Interview
When looking to hire a new employee, the ofce manager will conduct an interview of the applicant. The ofce

In addition, the OM should take note of the applicants appearance, eye contact, vocabulary, and general nature. The OM should let the applicant do most of the talking and should wait until the end of the interview to discuss salary questions. An interview worksheet helps ensure that the OM asks all applicants the same questions. She can then add the worksheet to the applicants folder along with the application and resume. The interview worksheet includes information that will help the interviewer decide which candidate is best suited to the job. Items will include the candidates skills, hours of availability, and expected salary range. (See Figure 15-1.) When conducting an interview, the OM is not legally allowed to ask about the applicants home life, such as if she is married or single, cares for an elderly relative, has children and good day care arrangements. If the OM were to ask these questions and the applicant was not offered the position, she could assume that she was a victim of discrimination and could le a lawsuit against the medical practice. Although the OM cannot ask these questions, an applicant will commonly offer information in an effort to show that she is a good candidate for the position. An applicant may inform the OM that, while she does have two children, the day care is only a 5-minute drive from the home of her mother, who frequently helps out with childcare. Although the OM cannot ask the questions, she can base hiring on information offered by the applicant during the interview. The OM is allowed to ask the applicant to disclose any felony convictions, and the applicant is required, by law, to answer truthfully. If the applicant discloses a felony conviction, the OM can ask for details about the crime committed. The decision to hire an individual with a felony conviction should be thought out carefully and should never compromise patient safety. The Americans with Disabilities Act of 1990 ensures the rights of persons with disabilities. Persons with disabilities can be asked if they need accommodation to perform job duties, such as a big-screen computer for a visually impaired applicant, a telephone amplier for a hearing-impaired applicant, or wheelchair access to a work area for an applicant in a wheelchair.

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Name Position

Jean Martinez front desk/reception

Interview date and time

10/16/08, 4:30 p.m.

(front office, clinical, float, etc.)

Ask the applicant if he/she can perform: Vital signs Height & weight Injections Scheduling Preauthorization Hospital scheduling Hgb, glucose Assisting with surgery Patient education Billing & coding Specialty referrals Financial reports

at previous job in ortho office familiar with Medisoft

Eye contact

Appearance

Professional, well dressed

good

Work experience

3 years front desk/billing dept. at Williamsville Orthopedics;

needs work closer to home; she moved to Blueville

Availability MTWTFS Overall impression Salary discussion

Days and evenings except Wed after 5 pm Professional, confident, experienced states she was making $14.50 at previous position

NEVER ASK Do you have children? Are you planning to get pregnant? Any personal questions about age, national origin, religion, sexual orientation, marital status.

FIG 15-1 Interview worksheet.

The OM should keep the application and resume of applicants private and avoid sharing the information with other personnel. Only the individuals who are responsible for making the hiring decision, such as the OM and physician-owner, should have access to these materials. Upon hiring, the OM should le the applicants application and resume in the employees personnel le. Personnel les are private; only the employee and supervisors should be viewing the personnel le. After the interview, the OM should check professional and, if applicable, personal references. The OM should call the reference and ask about the employees work ethic, ability to perform the job, and interactions with employees. The OM should ask if the employee:

Some companies allow only the HR manager to take reference calls. This person may not have worked directly with the applicant and may only offer the dates of employment as a matter of policy. The OM should not consider such a policy as a mark against an applicant. Instead, the OM should try to contact another reference who can speak more freely about the applicant. The physician-owner may interview applicants or review the OMs interview notes to make a decision. The OM should meet with the physician-owner to suggest that the most impressive applicant be hired, considering the personalities of the people the new employee will work with. Once an applicant is chosen, the OM should call the applicant to offer the position and agree on a starting date.

was on time every day for work had a pleasant attitude was empathetic towards patients was exible in job duties.

TIP Giving a Reference If an employee is seeking a new job and asks the OM for a reference, the OM should nd out what she can and cannot

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say. Some employers will only allow an OM to give the dates of employment, while others will allow a more detailed reference. The OM may need to keep the identity of the employee condential from the supervisor or physician-owner. Maintaining condentiality extends beyond patient les. An OM who can be trusted by her employees maintains this confidentiality and, in turn, gains her employees respect.

questions and ensures understanding of the policies and procedures. (See Procedure 15-1: Training new personnel using the policies and procedures manual.)

Conducting a Staff Meeting

Staff meetings are a great way for the team to discuss the effectiveness of work procedures, communicate concerns or changes to policies, and appreciate jobs well done. The staff meeting should begin with an agenda. The agenda is an outline of topics to be discussed and the order in which they will be presented. All employees appreciate organized meetings that are held in a reasonable amount of time. Staff meetings that run too long are counterproductive, and staff will begin to resent the meetings. (See Figure 15-2.) The OM should take steps to make the meeting successful, including:

New Employee Orientation

The rst day of a new job is full of excitement as well as uncertainty. The OM should introduce the new staff member to her coworkers and welcome her to the team. Many ofces have a new employee follow another employee through the workday. The new person will watch the work being performed and have the opportunity to ask questions. Once the new employee is comfortable with the job duties, she is allowed to perform tasks.

Policies and Procedures Manual

In addition to the new employee orientation, a policies and procedures manual is a powerful tool for learning a new job. Employees can refer to the manual as new tasks or situations arise. The policy portion of the manual refers to the rules of the ofce. For example, the ofce charges 5 cents per page for photocopying records for patients. That is the policy. The procedure outlines how to carry out the photocopying of the medical records and collecting payment: 1. 2. 3. 4. Verify the patients identity with a photo drivers license. Have the patient sign and date a release form. Photocopy pages from the patients medical record. Document the copying of pages in the notes and attach the signed release form. 5. Put the records into a large, sealed envelope. 6. Collect the 5 cents per page fee and give the records to the patient. A policies and procedures manual should be available for all employees to refer to. The OM should update the manual as needed. When in doubt about a policy or procedure, the manual should instruct employees to check with the OM or physician. An OM commonly gives a copy of the manual to a new employee to take home and review. The OM can direct the new employee to areas of the manual that specically relate to her job. For example, the newly hired billing and coding specialist will need to review the procedures for electronic transmission of billing and the policies for resubmitting rejected claims. The OM should not assume that reading the manual will give adequate information to the new employee; conducting a discussion with the new employee allows her to ask

e-mailing the agenda to staff members prior to the meeting and providing copies at the beginning of the meeting holding the meeting in the ofce when no patients are scheduled turning on the answering machine or answering service so that no one has to leave to answer phones offering beverages and snacks (optional).

The staff meeting helps make the staff aware of each individuals job and what gets accomplished on a daily basis. Hearing about coworkers responsibilities and accomplishments helps an employee understand that every person in the office is an important member of the team. If the administrative staff does not schedule appointments, the clinical staff will have no patients to see. If the clinical staff does not complete charting, the billing department cannot obtain payment for services. When employees realize that their jobs impact the ability of others to complete tasks, they will feel an obligation to others in the organization to do a good job. At the end of a busy day, the front office staff, clinical personnel, physicians, and office managers can feel a sense of pride in their accomplishments. For example, during the day, Amy, the front desk medical assistant, may help an elderly patient into a treatment room. Steve, who is a clinical assistant, calls an insurance company on behalf of a patient who has a billing question. Wendy, who works in the billing department, helps Steve find a lost patient chart. Amy, Wendy, and Steve can appreciate the help that coworkers offer.

Conducting an Employee Evaluation

As a supervisor, it is the OMs job to give employees feedback on their work. The OM should praise their good

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PROCEDURE 15-1

Training new personnel using the policies and procedures manual

Task Orient new personnel to the information contained in the policies and procedures manual. Conditions Policies and procedures manual New employee personnel le Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully train new personnel using the policies and procedures manual. Performance Standards 1. Role-play the supervisor and then the new employee with a classmate. The new employee will read a section of the policies and procedures manual. The supervisor then answers questions posed by the new employee. The supervisor ensures that the new employee understands the policies and procedures by asking questions. 2. Ask the new employee to read a section of the policies and procedures manual (as directed by the instructor) to promote understanding. 3. Ask the new employee to relate the policy and procedure outlined and give a rationale for the item to ensure that the employee not only knows how to do the procedure but has an understanding of why the procedure is conducted in this manner, which helps promote compliance with the procedure. 4. Give the new employee an opportunity to ask questions to demonstrate the importance of understanding the policies and procedures. 5. Answer the employees questions and be sure to ask if the explanation is clear to ensure proper understanding. 6. Ask the new employee to sign a statement in her personnel le to indicate that she has read and understands the policies and procedures manual (or designated section) to promote adherence to policies and procedures.

POLICIES AND PROCEDURES MANUAL REVIEW STATEMENT

I have read and understood the P&P manual, section(s) and will adhere to these policies and procedures. I understand that if I have questions regarding specific procedures, I can refer to the P&P manual or ask supervising personnel.

Signature of employee

Date

Signature of manager

Date

work and show appreciation for their efforts. Periodic raises and promotions for exceptional work encourage good employees to stay with the office. Adding additional responsibilities or supervisory functions to an employees job description shows the employee that competence and attention to detail is appreciated. Suggesting cross-training to the employee and steps to expand her knowledge base can further the employees career. (See Cross-train for success, page 194.)

If necessary, constructive criticism is always preferred to merely criticizing an employees efforts. Suggesting how the employee could do the work better, more efficiently, or in a more timely manner allows the employee to strive toward an attainable goal. If necessary, the OM should give the employee a corrective action plan. For example, if the employee is chronically late for work, the OM should explain that the employee must be on time 15 consecutive workdays or face dismissal. If misfiling is a

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AGENDA Staff meetingNovember 12, 2008 3:00 to 5:00 p.m. 1. Introduce new clinical medical assistant Wendy Jones 2. Front desk collection of copayments 3. Scheduling MRIs at hospital changes to procedure 4. New hemocytometer training schedule 5. Carpet cleaning next Friday reminder to move furniture into storage closet 6. Schedule changes for Dr. Greer 7. Employee of the month award 8. Items from you 9. Next months meeting date and time

FIG 15-2 Sample agenda for staff meeting.

problem, the OM should give the employee some resources on how to file, such as a medical assisting textbook with exercises for the employee to do. The OM should offer to help the employee as needed in the corrective action plan.

for improvement, and the employee will feel encouraged by the praise.

Disciplinary Actions and Terminations

A negative employee can make the whole ofce feel bad and produce a counterproductive environment. If corrective action is possible, the OM should meet with the employee and devise a plan for improvement that includes a timeline. The OM should document the employees efforts towards corrective action. In the event that such corrective action does not succeed, the OM may need to re an employee. To protect the ofce legally, the OM should keep a written le on an employee who is a problem. In the le, the OM should:

TIP The Sandwich Approach An OM conducting an evaluation should consider the sandwich approach. Begin the evaluation with praise, then discuss areas that need improvement, and end the evaluation with more praise. The OM will be able to address the need
Front ofceBack ofce connection

Cross-train for success

The ofce manager should encourage employees to crosstrain in order to be available to help departments that are busy. A multiskilled medical assistant is valued by the ofce. The clinical medical assistant who learns how to submit electronic insurance claims and answer patient billing questions can cover the billing department if someone is ill or on vacation. The administrative medical assistant who keeps up with clinical skills such as taking vital signs can assist busy clinical staff at a moments notice.

document the employees unacceptable behavior, such as tardiness, rudeness to patients or coworkers, and an inability or unwillingness to perform job duties date the incidents and include the names of other personnel who may be involved directly quote any inappropriate statements made by the employee to patients or other staff members.

When the physician-owner and the OM decide that the employee will be terminated, they should be prepared for the employee to react angrily. They should keep the dialogue as short as possible and tell the employee that they have chosen to terminate her employment and that she should leave

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the ofce. To avoid a scene, the OM may want to re the employee when patients are not in the ofce.

Taking an Inventory and Ordering Supplies

The OM may take an inventory of supplies and order the clinical and administrative supplies needed to run the ofce. Alternatively, the clinical staff may order clinical supplies and the administrative staff, the front desk supplies. In such a case, the OM should supervise staff members who are responsible for taking inventory and placing orders. Written or computerized inventory sheets can help determine the need for supplies. (See Clinical cabinet inventory.)

time period between maintenance inspections. The policies and procedures manual should contain instructions for maintaining laboratory and ofce safety. The OM should organize and maintain the laboratory and ofce contents to promote optimal function and ensure safety. (See Procedure 15-2: Taking and reordering inventory, performing maintenance, and checking safety, pages 196 and 197.)

Selecting Computer Hardware and Software

The OM may be required to update computer hardware and software or computerize an ofce that has previously recorded all information on paper. Because protected health information (PHI) is available on ofce computers, the OM must ensure that logins and passwords are used to protect patient privacy and that virus and spyware protection are installed and periodically updated. Failure to safeguard PHI could result in nes. Many software programs offer physician ofce management tools, including programs for:

Maintaining Laboratory Equipment and Supplies Inventory

The OM commonly has the task of inventorying and ordering supplies and maintaining equipment or directing a staff member to do so. These tasks must be performed on a weekly, monthly, or quarterly basis as needed. An inventory of frequently used supplies, such as bandages, syringes, and thermometer covers, is commonly necessary each week, because the ofce cannot run without these needed items. The OM or staff can take an inventory on a monthly basis for items that are used less frequently or kept in large supply, such as tongue depressors and examination table paper. The equipment manufacturers recommend maintenance schedules for equipment. They may base these recommendations on the number of times the machine is used or the

creating a patient database appointment scheduling insurance billing (electronic submission or U.S. mail claims) patient billing (with dunning notices for overdue bills) nancial reports (daily, weekly, or monthly revenues) sorting revenue by doctor or department online banking taking inventory.

Vendors who sell software packages to physician ofces may customize programs to t specic needs. Because

Clinical cabinet inventory

A clinical cabinet inventory sheet can be taped to the inside of the cabinet. When items are used, the medical assistant should change the quantity listed to reect usage. This type of inventory can also be tracked using a computer spreadsheet. The medical assistant must
ITEM MMR vaccines DPT vaccines Band-aids Alcohol pads Gauze pads Exam table paper rolls HGB slides Lancets AMOUNT 35 units 29 25 units 6 boxes 8 boxes (500 units/box) 10 boxes (1000 units/box) 2 boxes (6 rolls per box) 1 box (100 units/box) 2 boxes (100 units/box)

remember to update the items quantity in the inventory spreadsheet. The gure below shows an example of a printed clinical cabinet inventory sheet. As disposable items are used, the amount of remaining items is updated.

ORDER DATE 9/15/07 (exp 6 months) 9/15/07 (exp 6 months) 5/12/07 5/12/07 7/11/07 8/12/07 8/12/07 8/12/07

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PROCEDURE 15-2

Taking and reordering inventory, performing maintenance, and checking safety

Task Take an inventory of equipment and supplies and reorder supplies, perform routine equipment maintenance, and check laboratory safety. Conditions Various equipment and supplies in the classroom and laboratory Inventory log Reorder form Equipment safety and maintenance instructions (provided by the manufacturer) Equipment quality control log Pen Standards In the time specified and within the scoring parameters determined by the instructor, the student will successfully perform an inventory of equipment and supplies in the classroom and laboratory, fill out the reorder form, perform routine maintenance on equipment as directed by the instructor, check the condition of the laboratory and classroom for safety violations, and correct any violations. Performance Standards 1. Your instructor will assign a section of the laboratory or classroom for you to take an inventory. Using the inventory log and reorder form, count supplies and equipment and note items that need to be reordered. Be sure to check the contents of open packages to get an accurate count of items and ensure proper reorder. 2. Inspect the equipment for missing or broken parts, frayed electrical cords, or other safety hazards to ensure laboratory safety. 3. Report the condition of the equipment, noting the serial number on each item so that you can get the equipment repaired at no cost if a service contract is in place and to clearly identify each machine if the laboratory contains more than one of the same machine. Equipment to examine includes: a. autoclave b. ECG machine c. computers d. height and weight scale e. wall-mounted sphygmomanometer (blood pressure cuff ) f. wall-mounted ophthalmoscope-otoscope unit g. glucometer h. cholesterol meter. 4. Run a quality control check on a machine (as directed by your instructor). Fill out the results in the quality control log. Date and initial your work to show when the machine was last tested and ensure timely testing. 5. Clean the autoclave as directed by the manufacturers instruction manual to promote proper sterilization of instruments. 6. Check the entire laboratory for safety hazards and mark the laboratory safety inspection sheet to

REORDER FORM Supply Item Quantity Reorder Date

Bandaids

6 boxes

5/12/08

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PROCEDURE 15-2contd
QUALITY CONTROL LOG

Name of Equipment Date Time Strip # QC Reading Initials

7/14/08

8:51 a.m.

104

KM

prevent injury to staff and patients. Be sure to inspect: a. electrical cords for fraying or malfunctioning b. electrical outlets for loose covers or damage c. computer keyboards, monitors, towers, other components, and wiring

d. light sources and rechargeable batteries e. ECG leads and wires f. other equipment (as directed by the instructor). 7. Initiate repairs to the equipment (as directed by the instructor).

LABORATORY SAFETY INSPECTION SHEET

Equipment

Status

Repair needed

Initials

Electrical cords: computers Electrical cords: lights

One loose connection to the monitor OK

Tightened connection

LZ

LZ

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customized software can be expensive, the OM should compare prices and options that best t the needs of the ofce. The OM should consult the ofce staff who will be using the software. If vendors come to the ofce to demonstrate software packages, the OM should include the staff in the presentation. In addition, the OM should provide training to all staffclinical and administrative, if possible. (Many software companies will include staff training as a service for purchasing their software package.) Computer hardwarethe computer monitor, tower, printer, and keyboardmust be replaced and updated periodically. Service contracts are available on most computer equipment as well as trade-in allowances. If the OM is responsible for choosing computer hardware, she must do some research. Comparing prices, warranties, and service contracts could save the ofce money and save the staff from the aggravation of computer malfunction.

log off the computer when away from it. (In addition, the OM should be sure to deactivate the login and password of an employee who leaves the practice.)

Assisting with Physician Travel Arrangements

The OM will be charged with arranging the travel of physicians or staff members who attend seminars, continuing education courses, and lectures. The physician and staff members rely on the OM to arrange transportation, hotel accommodations, and registration for these events. The OM may need to call the provider of the seminar to determine the registration procedures at arrival time. The OM can help the physician or staff member by creating an itinerary that includes such items as ight information (including check-in time and ight time), registration time and location of seminar events, and hotel reservations (including a conrmation number). By reviewing the itinerary with the physician or staff member prior to departure, the OM can help the attendees have a positive experience. (See Procedure 15-3: Preparing physician travel.)

Using Computers in the Medical Ofce

Because computers in a medical ofce contain PHI and other sensitive information, the OM should train employees to:

turn off a computer screen when moving away from the computer place monitors so that patients cannot see the screen, to ensure privacy be sure that the patient at the front desk cannot see the computer screen (if necessary, by shielding the screen or positioning her body to prevent the patient from viewing the screen) (See Figure 15-3.) take printouts from the printer right away and not leave sensitive information in the printer or in a visible spot at the front desk

Marketing in the Medical Ofce

A successful medical ofce uses marketing to inform its patients of the services it offers. As the ofce expands, it should inform patients of new services, expanded ofce

FIG 15-3 Shield the computer monitor from the view of patients.

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PROCEDURE 15-3

Preparing physician travel

Task Prepare the physicians itinerary for travel arrangements, hotel and rental car reservations, and seminar registration. Conditions Computer with access to the Internet Physician or company credit card Standard In the time specied and within the scoring parameters determined by the instructor, the student will successfully arrange travel plans for the physician, including travel arrangements, hotel and rental car reservations, and seminar registration. Performance Standards 1. Discuss with the physician (role-played by the instructor) what city she needs to y to, the dates of the ight, and her preference for rental car, plane seating, and hotel accommodations to save time in deciding on options when making arrangements. 2. Research flights from your local airport to the destination. 3. Research hotels that are near the seminar and that meet the physicians criteria. 4. Find a rental car at the destination airport that meets the physicians criteria. 5. Print the travel information and conrm it with the physician to ensure that the physician is comfortable with the arrangements before purchase. 6. Create a conrmation notication for the physician that conrms travel reservations.

Dr. Wilson, Here is your information for travel: Air: Southwest Airlines leaves Bradley airport 8:48 a.m. on flight 708 connect in Chicago to flight 412 to San Diego arriving at 11:22 a.m. Shuttle to hotel - call on Radisson courtesy phone Hotel: Radisson Harbor San Diego Dates: April 17th thru April 22nd confirmation # ACF6790045 Conference - Pain management in reflex sympathetic dystrophy Conference registration confirmation #29888RSD Air: Southwest Airlines leaves San Diego airport 7:05 a.m. on flight 307 connect in Chicago to flight 1198 to Bradley arriving at 4:12 p.m.

hours, or changes to insurance policies. There are two types of marketing: internal and external.

Internal Marketing
Informing existing patients of changes in the practice is called internal marketing. If a patient regularly sees one of the doctors in the practice, she may not be aware of the services of the physical therapist or the acupuncturist. Mailing announcements to the existing patients can create business for

a new service being offered. In addition, they may tell friends and family about the expanded services. (See Figure 15-4.) Reminder cards and newsletters are other tools for internal marketing. Patients may not remember to call to schedule their yearly physical; sending reminder cards generates ofce visits. Sending periodic newsletters can keep the ofce name in a patients mind. Marketing companies create newsletters that the ofce can send to existing patients. The topics of the newsletters can vary from vaccine schedule

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Ed: pls provide new art

Blueville Family Medicine 15 Main Street Blueville, CT 860-555-3212

June 23, 2008 Dear Rosa:

PATIENTS NAME INSERTED AUTOMATICALLY BY MAIL MERGE PROGRAM

Please join us in welcoming Dr. Henry Lee to our practice. Dr. Lee is a board certified acupuncturist who graduated from Beijing Universtiy School of Medical Acupuncture. He and his wife, Lui, and their children, Benjamin and Stacy, have recently moved from Baltimore to join us. Dr. Lee has 15 years of experience in using acupuncture to treat sinusitis, weight loss, smoking cessation, migrane headache, muscle pain, and lower back pain. He has also had great results with patients receiving chemotherapy and acupuncture to stimulate appetite and reduce nausea. Dr. Lees weight loss and smoking cessation acupuncture programs will be available and he will offer a seminar on the programs on Tuesday, July 15, and Wednesday, July 16, 2008, at 7 p.m. at the office. Dr. Lee will begin seeing patients on July 21, 2008. Please call the office for an appointment. Thank you, Dr. Robert Greer and staff

FIG 15-4 Internal marketing letter to an existing patient.

reminders to handwashing for infection prevention. (See Figure 15-5.)

Tracking Marketing
Because the ofce will use many forms of marketing, the OM should keep a record of which forms of advertising and marketing yield patients and which do not. A list of promotional codes can be created to track effective marketing practices. The OM can create a simple database that tells her the source of each referralfor example, A for yellow pages, B for patient referral, C for physician referral, D for newsletter, E for HMO listing, and F for other. The OM can review the database periodically to determine which forms of marketing are most effective. In addition, the new patient intake form should include the question, How did you hear about us? The medical assistant can add the source of the referral to a marketing tracking le. Marketing sources that can be included in the marketing tracking le might include a yellow pages advertisement, a patient referral, an HMO listing, or a newspaper advertisement. If

TIP Referral Requests

A great marketing tool is to ask people to refer their friends and family to the ofce. When patients express gratitude for quality care, the medical assistant should tell them that the best compliment is a referral. The ofce manager should make sure that the medical assistant is trained in how to appropriately ask for referrals.

External Marketing
External marketing refers to marketing that targets people who have not been patients of the practice. Yellow page, newspaper, radio, and television advertising can be used to let the public know the services the ofce provides, where it is located, and how to contact the ofce. (See Figure 15-6.)

CHAP TER 15

Office Management

201

Blueville Family Medical News July 2008 Keeping in touch with all your health needs

Ed: pls provide new art

Blueville Family Medicine 15 Main Street Blueville, CT 860-555-3212

Robert Greer, MD Hector Rodriguez, MD Anne Wilson, MD Sharon Piecek, APRN Henry Lee, MD, L.A.C. New Happenings in our office Expanded Office Hours In an effort to make our office hours convenient to our busy patients, we have expanded our hours to include Monday and Thursday evenings until 7:30 p.m. and Saturdays from 8:30 to 1 p.m. Call the office for an appointment. Welcome Dr. Henry Lee Please join us in welcoming Dr. Henry Lee to our practice. Dr. Lee is a board certified acupuncturist who graduated from Beijing University School of Medical Acupuncture. He and his wife, Lui, and their children, Benjamin and Stacy, have recently moved from Baltimore to join us. Dr. Lee has 15 years of experience in using acupuncture to treat sinusitis, weight loss, smoking cessation, migraine headache, muscle pain, and lower back pain. He has also had great results with patients receiving chemotherapy and acupuncture to stimulate appetite and reduce nausea. Dr. Lees weight loss and smoking cessation acupuncture programs will be available and he will offer seminars on the programs on Tuesday, July 15, 2008, at 7 p.m. and Wednesday, July 16, at 6 p.m. Call the office to reserve a seat at one of the seminars. Dr. Lee will begin seeing patients on July 21, 2008. Please call the office to schedule an appointment. Welcome, New Baby! Please join us in congratulating Kelly Manera, our billing coordinator, and her husband Ken on the birth of their daughter, Kathryn Elizabeth, on June 11, 2008. Mom and baby are doing fine and Kelly will return to work in September. Welcome Kathryn Elizabeth!

Nutrition Notes from Sharon Piecek, APRN, RD Preventing Cataracts with Good Nutrition A cataract is an age-related thickening of the lens of the eye that impairs vision. Surgical removal of the cataract will prevent blindness, but good nutrition can reduce your chances of developing cataracts. Oxidative stress plays a big role in the development of cataracts. A diet rich in antioxidant foods can reduce your risk of cataracts. Specifically, foods high in vitamin A, vitamin C, and vitamin E have been known to decrease cataract development. To reduce your risk of cataracts, include the following foods in your diet: Sweet potatoes Carrots Broccoli Fresh strawberries Almonds Sunflower seeds 950 mcg of vitamin A per cup cooked serving 320 mcg of vitamin A per cup raw serving 60 mg of vitamin C per cup serving 70 mg of vitamin C per cup serving 36 mg of vitamin E per 1 cup serving 13 mg of vitamin E per cup serving

In addition to reducing your risk for cataracts, vitamins A, C, and E are antioxidants that protect the body against all forms of oxidative stress and, therefore, help you fight infection. Remember A, C, and E are your ACE against infection! For more nutritional counseling, call the office and make an appointment to see me. I am happy to assist you in making healthy food and lifestyle choices.

Sharon

Best of Health,

Human Papilloma Virus V accines Are Available HPV vaccines are available for female patients who are age 12 and older. Although the vaccine is not mandated by the state for public school attendance, the vaccine has been shown to reduce susceptibility to HPV infection. Ask Dr. Rodriguez or Dr. Wilson for more information. Dont Miss out on Fall Sports! High school and junior high school sports physicals are available with Dr. Rodriguez, Dr. Wilson, or Sharon Piecek, APRN. Without a signed physical form, athletes cannot participate in school sports teams and clubs. Physicals take approximately 45 minutes; call the office for an appointment.

FIG 15-5 Sample newsletter.

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group. Are the policies stated in understandable terms? Are the policies reasonable and enforceable? Are the procedures outlined in a step-by-step manner? Are the steps easy to follow? Each group should provide constructive comments.

Case Studies
Blueville Family Medicine 15 Main Street Blueville, CT 860-555-3212 Robert Greer, MD.....Family medicine Hector Rodriguez, MD.....Family medicine Anne Wilson, MD.....School and sports physicals Sharon Piecek, APRN.....Nutritional counseling, weight loss, and diabetes management Henry Lee, MD, L.A.C......Acupuncture

Role-play the following scenarios with classmates. 1. Barbara is chronically late for work. Although she is expected to be in the ofce by 8:30 a.m. to call the answering service and get messages from the previous day, she has not arrived at the ofce before 8:45 a.m. on any day for the past 2 weeks. Two other staff members have complained to the ofce manager that the telephone and scheduling have been compromised due to Barbaras tardiness. How should the ofce manager approach the problem with Barbara? One student should role-play as the ofce manager and another role-play as Barbara and then switch roles and repeat the exercise. 2. Jayne and Kelly do a great job running the front desk and processing insurance claims. They usually collect between $6000 and $7000 per week. In the past week, however, the billing department collected a record $9737.12. Sarah, the ofce supervisor, plans to mention the weeks record collections at the staff meeting on Friday. Brainstorm with classmates what types of incentives and recognition Jayne and Kelly deserve. Then role-play the staff meeting. 3. A student extern will be starting to work in the ofce next week. The student medical assistant will need to spend time in each department learning the roles and responsibilities of many of the employees. The ofce manager, receptionists, billing coordinator, and clinical medical assistants must meet to discuss how teaching a student will impact their busy work schedule and why teaching externs is important to the practice. Role-play the meeting. 4. In pairs, classmates should play the roles of interviewer and interviewee. Create interview worksheets to guide questions during the interview. After conducting the interviews, discuss the strengths and weaknesses of the interviewer and interviewee. Then switch roles and repeat the exercise.

FIG 15-6 Sample Yellow Pages advertisement.

the source of the referral is another patient, sending a note thanking the patient for the referral is a friendly gesture and might engender more referrals.

Chapter Summary

The role of the ofce manager is to create a constructive working environment for all employees. Creating a positive environment that promotes teamwork and mutual respect is essential. Conducting staff meetings enables the ofce manager to update procedures, address staff concerns, and recognize employees for exceptional performance. Periodic performance reviews give employees feedback so that they can continuously improve their work. When the ofce manager leads by example with hard work and dedication, she shows that she cares about patients, coworkers, and physicians.

Team Work Exercises

1. Discuss with classmates your favorite supervisor or teacher. How did this person use the strategies of good leadership to create a team environment? 2. Discuss with your classmates a situation where leadership was lacking. How did that lack affect the outcomes of the group or work team? 3. Divide into groups of four to seven persons. Each group should discuss ve tasks that can be included in a policies and procedures manual. For each item, create a policy regarding conditions for the task and a procedure that outlines how the task should be performed. When all ve tasks have been addressed, the groups should exchange their policies and procedures and critiques those of the other

Resources

Medical practice managers network: www.mpmnetwork.com/ Professional Association of Health Care Ofce Management: www.pahcom.com/ Newsletter for Physician Ofce Administrators: www .ardmorepublishing.com/mompage1.html Moghadas, K.I.: Medical Practice Policies and Procedures. Chicago: American Medical Association, 2005. Rainer, C.: Practice Management: A Practical Guide to Starting and Running a Medical Office. Lima, OH: Wyndham Hall Press, 2004.

CHAPTER

Coding and Insurance

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary describe how a claim travels through the medical ofce describe the different types of insurance products explain how a resource-based relative value system impacts claims coding explain how an effective superbill can help achieve a quick, clean claim processing apply skills to locate CPT codes apply skills to locate an ICD-9-CM code discuss how effective communication among the front desk, medical assistant, and physician is vital to the accurate processing of an insurance claim explain how to process a referral to a specialist or from a primary care physician accurately complete a CMS-1500 form describe the registration process for a new patient explain fraud and abuse and their consequences.
Perform procedural coding Perform diagnostic coding Complete insurance claim forms

16
Insurance in the Physicians Ofce
Employer Insurance Programs Managed Care Health maintenance organization Independent practice association Preferred provider organization Traditional Insurance Consumer-Driven Health Plans Health savings account Health reimbursement account Flexible spending account Government Programs Medicare Medicaid CHAMPUS CHAMPVA Workers Compensation Multiple Insurance Policies COBRA Self-Pay Patients Insurance Claims HIPAA Submitting a claim Life cycle of an insurance claim Obtaining referrals Payment Systems Usual, customary, and reasonable Fee-for-service Resource-based relative value scale Capitation Payment Processing Payment Denials and Appeals Process

Operational Functions
Utilize computer software to maintain ofce systems

ABHES Competencies
Administrative Duties
Apply managed care policies and procedures Obtain managed care referrals and precertication Perform diagnostic coding Complete insurance claim forms Use physician fee schedule

Financial Management
Implement current procedural terminology and ICD-9-CM coding Analyze and use current third-party guidelines for reimbursement

Procedures
Coding procedures and diagnoses Submitting a CMS-1500 form to a third-party payor Communicating with a third-party payor

Chapter Outline
Health Insurance and Payment Coding
Procedural Coding CPT-4 coding HCPCS Diagnostic Coding ICD-9-CM coding Multiple diagnosis codes Conventions Superbill

CAAHEP Competencies
Administrative Competencies Process Insurance Claims
Apply managed care policies and procedures Apply third-party guidelines

Fraud and Abuse Chapter Summary Team Work Exercises Case Studies Resources

203

Key Terms
beneciary

Health Insurance and Payment

Health insurance is a contract between an insurance provider and the policyholder, the person who buys the insurance. A policyholder can also include dependent children, a spouse, and, in some states, a domestic partner as beneciaries, or additional persons insured on the plan. The policyholder pays a premium, which is a monthly payment to the insurance company that guarantees the policyholder and his beneciaries will receive the benet of insurance coverage according to the coverage plan. A plan commonly includes coverage by the insurance company for some portion of medical expenses, including diagnostic and therapeutic procedures, for the policyholder and his beneciaries. The list of covered services varies with the insurance carrier and the specic plan that the policyholder selects. Health insurance benets are paid by the insurance company after submission of a medical insurance claim, which is a request from the health care provider for payment. The administrative medical assistant submits this claim to the insurance company by coding the claim, which involves assigning alphanumeric codes to the diagnostic procedures used to identify the patients condition and the procedures performed to treat it. All claims must be submitted on a CMS1500 form, the claim form created by the U.S. Department of Health and Human Services. The coding system and the CMS-1500 form are recognized internationally and are written in the language used for reimbursement of medical claims. In addition, the patient may be responsible for a portion of the payment, known as coinsurance. The patients responsibility may be a percentage of the total fee charged or a copayment, which is a set amount paid at each ofce visit.

Recipient of insurance coverage

benet year

12-month period starting with the date of initial insurance coverage

birthday rule

Insurance regulation that uses the subscribers dates of birth to determine primary and secondary coverage for dependents
capitation

System of payment in which physicians are paid a at rate per patient

coordination of benets

Insurance carriers explanation of how it will pay benets if a patient has more than one insurance plan
copayment

Patients share of the cost of an ofce visit

Current Procedural Terminology, 4th ed.

Coding manual used to identify the procedures performed by physicians and their staff; also called CPT-4
demographics

Personal information used to identify a patient

fee-for-service

Payment method based on each item billed to the insurance company

modier

Two-digit number added to the end of a procedure code that changes and further denes the procedure
policyholder

Person who purchases an insurance policy

preferred provider organization

Managed care plan that contracts with physicians to furnish services to its members
premium

Money paid to an insurer to obtain insurance

referral

Request by a physician to have another physician examine a patient

registration

Coding
The medical assistant must include on an insurance claim a procedural code and a diagnostic code for each service provided to the patient in order to receive reimbursement from an insurance company or other third-party payor. The process of coding claims is complex and commonly requires a person who is professionally trained as a coder. This text introduces the medical assistant to basic coding. Medical assistants interested in developing more advanced coding skills should pursue certication through the American Academy of Professional Coders.

Process of collecting patient demographic and insurance information when the patient begins care
superbill

Document used in a medical ofce to indicate the services provided by a physician to a patient during an ofce visit
upcode

Illegal practice of using a procedure code that yields higher reimbursement than the procedure that is actually performed
utilization review

Determination by a managed care organization of the medical necessity of a procedure or service

verication

Process of conrming insurance benets with the patients insurance carrier

write-off

Procedural Coding
In order to obtain payment for a physician from an insurer, the medical assistant must tell the insurer what services the physician provided to the patient. These services, or procedures, are not described using words, but by assigning specic codes. In

Difference in the amount charged for a service and the amount contractually allowed by an insurance company

CHAP TER 16

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the physicians ofce, the medical assistant will use codes from Current Procedural Terminology, 4th edition, and health care procedural coding systems.

CPT-5
Insurers and practitioners anticipate a new edition of the Current Procedural Terminology (CPT) manual, CPT-5, to be published by 2011. The major changes to the CPT manual will be the use of terminology that more clearly describes procedures and services. The descriptions in the CPT-4 edition commonly include such phrases as with or without, and/or, or by any method. The fth edition will contain more precise denitions for procedures. Such phrases as with or without will no longer accompany one code; rather, two separate codes will be used to describe each procedure. The fth edition of CPT, with its more precise language, will also conform more to HIPAA standards that require common, concise coding language.

CPT-4 Coding
Current Procedural Terminology, 4th edition, (CPT-4), is a coding system that converts descriptions of medical, surgical, and diagnostic services delivered by providers into ve-digit numeric codes. The rst edition of CPT was published by the American Medical Association in 1966 and was revised three times during the late 1960s and early 1970s. Because procedures and technologies in medicine are always changing, updates to the CPT manual are published annually. The medical assistant must use the most current manual. (See CPT-5.) There are several types of CPT-4 codes:

category I codes category II codes category III codes modiers.

5. Pathology and Laboratorycodes 80048 through 89356 6. Medicinecodes 90281 to 99199 and codes 99500 through 99602. Within the six sections, procedures and services are described by subsections, subheadings, categories, and subcategories. Reading the full description of the procedure code enables the medical assistant to choose the appropriate code. (See Coding options for leg casts.) An insurance company can charge a medical ofce for upcoding, or using a code that yields a higher reimbursement than the actual service performed. If a pattern of upcoding is established, the insurer may accuse an ofce of intentional fraud.

Category I
Category I codes are the primary codes used to describe procedures. They are divided into six sections in the CPT manual: 1. Evaluation and Managementcodes 99201 through 99499 2. Anesthesiacodes 00100 through 01999 and codes 99100 through 99140 3. Surgerycodes 10021 through 69990 4. Radiologycodes 70010 through 79999

Coding options for leg casts

Because CPT-4 coding is very specic, the medical assistant must ensure that she uses the correct code for the service
Code 29345 29355 29358 29365 29405 29425 Description Application of a long leg cast (thigh to toes) walker or ambulatory type Application of long leg cast brace Application of cylinder cast (thigh to ankle) Application of short leg cast (below knee to toes) walker or ambulatory type INDENTED CODE MUST INCLUDE STATEMENT DIRECTLY ABOVE IT.

provided. For example, the following list demonstrates the many different options for coding a leg cast application.

The medical assistant must code for the specic type of cast applied to the patient to ensure correct payment. Coding a cast incorrectly could delay payment or lead to nes for inappropriate coding. In the example above, a medical practice would be in error if it coded for a long leg cast

when a short leg cast was actually applied. The medical ofce may be reimbursed at a higher rate for the application of a long leg cast and would therefore receive reimbursement for services that they did not actually provide.

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Evaluation and Management Codes Evaluation and management (E/M) codes (99201 through 99499) are used to describe physician services based on three main factors:

place of service, such as a hospital (inpatient) or ofce visit (outpatient) type of service, such as a consultation, admission to a hospital, newborn care, or ofce visit for primary management of the patients health care status patient status, including: new patient (patient who has not previously received professional face-to-face services from the physician or other provider of the same group within the past 3 years)

established patient (patient who has received professional face-to-face services from the physician or other provider of the same group within the past 3 years) outpatient (patient who is not formally admitted to a health care facility) inpatient (patient who has been formally admitted to a health care facility). In addition to the three categories, the E/M codes are further divided by such factors as patient history, physical examination, and the complexity of the decision-making process. To choose the appropriate E/M code, the medical assistant should read the description in the CPT manual to ensure that she chooses the correct code. (See Common E/M code criteria.)

Common E/M code criteria

The following chart shows the criteria for some common evaluation and management (E/M) codes for new and established patients.

Code
New patients 99201

History
Problem-focused Chief complaint Brief history of present illness or problem

Examination
Problem-focused Limited examination of the affected body area or organ system

Medical Decision Making

Straightforward Minimal number of diagnoses or management options Minimal amount or complexity of data to be reviewed Minimal risk of complications, morbidity, or mortality

99202

Expanded problemfocused Chief complaint Brief history of present illness Problem-pertinent system review

Expanded problemfocused Limited examination of the affected body area or organ system and other symptomatic or related organ system(s) Detailed Extended examination of the affected body area(s) and other symptomatic or related organ system(s)

Straightforward

99203

Detailed Chief complaint Extended history of present illness Problem-pertinent system review extended to include a review of limited number of additional systems Pertinent past, family, and social history directly related to the patients problems

Low complexity Limited number of diagnoses or management options Limited amount or complexity of data to be reviewed Low risk of complications, morbidity, or mortality

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Common E/M code criteriacontd

Code
New patients 99204 Comprehensive Chief complaint Extended history of present illness Review of systems that are directly related to the problem(s) identied in the history of present illness plus a review of all additional body systems Complete past, family, and social history 99205 Comprehensive Comprehensive High complexity Extensive number of diagnoses or management options Extensive amount or complexity of data to be reviewed High risk of complications, morbidity, or mortality Established patients 99212 99213 99214 99215 Problem-focused Expanded problem-focused Detailed Comprehensive Problem-focused Expanded problem-focused Detailed Comprehensive Straightforward Low complexity Moderate complexity High complexity Comprehensive General multisystem examination or a complete examination of a single organ system Moderate complexity Multiple number of diagnoses or management options Moderate amount or complexity of data to be reviewed Moderate risk of complications, morbidity, or mortality

History

Examination

Medical Decision Making

Category II
Category II codes are a set of supplemental tracking codes used for performance measurement. Category II codes are optional, but their use will decrease the likelihood that the insurance company will want to examine all of the claims for the patient, called record abstraction. The additional information offered by the category II codes includes results from laboratory testing or clinical ndings from evaluation and management. These codes support the need for further services. When these codes are included on a claim, the insurer does not need to ask the physician for more documentation to support the claim. Category II codes are not reimbursable and should never be used without a category I code. (See Added information from category II, page 208.)

technologies. Because emerging technologies in medicine are common, the category III codes allow physicians to be reimbursed for new procedures. Category III codes are located after the medicine section of the coding manual. Codes can remain in the category III section for a maximum of 5 years. At that point, the AMA must decide to move them up to category I or delete them from the list.

CPT Modiers
CPT modiers are two-digit numeric codes that are added to a CPT-4 code. The addition of the modier indicates that the service or procedure has changed. The modier is indicated on the CMS-1500 form on line 24, box D, to the right of the CPT code. (See Figure 16-1.) While many CPT-4 codes do not require a modier, they are necessary to describe special circumstances during procedures. (See Examples of CPT modiers, page 209.)

Category III
In 2002, category III was added to the manual. Category III is a listing of temporary codes used to identify new

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Added information from category II

Category II codes are CPT code descriptors. They are not stand-alone procedure codes, but rather additional codes that give information to support the need for a procedure. To choose the appropriate category II codes, the medical assistant should carefully review the medical record. For example, the physician sees a patient with COPD for a physical examination. During the examination, the physician discusses the patients smoking habit with her and, based on the patients response, prescribes acupuncture as a smoking cessation treatment. He documents these details in the patients medical record.
Date 10/15/08; 7:09 a.m PE - BP - 140/88, T-98.4, R-22, HEENT-WNL. Resp-wheezing, cough. The patient reports smoking 11/2 to 2 packs of cigarettes per day. The patient states that I want to quit, I just dont have the willpower. Acupuncture for smoking cessation prescribed with Dr. Lee. -------------------------------------------------------------------- R. Greer, MD

The medical assistant can use this additional information to support services aimed at smoking cessation, such as a prescription for acupuncture or nicotine replacement therapy. Use of category II codes can save time because it gives additional information without narrative documentation. Thus, the medical assistant can add category II codes 1000F (the patient was asked about her tobacco use) and 1034F (the patient reports she is a current tobacco user) to support the prescription of acupuncture treatment.

24. A. MM

DATE(S) OF SERVICE From To DD YY MM DD

YY

B. C. PLACE OF SERVICE EMG

SUPPLIES D. PROCEDURES, SERVICES, OR SUP (Explain Unusual Circumstances) MODIFIER CPT/HCPCS MODI

E. DIAGNOSIS POINTER

F. $ CHARGES

DAYS OR UNITS

G.

EPSDT ID. Family Plan QUAL.

H.

I.

J. RENDERING PROVIDER ID. #

1 2

03 04

08

03 04

08

11

99204

32

1,2

85.00

NPI

NPI

OFFICE VISIT, NEW PATIENT, COMPREHENSIVE HISTORY, EXAMINATION, AND DECISION MAKING OF MODERATE COMPLEXITY

MANDATED SERVICE

FIG 16-1 CMS-1500 form with CPT code and modier.

HCPCS
In addition to CPT codes that identify examinations and procedures, medical assistants must translate medical equipment and transport services provided to patients into codes for reimbursement. Health care procedural coding system (HCPCS) is a standardized coding system used for this purpose. These codes primarily identify products, supplies, and services not included in CPT coding, such as ambulance services, durable medical equipment, prosthetics, orthotics, and supplies when used outside a physicians ofce. HCPCS codes are found in the CPT or ICD-9-CM manual and can be used with CPT codes for examinations and procedures. HCPCS codes are comprised of a single alpha character and then 4 numerical digits, for example:

A4211supplies for self-administered injections E0130walker, rigid (pickup), adjustable or xed height.

Diagnostic Coding
In order to receive payment for procedures and services, the medical ofce must prove that the patient needed those procedures or services. The medical ofce establishes the necessity for procedures by determining a diagnosis. Diagnoses, just like procedures, are communicated to the insurer using a code. These diagnostic codes are numeric or alphanumeric codes called ICD-9-CM codes.

ICD-9-CM Coding
The International Classication of Diseases, 9th edition Clinical Modications, is the coding manual used to report the patients diagnosis. The medical ofce must assign an
(Text continues on page 212.)

A0021ambulance service, outside state per mile, transport

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Examples of CPT modiers

The following table lists CPT modier codes along with a description and example.

Code
21

Description
Scenario Prolonged evaluation and management (E/M) services Assigned when E/M services provided are greater than the highest reportable level of service. (Providing documentation of the service with the claim is recommended.)

Example
Code and meaning 99215-21 Comprehensive E/M

A patient being evaluated for anxiety is upset. The provider spends an hour counseling the patient.

22

Unusual procedural service Assigned when a procedure requires greater than usual services. (Documentation is required for reimbursement.)

A patient needs a revision of an external xation device under anesthesia. During the procedure, the provider determines that the fracture is not healing and requires more pins, wires, and rings than expected. A patient who has a history of anxiety needs a suspicious dermal lesion removed. Although this procedure is usually done with a local anesthetic, the provider determines a need for a general anesthetic. Two weeks after knee surgery, a patient falls and breaks his radial shaft. Provider performs a reduction of a wrist fracture.

20693-22 Adjustment of external xation device requiring anesthesia

23

Unusual anesthesia Assigned for anesthesia administered for services that usually require local or no anesthetic

11302-23 Shaving of epidermal lesion diameter 1.2 to 2.0 cm

24

Unrelated E/M service by same physician during postoperative period Assigned when an E/M service is performed in the standard postoperative period for a condition unrelated to a surgical diagnosis

25500-24 Closed treatment of radial shaft fracture

25

Signicant, separate, identiable E/M service by the same physician on the same day of the procedure or other service Assigned when E/M service was performed on the same day as another procedure. (Requires additional documentation.)

During a well-child visit, a physician notes bruising on the child that suggests abuse. The physician decides to examine and interview the patient more thoroughly.

99215-25 Comprehensive E/M

26

Professional component Assigned when an interpretation of an x-ray, magnetic resonance imaging (MRI) scan, or other diagnostic test is performed by another physician

A chiropractor interprets x-rays of a patients lower back taken at the hospital.

72100-26 Radiologic examination; spine, lumbosacral; 2 or 3 views

32

Mandated services Assigned when services were mandated by a third party (such as a payor, attorney, or court order)

A patient wants to have a gastric banding procedure for weight loss. The insurer requires two physicians to recommend the procedure.

99203-32 New patient E/M detailed history; detailed examination

Continued

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Examples of CPT modierscontd

Code
47

Description
Scenario Anesthesia by surgeon Assigned when a surgeon administers anesthesia while performing surgery

Example
Code and meaning 55100-47 Drainage of scrotal wall abscess

A patient has an abscess on the wall of his scrotum. The surgeon administers anesthesia and drains the abscess. A patient has an arthroscopic surgical repair of the anterior cruciate ligament (ACL) in both knees.

50

Bilateral procedure Assigned when a procedure is performed bilaterally during the same session

29888-50 Arthroscopically aided anterior cruciate ligament repair/ augmentation or reconstruction

51

Multiple procedures Assigned when multiple procedures are performed during the same session

A patient has an arthroscopic repair to her left ACL and a meniscectomy of her right knee.

29888 Arthroscopy with meniscus repair (medial or lateral) AND 29880-50 Arthroscopically aided anterior cruciate ligament repair/ augmentation or reconstruction

52

Reduced services Assigned when service is reduced and does not match the CPT code

During an upper GI series with a barium swallow, a patient vomits and can no longer continue the examination.

74246-52 Radiologic examination, GI tract, upper air contrast, with specic high-density barium

53

Discontinued procedure Assigned when a physician terminates the procedure for the well-being of the patient

A patient is anesthetized and prepared for a heart transplant, but the heart arrives in damaged condition.

33945-53 Heart transplant, with or without recipient cardiectomy

54

Surgical care only Assigned when a surgeon performed only the surgical portion of a surgical package

A patient has a car accident while on vacation 300 miles from home, requiring a repair of a fractured femoral shaft. Emergency surgery will be followed by care from a specialist near the patients home. A patient has a car accident while on vacation. A specialist near the patients home monitors his postoperative progress.

27506-54 Open treatment of femoral shaft fracture, with or without external xation 99024-55 Postoperative follow-up visit normally included in the surgical package

55

Postoperative management only Assigned when a physician cares for a patient after surgery performed by another physician

56

Preoperative management only Assigned when a physician clears a patient for surgery (nonemergency)

A physician examines a patient with severe heart disease and determines that the patient is healthy enough to undergo a heart transplant by a cardiac surgeon. A patient arrives in the emergency department (ED) after a car accident with a ruptured spleen. The ED physician diagnoses the rupture and sends the patient to surgery.

99214-56 Detailed E/M

57

Decision for surgery Assigned when a physician examines a patient and recommends surgery that will be performed by another physician

99283-57 Emergency department visit, expanded problem-focused history

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Examples of CPT modierscontd

Code
58

Description
Scenario Related procedure or service by the same physician during the postoperative period Assigned for services that a physician provides during the postoperative period that are related to the surgery that physician performed earlier

Example
Code and meaning 11008-58 Removal of prosthetic material or mesh, abdominal wall for necrotizing soft tissue infection

A patient has an infection at a previous surgical site. The patient must undergo debridement of the surgical wound and removal of the mesh inserted on his abdominal wall.

62

Two surgeons Assigned when two primary surgeons are required for a surgical procedure

A patient falls, breaking his left hip and damaging his right hip, which had previously been replaced. Both hips require surgical repair.

27130-62 (left, initial) 27134-62 (right, revision) Initial hip replacement, left, and revision of hip replacement on the right; done by two surgeons at the same time to reduce anesthesia time

63

Procedure performed on infant less than 4 kg Assigned when a procedure is performed on a premature baby

An infant weighing less than 4 kg has an abnormal passageway between his stomach and intestines, requiring repair.

43880-63 Closure of gastrocolic stula

66

Surgical team Assigned when a highly complex surgery is performed that requires more than two surgeons. (Each surgeon reports the same procedure using the 66 modier.)

A patient with severe chronic obstructive pulmonary disease (COPD) requires a double lung transplant. During the procedure, another surgeon will bypass the heart.

32854-66 Lung transplant, double, with cardiopulmonary bypass

76

Repeat procedure by same physician Assigned when a physician repeats a surgical procedure originally performed by that same physician

A patient has a vasectomy, but follow-up sperm count indicates that the vas deferens has reattached. The surgeon who initially performed the surgery repeats the procedure. A patient who has a vasectomy but experiences reattachment of the vas deferens schedules a repeat of the procedure with a different surgeon.

55250-76 Vasectomy, unilateral or bilateral, including postoperative semen examinations 55250-77 Vasectomy, unilateral or bilateral, including postoperative semen examinations

77

Repeat procedure by another physician Assigned when a physician repeats a surgical procedure originally performed by a different physician

78

Return to operating room for related procedure during postoperative period Assigned when a physician must perform a procedure during the postoperative period that is related to the original surgical procedure that the physician performed

A patient has a repair to the meniscus of his left knee. Four days after the surgery, he falls off of his crutches and ruptures his patellar tendon.

27380-78 Suture of infrapatellar tendon

Continued

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Examples of CPT modierscontd

Code
79

Description
Scenario Unrelated procedure or service by the same physician during the postoperative period Assigned when the same physician performs two surgical procedures on a patient but the second procedure is unrelated to the rst

Example
Code and meaning 27500-79 Closed treatment of femoral shaft fracture, without manipulation

A patient has a repair to the meniscus of his left knee. Four days after the surgery, he falls off of his crutches and fractures his right femur.

80

Assistant surgeon Assigned when surgery requires an assistant surgeon due to the complexity of the procedure or its duration

A patient has a growing heart tumor. The surgery will take several hours and requires an assistant to perform cardiopulmonary bypass.

33120-80 Excision of intracardiac tumor, resection with cardiopulmonary bypass, assistant surgeon performs closure

81

Minimum assistant surgeon Assigned when surgery is started with one surgeon and a second surgeon is called in for a short time to assist

While a patient is undergoing repair of perforated ulcers of the small intestine, the surgeon becomes ill, requiring a second surgeon to nish the procedure.

44603-81 Suture of small intestine for perforated ulcers (multiple); assistant surgeon required since more ulcers are found than expected

90

Reference (outside) laboratory testing Assigned when a physician requests laboratory test results from an outside laboratory

A physician orders a complete blood count (CBC) for a patient. The medical assistant performs the venipuncture but does not test the blood. She sends the blood to an outside laboratory to perform the CBC. A patient undergoes a glucose tolerance test. During the test, three samples are taken at 1-hour intervals.

85025-90 and 36415 (venipuncture) Physician reports CBC

91

Repeat clinical diagnostic laboratory test Assigned when a clinical diagnostic test is repeated on the same day for multiple test results

82951-91 Glucose tolerance testing

99

Multiple modiers Assigned to report use of more than one modier. (Must list modier 99 rst and then other related modier codes in numerical order.)

Premature infant (weight 3.8 kg) undergoes surgical repair of a stula joining the trachea and esophagus. Because of the complexity of the surgical case, it requires two primary surgeons.

43305-99 43305-62 43305-63 Two primary surgeons needed for repair of tracheoesophageal stula in infant weighing less than 4 kg

ICD-9-CM code to every claim that is processed by an insurance carrier. The coding system provides a numeric or alphanumeric code for every illness, injury, and condition. ICD-9-CM codes are updated yearly, so the medical assistant must be sure to use the current codes when ling claims. If the medical ofce does not provide an accurate diagnostic code with each procedural code, the insurance

company will deny the claim and withhold payment for those services.

TIP The Importance of Accurate Diagnostic Coding Because the diagnostic code (ICD-9-CM) must support the medical necessity of a procedure to garner reimbursement, it

CHAP TER 16

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213

is essential for the medical assistant to check and recheck claims coding. A common error in coding claims is transposing two or more digits in a code. Thus, checking the codes for errors in transposition is a good way to ensure accurate coding and swift reimbursement. For example, in order to receive reimbursement for a throat culture done in the medical ofce, the diagnostic code on the claim must support the procedure code. If the claim lists the diagnostic code 463 (for acute tonsillitis) to support the procedure code 87650 (for a throat culture), the medical ofce is sure to receive speedy payment. However, if the medical assistant transposes digits in, say, the diagnostic code and codes acute tonsillitis as 436 (which is actually the code for ill-dened cerebrovascular disease), she will fail to support the procedure code 87650 for throat culture, because the diagnosis of cerebrovascular disease does not support the medical necessity of a throat culture.

physicians ofce. The only exception to this rule is coding for psychiatric disorders. Psychiatric disorders are listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), which is not discussed in this text.

V Codes
V codes are used to describe a patients health status and identify the reason for the medical care other than for a disease process or an injury. V codes fall into three categories:

ICD-9-CM Coding Manual

The ICD-9-CM coding manual provides a listing of all diagnostic codes as well as instructions on how to code diagnoses. The medical assistant should be sure to read the instructions at the beginning of the book to understand the correct procedure for choosing an accurate code. She must understand that the ICD-9-CM manual should be used as a resource book. All of the information needed to accurately code diagnoses is contained in the book itself. While diagnostic coding is complex, with practice, the medical assistant can become a confident, efficient diagnostic coder. The ICD-9-CM coding manual is divided into two sections: 1. The introduction offers instructions to the reader on how to code diseases and disorders. Because the introduction includes the latest updates to the coding guidelines, it is imperative that the medical assistant use the most current manual. 2. The second section is divided into three volumes: Volume 1 is a tabbed list of codes, arranged in numerical order and divided into chapters by diseases or disorder. (See ICD-9-CM, Volume I chapters, page 214.) Volume 2 begins with an alphabetical listing of diseases and disorders with their corresponding numeric codes. It also contains a Table of Drugs and Chemicals and an Index to External Causes of Injuries and Poisonings. Volume 3 is a tabbed alphabetical listing of hospital procedures. The medical assistant should not use these codes for physicians ofce procedures. (Coding procedures in the physicians ofce requires the use of CPT-4 codes.) The medical assistant should use Volumes 1 and 2 of the ICD-9-CM coding manual to code diagnoses in the

Problem-oriented V codes identify risk factors that may affect the patient but are not an injury or illnessfor example, V02, which indicates a carrier or suspected carrier of an infectious disease, and V69.0, which indicates lack of physical exercise. Service-oriented V codes identify services for patients who are not currently sick but are seeking medical services for other reasons, such as injury aftercare and routine examinationsfor example, V67.4, which indicates a follow-up examination of a healed fracture after treatment, and V20.2, which indicates a routine infant or child health check. Fact-oriented V codes simply identify the patients conditionfor example, V27.0, which indicates the outcome of delivery of a single newborn, and V09.0, which indicates infection with a microorganism that is resistant to penicillins.

E Codes
E codes are used to establish medical necessity, identify causes of injury and poisoning, and identify medications. Certain rules apply when using E codes:

E codes can never be a primary code; they will not support medical necessity for a procedure. E codes will not affect the amount of reimbursement E codes can speed up the process of reimbursement by providing additional information to the insurance company, such as liability. If multiple E codes are used, the following priority is given: child abuse (E967.0 to E967.9) cataclysmic events (E908.0 to E909.9) transportation accident (E800 to E848).

TIP Where Do I Start?

Although the tabbed numeric list of codes is called Volume 1 and the alphabetical list is Volume 2, Volume 2 appears in most manuals before Volume 1. When searching for a code, the medical assistant will usually need to search Volume 2 (alphabetical) rst, then Volume 1. The alphabetical listing of codes in Volume 2 enables the medical assistant to look up a diagnosis by several listings. For example, osteogenesis imperfecta is also called Adair-Dighton syndrome with an

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ICD-9-CM, Volume 1 chapters

The following table lists the chapters and appendices included in Volume I of the International Classication of Diseases, 9th editionClinical Modications (ICD-9-CM) manual.

Chapters and Appendices

1. Infectious and Parasitic Diseases 2. Neoplasms 3. Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders 4. Diseases for the Blood and Blood-Forming Organs 5. Mental Disorders 6. Diseases of the Nervous System and Sense Organs 7. Diseases of the Circulatory System 8. Diseases of the Respiratory System 9. Diseases of the Digestive System 10. Diseases of the Genitourinary System 11. Complications of Pregnancy, Childbirth, and the Puerperium 12. Diseases of the Skin and Subcutaneous Tissue 13. Diseases of the Musculoskeletal System and Connective Tissue 14. Congenital Anomalies 15. Certain Conditions Originating in the Perinatal Period 16. Symptoms, Signs, and Ill-Dened Conditions 17. Injury and Poisoning V codesSupplemental Classication of Factors Inuencing Health Status and Contact with Health Services E codesSupplemental Classication of External Causes of Injury and Poisoning Appendix AMorphology of Neoplasms Appendix BGlossary of Mental Disorders (glossary) Appendix CClassication of Drugs by the American Hospital Formulary Service List Number and their ICD-9-CM Equivalents Appendix DClassication of Industrial Accidents According to Agency (used for statistical purposes only) Appendix EThree-Digit Categories (all three-digit ICD-9-CM codes, V codes, and E codes)

Diagnostic Code Range

001 through 139 140 through 239 240 through 279 280 through 289 290 through 319 320 through 389 390 through 459 460 through 519 520 through 579 580 through 629 630 through 677 680 through 709 710 through 739 740 through 759 760 through 779 780 through 799 800 through 999 V01 through V83 E800 through E999 M codes (M8000 through M9970) No codes provided 4:00 through 92:00 111 through 690 001 through 999; V01 through V82; E800 through E999

ICD-9-CM code of 756.51. The code is listed in Volume 2 under both names for the disorder. In Volume 1, the code is only listed once, with the disorder name osteogenesis imperfecta. (See Basics of diagnostic coding.)

Multiple Diagnosis Codes

If more than one diagnosis code is used, the codes must be prioritized and entered on the CMS-1500 form in order of signicance. The codes must also be linked to the appropriate procedures on the CMS-1500 form. For example, a patient is seen for a sore throat and a well-child visit. The procedures are an ofce visit (CPT-4 code 99213) and a throat culture (CPT-4 code 87650). Because the main

purpose of the visit was the well-child visit, the medical assistant should code that procedure rst on the CMS-1500 form and code the sore throat second. When relating the procedures to the diagnoses, the medical assistant should match the ofce visit with the diagnosis of well child and the throat culture with the sore throat. A maximum of four diagnostic codes are allowed per CMS-1500 form. (See Figure 16-2.)

Conventions
The ICD-9-CM manual contains symbols, abbreviations, punctuation, and notations that are collectively called conventions. Conventions and their corresponding denitions are listed in the front of the ICD-9-CM manual. Many of

CHAP TER 16

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215

Basics of diagnostic coding

For a medical assistant to determine the correct diagnostic code for a condition (diagnosis), she must refer to the International Classication of Diseases, 9th editionClinical Modications (ICD-9-CM) manual and follow these steps: Find the patients condition in Volume 2, the alphabetical index of the manual, which is arranged by condition. Some conditions have multiple entries. Find the numeric code listed with the condition in the alphabetical index. Go to the tabbed code list, which is arranged numerically, and nd the code. Read the additional information in the tabbed listing for the code to choose the most appropriate code for the condition. If a fth digit is required (indicated by a range or series of numbers set in brackets under the numeric code), refer to the listing of symptoms with assigned digits at the beginning of the group of codes describing the condition. For example, to nd the ICD-9-CM code for spastic hemiplegia, dominant side, the medical assistant should rst look in the alphabetical index under hemiplegia and take the three-digit base code from that listing.

Hemiparesthesia (see also Disturbance, sensation) 782.0 Hemiplegia 342.9 acute (see also Disease, cerebrovascular, acute) 436 alternans facialis 344.89 apoplectic (see also Disease, cerebrovascular, acute) 436

Next, the medical assistant should look up the code 342 in the tabbed numeric listing. There, she will nd the coding list for Hemiplegia and hemiparesis, which includes the four-digit code for spastic hemiplegia: 342.1. To nd the fth-digit code, the medical assistant must look at the
342

symptoms listing at the beginning of the group of codes. There, she will nd that affecting dominant side is indicated with a 1. So, the complete code she must use is 342.11.

Hemiplegia and hemiparesis Note: This category is to be used when hemiplegia (complete) (incomplete) is reported without further specification, or is stated to be old or long-standing but of unspecified cause. The category is also for use in multiple coding to identify these types of hemiplegia resulting from any cause.

Excludes

congenital (343.1) hemiplegia due to late effect of cerebrovascular accident (438.20438.22) infantile NOS (343.4)

The following fifth digits are for use with codes 342.0342.9 0 affecting unspecified site 1 affecting dominant side 2 affecting nondominant side 342.0 342.1 342.8 342.9 Flaccid hemiplegia Spastic hemiplegia Other specified hemiplegia Hemiplegia, unspecified

Continued

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Basics of diagnostic codingcontd

Coding guidelines for the CMS-1500
In addition to determining the coding, the medical assistant must understand the best way to record that information on the CMS-1500 form. Here are some guidelines on the best way to list the coding on the form: When the medical assistant determines the primary reason (diagnosis, condition, problem) for the visit, procedure, service, or supply provided as documented in the patients medical record, she should list the corresponding ICD-9-CM code for this reason rst on the CMS-1500 form. She should then list additional ICD-9-CM codes that describe current, coexisting conditions. She should not code conditions that were previously treated and no longer exist. The medical assistant should be sure to list all ICD-9-CM codes at their most specic level. The insurance carrier may choose to return claims submitted with three- or four-digit codes if four and ve digits are available. The medical assistant should be sure to avoid coding diagnoses documented as probable, suspected, questionable, or rule out as if the diagnosis is conrmed. She should code the condition to the physicians highest degree of certainty at the encounter described, such as describing symptoms, signs, abnormal test results, or other reasons for the encounter. The medical assistant should code and report a chronic disease treated on an ongoing basis as many times as the patient receives treatment for the condition. When a patient receives only ancillary diagnostic or therapeutic services during an encounter, the medical assistant should rst list the code for the diagnosis or problem associated with the procedures and then list the appropriate V code for the service second. For surgical service, the medical assistant should use the ICD-9-CM code that corresponds to the diagnosis for which the surgery was performed. If the postoperative diagnosis is different from the preoperative diagnosis at the time the claim is led, the medical assistant should use the ICD-9-CM code for the postoperative diagnosis. The medical assistant should be sure to list codes for all documented conditions that exist at the time of the visit and require or affect patient care, treatment, or management. Conversely, the medical assistant should not list codes for conditions that were previously treated and no longer exist.

these conventions will be used in the ICD-10 manual, which will replace ICD-9-CM in 2010 or 2011. (See A look to the future.) The conventions give information that is used to help the medical ofce nd the diagnostic code that relates most closely to the written description of the diagnosis. (See Conventions in ICD-9-CM codes, page 218.)

A look to the future

The International Classication of Diseases, 9th edition Clinical Modications (ICD-9-CM) will be replaced with a newer classication system, ICD-10, by 2011 and the term clinical modications will be deleted. The following table outlines the changes expected in the ICD-10 manual.

Superbill
In order to le a claim for reimbursement, a physician must indicate diagnoses and treatments associated with the services he provides to a patient during an ofce visit or other encounter. To do so, he will commonly use a form called a superbill. (See Figure 16-3.) Superbills are designed to include commonly used ICD-9-CM and CPT-4 codes for that ofce. When the physician has seen the patient, he checks off the services provided on the superbill and assigns a diagnostic code to the visit. If the physician provided multiple services, the medical assistant must link the diagnostic codes to their respective procedure codes by indicating the ICD-9-CM code (from the form) next to the CPT-4 code where appropriate. A medical assistant may also need to check off services provided on a superbill. For example, a clinical medical assistant provides gait training for a patient who has crutches for a sprained ankle. She must then check
ICD-9-CM
International Classication of Diseases, 9th edition Clinical Modications Diseases of the Nervous System and Sense Organs (one chapter)

ICD-10
International Statistical Classication of Diseases and Related Health Problems Diseases of the Nervous System Diseases of the Eye and Adnexa Diseases of the Ear and Mastoid Process (three chapters)

Mental Disorders (appendix)

Mental and Behavioral Disorders (appendix)

Fourth- and fth-digit requirements

Fourth-, fth-, and sixth-digit requirements

(Text continues on page 219.)

CHAP TER 16

Coding and Insurance

217

HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1. MEDICARE MEDICAID TRICARE CHAMPUS (Sponsors SSN) CHAMPVA GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) SEX M OTHER 1a. INSUREDS I.D. NUMBER PICA (For Program in Item 1)

(Medicare #)

(Medicaid #)

(Member ID#)

(ID)

XXHL129973534
4. INSUREDS NAME (Last Name, First Name, Middle I le Initial)

2. PATIENTS NAME (Last Name, First Name, Middle Initial)

OLESNEVICH

JUSTIN

3. PATIENTS BIRTH DATE MM DD YY

03 08 1998
Spouse

X X

OLESNEVICH

MARY

5. PATIENTS ADDRESS (No., Street)

6. PATIENT RELATIONSHIP TO INSURED Self STATE Child Other

7. INSUREDS ADDRESS (No., Street)

277 WESTON ROAD

CITY

277 WESTON ROAD BLUEVILLE

ZIP CODE

BLUEVILLE
ZIP CODE

CT
TELEPHONE (Include Area Code)

Single

Married Full-Time Student

Other Part-Time Student

CT
TELEPHONE (Include Area Code)

06100

( 860 )

111 7736

Employed

06100 678844

( 860 )

111 7736

9. OTHER INSUREDS NAME (Last Name, First Name, Middle Initial)

10. IS PATIENTS CONDITION RELATED TO:

11. INSUREDS POLICY GROUP OR FECA NUMBER

a. OTHER INSUREDS POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous) YES

X X X

REDS a. INSUREDS DATE OF BIRTH MM DD YY

SEX M F

NO PLACE (State) NO

b. OTHER INSUREDS DATE OF BIRTH MM DD YY M c. EMPLOYERS NAME OR SCHOOL NAME

SEX F

b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES

07 17 1974

b. EMPLOYERS NAME OR SCHOOL NAME

BLUEVILLE FAMILY SERVICES

c. INSURANCE PLAN NAME OR PROGRAM NAME

NO

UNITED HEALTH SYSTEMS

PLAN? d. IS THERE ANOTHER HEALTH BENEFIT P
YES

d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. RESERVED FOR LOCAL USE E

NO

If yes, re s return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment y below. SIGNED 14. DATE OF CURRENT: MM DD YY ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP) DATE

PERSONS SIGNATURE I authorize 13. INSUREDS OR AUTHORIZED P payment of medical benefits to the undersigned physician or supplier for services described below.

SIGNED

SIGNATURE ON FILE

WELL-CHILD VISIT; 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. USE 9921217b. NPI (E/M)
19. RESERVED FOR LOCAL USE

06 07 09

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIE NT PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DD YY MM MM DD YY GIVE FIRST DATE MM IRST DD YY TO FROM HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 18. HOSP MM DD YY MM DD YY FROM TO F 20. 2 OUTSIDE LAB? YES $ CHARGES NO

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) Relate 1.

V20.2

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER

3.

YY

B. C. PLACE OF SERVICE EMG

E. DIAGNOSIS POINTER

F. $ CHARGES

DAYS OR UNITS

G.

EPSDT ID. Family Plan QUAL.

H.

I.

J. RENDERING PROVIDER ID. #

1 2 3 4
5

07 17 07 17

09 09

07 17 07 17

09 09

11 11

99212 95004

1 2

85.00 104.00

1 1

NPI

NPI

NPI

NPI

DERMATITIS (RASH) DUE TO UNSPECIFIED SUBSTANCE; USE 27. ACCEPT ASSIGNMENT? 25. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. AL S (For govt. claims, see back) 95004 NO 865623498 X 1754 X YES (PERCUTANEOUS 31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LOCATION INFORMATION ALLERGY TESTING) EES INCLUDING DEGREES OR CREDENTIALS
me (I certify that the statements on the reverse apply to this bill and are made a part thereof.)

NPI

NPI

28. TOTAL CHARGE $

29. AMOUNT PAID $

30. BALANCE DUE $

189 00

33. BILLING PROVIDER INFO & PH #

HECTOR RODRIGUEZ, MD
SIGNED DATE a.

NPI

b.

HECTOR RODRIGUEZ, MD 15 MAIN STREET BLUEVILLE CT 06100 a. 1077358914 b. NPI

( 860 ) 555

189 00 3212

NUCC Instruction Manual available at: www.nucc.org

PLEASE PRINT OR TYPE

APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)

FIG 16-2 CMS-1500 form with linked procedure and diagnosis codes.

PHYSICIAN OR SUPPLIER INFORMATION

2. 693.9 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD

4. SUPPLIES D. PROCEDURES, SERVICES, OR SUP (Explain Unusual Circumstances) MODIFIER CPT/HCPCS MODI

PATIENT AND INSURED INFORMATION

8. PATIENT STATUS

CITY

STATE

CARRIER

1500

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Conventions in ICD-9-CM codes

The following table lists the symbols, abbreviations, punctuation marks, and notations known as conventions in the International Classication of Diseases, 9th editionClinical Modications (ICD-9-CM) manual along with the meaning and examples of each.*

Convention
(octagon)

Meaning
Must use additional digits (fourth and sometimes fth digits for ICD-9-CM; ICD-10 will have some codes with a sixth digit)

Example
The full code 642.52 Severe pre-eclampsia; delivered, with mention of postpartum complication is broken down as: 642 Hypertension complicating pregnancy, childbirth, and the puerperium 642.5 Severe pre-eclampsia 642.52 delivered, with mention of pospartum complication

(triangle pointing left)

New code; changed from previous edition of ICD-9-CM manual

783.2 Abnormal loss of weight and underweight 783.21 Loss of weight

(solid circle) with italic text

Not a principal diagnosis; must be used with other primary code

774.0 Perinatal jaundice from hereditary hemolytic anemias Code rst underlying disease (282.0-282.9)

(empty box)

Unspecied code used only if additional information is not yet available (for example, in the emergency department); changed to more specic code when further information becomes available

802 Fracture of face bones 802.2 Mandible, closed 802.20 Unspecied site 686.0 Pyoderma Dermatitis: purulent septic suppurative 537.3 Other obstruction of duodenum cicatrix stenosis stricture volvulus of duodenum

: (colon)

Used after an incomplete term that needs one or more of the descriptions listed to make it assignable to a code

} (brace)

Used to enclose a series of terms, each modied by a statement to the right of the brace

[ ] (brackets)

Used to enclose synonyms or to indicate range or series of possible diagnoses for fth digit

443.1 Thromboangiitis obliterans [Buergers disease]

( ) (parentheses)

Used to enclose supplementary words or nonessential modiers that can be used but are not required in the code and do not affect the code

Jaksch (-Luzet) disease or syndrome (pseudoleukemia infantum) 285.8

Excludes

Cannot be used if associated condition is present

690 Erythematosquamous dermatosis Excludes eczematous dermatitis of eyelid (373.1)

CHAP TER 16

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219

Conventions in ICD-9-CM codescontd

Convention
Includes:

Meaning
Used to further dene or give an example

Example
280 Iron deciency anemia Includes: anemia asiderotic hypochromic-microtic sideropenic

With

Two conditions included; both must be present

487 Inuenza 487.0 With pneumonia

And

One of two descriptors must be present

Adair-Dighton syndrome (brittle bones and blue sclera, deafness) 756.51

NOS

Not otherwise specied; used if no further information is given

378.9 Unspecied disorder of eye movementsOphthalmoplegia NOS Strabismus NOS

NEC

Not elsewhere classied; used if information at hand indicates a specic condition that has no separate code

459.0 Hemorrhage, unspecied Rupture of blood vessel NOS Spontaneous hemorrhage NEC Actinomyces israelii (infection)see Actinomycosis Adaptation reaction (see also Reaction, adjustment) 309.9

See

Cross reference to look elsewhere; code not listed

See also

Cross reference to look under another main term; code is listed

* The conventions and symbols listed are common. However, some manuals vary in the use of one or more symbols. The medical assistant should be sure to check the symbol key in whatever manual she uses to ensure correct coding.

off the box for gait training and the amount of time spent with the patient on the superbill. The medical assistant then sends the superbill to the coding department. The coder will review the superbill to make sure all of the essential information has been included and that modiers are applied appropriately in order to submit an accurate claim. If the physician has written in a diagnosis or a procedure instead of checking off a box, the coder must determine the appropriate code for the diagnosis or procedure. At one time, superbills, also called encounter forms, could be sent directly to insurance companies with a request for payment. However, now superbills are used only as a communication tool within the ofce. (See Procedure 16-1: Coding procedures and diagnoses, page 221.)

Insurance in the Physicians Ofce

In the physicians ofce, the medical assistant will work with various forms of insurance to obtain payment for services rendered to the patient. The most common form of health

insurance is a policy obtained through an employer. However, people who are self-employed or work for a small company that does not offer health insurance can buy individual policies. In addition, government programs provide health insurance to people ages 65 and older, people with disabilities, people of low income, active duty military and their families, and veterans. Accidental injuries, depending on their cause, may be paid through workers compensation insurance or through a homeowners, commercial, or automobile liability policy. The various forms of insurance all have specific rules for obtaining payment for services but share some common rules. Insurance claims processing is a complex task, but the medical assistant will become proficient as she processes the various forms of insurance. When filing any form of insurance claim, accuracy and completeness of the claim is vital.

Employer Insurance Programs

Employers will negotiate with health insurance carriers to obtain health insurance for their employees. It is extremely expensive for an individual to buy health insurance; the

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Blueville Family Medicine 15 Main Street Blueville CT 860-555-3212 Patient Name: Date: Provider: Robert Greer, MD Hector Rodriguez, MD Anne Wilson, MD Sharon Piecek, APRN Henry Lee, MD

CPT-4 Codes Examinations Exam brief (New Pt) Exam intermediate (New Pt) Exam detailed (New Pt) Exam comprehensive (New Pt) Exam comp, high complex (New Pt) Exam brief (Est Pt) Exam intermediate (Est Pt) Exam detailed (Est Pt) Exam comprehensive (Est Pt) Exam comp, high complex (Est Pt) X-rays Chest - one view Chest - 4 views Spine - single view (specify level) X-ray - shoulder 1 view X-ray elbow X-ray wrist (2 views) X-ray hip (1 view) X-ray knee X-ray ankle (3 views) X-ray foot (2 views)

99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 71010 71030 72020 73020 73085 73100 73500 73560 73610 73620

Laboratory Urinalysis Pregnancy test UA volume Allergy test - skin extracts Allergy - biologicals Allergy - patch test PTT Hematocrit Hemoglobin Diff WBC Occult blood Throat culture ECG ECG - 24-hour monitor

81000 81025 81050 95004 95010 95044 85002 85014 85018 85004 82270 87650 93270 93224

Physical Medicine Acupuncture Acupuncture with ES Gait Training Nutritional counseling (subsequent) Myofascitis Sinusitis Tonsillitis Otitis media Otitis externa Otitis interna Urinary tract infection Conjunctivitis Angina COPD

97780 97813 97116 97803 729.1 473.9 474.0 382.9 380.10 386.30 599.0 077.99 413.9 496

ICD-9-CM Codes Well-child visit Prenatal visit Prenatal visit - high risk Allergy exam Anemia Lower back pain Neck pain Hypertension Fatigue HF

V20.2 V22 V23 V72.7 285.9 724.2 723.1 642.2 789.79 428.0

FIG 16-3 Superbill.

risk to the insurer that one person will become very ill and require expensive services is high. The insurer must charge a high monthly premium for an individual or individual family policy. For this reason, many employers offer health insurance to their employees at a group rate. A large employer can negotiate a lower cost with a health insurer

because the more people who enroll in the insurance program, the lower the risks and, therefore, the costs to the insurer. The risk of high-cost care to the insurer decreases if a large number of people enroll because, although a few people within the group may become ill and require expensive care, others in the group will remain healthy and cost

CHAP TER 16

Coding and Insurance

221

PROCEDURE 16-1

Coding procedures and diagnoses

Task Using a superbill and CPT-4 and ICD-9-CM coding manuals, choose the correct procedural and diagnostic codes for a patient visit and correctly ll out the appropriate elds on the CMS-1500 form. Conditions Pen Superbill CMS-1500 form (obtained from instructor) CPT-4 and ICD-9-CM coding manuals
Blueville Family Medicine 15 Main Street Blueville CT 860-555-3212 Patient Name: Date:

Standards In the time specied and within the scoring parameters determined by the instructor, the student will accurately choose codes for a patient visit and correctly ll out the appropriate elds on the CMS-1500 form. Performance Standards 1. Refer to the patient superbill (below) and note the procedures and diagnosis written by the physician.

Christine Vanover 07/17/09

Provider:

Robert Greer, MD Hector Rodriguez, MD Anne Wilson, MD Sharon Piecek, APRN Henry Lee, MD

CPT-4 Codes Examinations Exam brief (New Pt) Exam intermediate (New Pt) Exam detailed (New Pt) Exam comprehensive (New Pt) Exam comp, high complex (New Pt) Exam brief (Est Pt) Exam intermediate (Est Pt) Exam detailed (Est Pt) Exam comprehensive (Est Pt) Exam comp, high complex (Est Pt)

99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 71010 71030 72020 73020 73085 73100 73500 73560 73610 73620

Bartholins gland I & D

X-rays Chest - one view Chest - 4 views Spine - single view (specify level) X-ray - shoulder 1 view X-ray elbow X-ray wrist (2 views) X-ray hip (1 view) X-ray knee X-ray ankle (3 views) X-ray foot (2 views)

Laboratory Urinalysis Pregnancy test UA volume Allergy test - skin extracts Allergy - biologicals Allergy - patch test PTT Hematocrit Hemoglobin Diff WBC Occult blood Throat culture ECG ECG - 24-hour monitor

81000 81025 81050 95004 95010 95044 85002 85014 85018 85004 82270 87650 93270 93224

Physical Medicine Acupuncture Acupuncture with ES Gait Training Nutritional counseling (subsequent) Myofascitis Sinusitis Tonsillitis Otitis media Otitis externa Otitis interna Urinary tract infection Conjunctivitis Angina COPD

97780 97813 97116 97803 729.1 473.9 474.0 382.9 380.10 386.30 599.0 077.99 413.9 496

ICD-9-CM Codes Well-child visit Prenatal visit Prenatal visit - high risk Allergy exam Anemia Lower back pain Neck pain Hypertension Fatigue HF

V20.2 V22 V23 V72.7 285.9 724.2 723.1 642.2 789.79 428.0

Bartholins gland cyst Interstitial cystitis

Continued

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PROCEDURE 16-1contd

2. Using the CPT-4 coding manual, assign the appropriate ofce visit code, laboratory code, and ofce surgical procedure code. 3. Using the ICD-9-CM coding manual, assign the appropriate diagnosis codes for the patient. Write the procedure and diagnostic codes on the superbill to ensure that the superbill reects all of the diagnoses and procedures related to the visit.

4. Fill out the appropriate elds on the CMS-1500 form, being sure to link the diagnosis and procedure codes. 5. Recheck the CPT-4 and ICD-9-CM codes against each coding manual to prevent transposition of digits and other errors.

the insurer little while still paying their premiums. Thus, the risk to the insurer is spread across a larger group. Lowcost health insurance is a benefit that will attract employees to a company. Employers offer health insurance as a benefit to help employees stay healthy and productive. Large employers will commonly offer their employees several different insurance plans, covering varying services at varying premium costs. Employees who have children may choose a policy that covers more pediatric services than do employees whose children are grown. Employees who take expensive medications may choose a policy that offers the most medication benet. The medical assistant must be aware that people working for the same employer may have different policies and, therefore, different benefits. Dental insurance is commonly offered by the employer as a separate policy that employees can choose to buy. Dental services are generally not covered by health insurance, with the exception of procedures requiring general anesthesia, which may be covered as a medical service. Employer insurance plans can include managed care, indemnity plans, health savings accounts, and health reimbursement accounts.

Managed Care
Managed care is a way of providing health insurance while controlling costs and involves a contract between an insurer and a physician to provide services to insurance members at predetermined rates. Managed care encompasses a variety of methods of integrating the nancing and delivery of health care, including:

hiring providers as employees offering a at-rate payment per patient offering a fee-for-service arrangement, in which payment for each service is provided using a discounted scale.

referral is essentially the PCPs request to the specialist to examine the patient. The insurance company requires a referral to be in written form; if not, the insurer will not pay for the specialists services. The insurance company encourages the PCP to refer patients to specialists within the managed care system who have agreed to the predetermined rates. While PCPs strive to maintain clinical objectivity in diagnosing and treating patients, managed care administrators will commonly attempt to steer the clinical decision-making process in order to control costs. One way the insurers have of controlling costs involves subjecting the services a physician offers to a utilization review, which is an evaluation of the necessity, quality, and effectiveness of a medical service. The PCP requesting services for her patient must prove the necessity of those services to the utilization review staff of the managed care organization to obtain payment. Insurers may also give PCPs nancial incentives, such as a bonus, to reduce costs. Insurers with managed care plans offer provider relations representatives to answer questions that staff members ling insurance claims may have or to update the ofce on changes to policies and procedures for reimbursement or referral. Managed care websites, seminars, and newsletters also offer providers and staff information on covered services, fee schedules, and reimbursement procedures. The medical assistant ling claims to managed care plans must keep up with changes to the plans and inform patients of their changes to insurance coverage as needed. Several forms of managed care include health maintenance organizations (HMOs), independent practice associations (IPAs), and preferred provider organizations (PPOs).

Health Maintenance Organization

A health maintenance organization (HMO) is a form of managed care offered by many insurers. Because varying strategies to control the cost of health care are employed, out-of-pocket expenses to the patient can vary. Patients can select the plan that offers the most services that their

Commonly, the managed care system includes a primary care provider (PCP), a physician who is responsible for referring the patient to a specialist when appropriate. A

CHAP TER 16

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family will use at the lowest cost. Small copayments are common in HMOs. Several forms of HMOs are available, including:

Point-of-service HMO
Physicians working in a point-of-service HMO are not employees of the HMO but are contracted to provide services to HMO members at discounted rates. Payments are made on a fee-for-service system. Patients must choose a PCP from a list of providers and obtain referrals for specialty care. Pediatric well-child visits and annual gynecological examinations do not require referrals. Because insurance companies are paying discounted rates, they can offer attractive rates to employers, which makes point-of-service HMOs extremely popular. The insurance company, the employer, and the employee all pay a lower cost for care. The point-of-service plan is also attractive to physicians because large companies have many employees, which means many patients for the physician. In this type of HMO, the insurer pays no benets to nonparticipating providers.

staff model group model open-ended point-of-service.

Staff Model HMO

A staff model HMO employs salaried providers who provide services only to plan members; they do not see patients outside of the HMO plan. A wide variety of services that include radiology, pediatrics, internal medicine, obstetrics, gynecology, endocrinology, physical therapy, and oncology are offered by HMO employees at a clinic or hospital. A medical doctor is designated as the patients PCP, who is responsible for preventive and routine care. If the patient needs the services of a specialist, the patient must obtain a referral from the PCP and see one of the specialists within the staff model HMO. Life-threatening emergencies do not require a referral. If a patient is traveling outside of the HMO service area, he must obtain preauthorization for nonemergency care. Other than emergency and out-of-area preauthorized care, no coverage is offered if the patient sees a provider outside of the HMO network of providers.

Independent Practice Association

An independent practice association (IPA) is a group of individual health care providers who join in an agreement with an insurer to provide health care to patients enrolled in the IPA plan. The physicians and providers are not nancially connected to each other but do agree to refer to one another within the group. IPA physicians hire their own staff and maintain their own ofces. IPA physicians can also see patients who are not enrolled in the IPA plan. Insurers pay a primary care physician on a capitated fee system and specialists on a fee-for-service basis. They require referrals and utilization reviews for specialty services and pay benets only to providers in the IPA program. Thus, patients enrolled in this type of program must see physicians within the group.

Group Model HMO

Physicians working in a group model HMO are paid a set fee each month per patient. The physicians fee does not change with the number of office visits or services provided to the patient. This form of payment is called capitation. The physician is not an employee of the group model HMO and can see patients outside of the HMO. Physicians are commonly members of several group model HMOs while also seeing patients with other forms of health insurance. A group model HMO requires a referral from the PCP for specialty care. No benefits are paid to nonparticipating providers with the exception of lifethreatening emergencies.

Preferred Provider Organization

A preferred provider organization (PPO) is a managed care plan that contracts with local physicians. Physicians agree to accept a set fee for each service provided, instead of the fee that the physician usually bills. Patients will pay a copayment upon arrival at the physicians office. Some plans will require that the patient also have a referral to see a specialist. PPO plans can be purchased at group rates through employers or purchased by an individual. Benefits to nonparticipating providers are subject to deductibles and are generally paid at 80% of the accepted fee contract.

Open-ended HMO
Physicians working in an open-ended HMO are not employees of the HMO. They are paid on a fee-for-service basis. Patients do not select a PCP and do not need a referral to see a specialist. Patients must choose providers from a list of providers on the HMO panel, the physicians that agree to the HMO reimbursement contract. Patients may also choose a nonparticipating provider but will need to pay a larger deductible before the insurer will pay benefits. Benefit payments to nonproviders are generally paid at 80% of HMO rates after the patient has paid the deductible.

Traditional Insurance
In addition to managed care, patients can choose a traditional insurance policy, called an indemnity plan. An indemnity plan is more expensive than managed care products but offers the most exibility to patients. Providers are paid a percentage of the charges, and the patient pays the remainder. This form of

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payment is also called fee-for-service and covers many procedures. The most common plans pay 80% and the patient then pays 20%. The insurance company does not set the fees, as in an HMO or PPO. Instead, the physician determines the fee using the standard of usual, customary, and reasonable (UCR) rates. UCR payments are determined by examining the physicians usual fee, the fee customarily charged by physicians in the same locality, and what is considered to be a reasonable fee for the service. In order to reduce the premium costs of the indemnity plan, the patient commonly assumes responsibility for a deductible, which is a set amount of money that must be paid by the patient for services before the insurance company will begin paying the 80% reimbursement. Indemnity plans can be purchased at group rates through employers or purchased by an individual. (See What type of insurance should I choose?.)

expenses or pay more out-of-pocket for services rather than pay higher premiums for more comprehensive insurance coverage. All of the plans are used in conjunction with highdeductible health policies (HDHPs). The HDHPs are designed to provide coverage for routine care after a high deductible is paid. After a maximum out-of-pocket expense paid by the patient, the HDHP covers most health costs, including prolonged hospitalization, surgery, and long-term care. The focus of the HDHP is to insure the patient for high-cost care while he pays out-of-pocket for lower-cost care. The HDHP can be an HMO, a PPO, or an indemnity plan as long as it meets the requirements. A plan is defined by the federal government as an HDHP if:

Consumer-Driven Health Plans

Consumer-driven health plans (CDHPs) offer options for health care insurance in addition to managed and traditional care plans. People may elect to save for their own health

The minimum deductible is $1,100 per individual or $2,200 per family (or higher). The annual out-of-pocket expense is $5,500 per individual and $11,000 per family (or higher). Only rst-dollar coverage (no deductible) is provided for qualied preventive care, such as well-child visits, usually with a copayment.

Patient Education

What Type of Insurance Should I Choose?

Because of the range of insurance options available, a patient may ask the medical assistant for advice about what type of policy would be best for him and his family. The following table compares managed care and traditional coverage options.

Policy Type
Staff model HMO

Provider Payment Method

Primary care providers (PCPs) as salaried employees of the HMO

Referral Required from PCP

Yes

Patients Choice of Provider

No, all covered providers are HMO employees.

Group model HMO

Capitation

Yes

No, only in-network providers are covered.

Open-ended HMO

Fee-for-service at HMO rates

No

Nonparticipating providers are paid at 80% of HMO rates.

Point-of-service HMO Independent provider association (IPA)

Fee-for-service at HMO rates Capitation (for PCPs) or feefor-service at HMO rates (for specialists)

Yes Yes

No, only in-network providers are covered. No, only in-network providers are covered

Preferred provider organization (PPO)

Fee-for-service at HMO rates

Some

Nonparticipating providers are paid at 80% of usual, customary, and reasonable (UCR) rates.

Indemnity policy

80% of UCR fee-for-service basis

No

All providers are eligible for payment at 80% of UCR rates.

CHAP TER 16

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The three forms of CDHPs are the health savings account, health reimbursement account, and exible spending account.

HSA and HRA differences

The following table outlines the different characteristics of a health spending account (HSA) and a health reimbursement account (HRA).

Health Savings Account

A health savings account (HSA) is a tax-sheltered savings account that can be used to pay for medical expenses not covered by many insurance plans. Qualified expenses covered by an HSA include remodeling done to a home to accommodate patients with disabilities, ambulance services, orthopedic appliances, and telephone and TV modications to assist patients with vision and hearing impairments. High deductibles apply to HSA plans and must be paired with a qualied health plan to cover the costs of routine care. Money in the account that is not used for medical care earns interest and remains in the account, similar to an independent retirement account (IRA). Contributions to the account are made by the employee, employer, or both. Contributions made by the employee are taken from the employees paycheck before federal and state taxes are calculated. Maximum contributions allowed by law are set yearly. Beginning in 2007, individuals can make a one-time transfer from their IRA to their HSA, subject to the maximum allowed contribution of $2,850 for an individual and $5,650 for a family. Every year, the U.S. Treasury Department determines the maximum allowable contributions to a health care plan for that year. If the employee changes jobs, the HSA account can be moved to a new employer.

HSA
Payments to the account may be made by the employee, employer, or both. The employee can take the account from job to job.

HRA
Payments to the account are made only by the employer.

The employee forfeits all benets when he leaves the employer. The account operates on a calendar-year basis only.

The account may operate on a benet-year or calendaryear basis. The account may reimburse for home remodeling and accommodations related to health needs.

The account reimburses only for qualied medical expenses.

Health Reimbursement Account

A health reimbursement account (HRA) is designed to reimburse an employee for medical expenses incurred by high deductibles and copayments associated with HDHPs. HRAs are funded exclusively by the employer; employees do not make any salary contribution to pay for the HRA. Expenses covered by the HRA are any medical care expenses covered by the primary medical insurance but not paid by the insurance company because of a deductible or copayment. The HRA operates on a calendar-year basis. The employer establishes the annual maximum reimbursement to employees on January 1 of each year. An employee may qualify for reimbursement from the HRA only while employed by the employer. The employer may cancel or amend the HRA program at any time. (See HSA and HRA differences.)

employee must consider how much money he wants to contribute since the money will not accumulate from year to year. The amount of contribution can be adjusted each year in anticipation of expenses. Funds can be used to pay for qualied medical expenses and dependent-care expenses, such as day care. Many people with children elect to contribute to an FSA to pay for day-care expenses with pretax dollars.

Government Programs
While many people buy health insurance for themselves and their dependents through their employer or through an individual policy, many others are covered by government plans designed to offer health insurance to people who are retired, have a low income, or are active or retired military personnel and their dependents. Government plans that cover these people are Medicare, Medicaid, CHAMPUS, and CHAMPVA.

Medicare
Medicare is a government health insurance program for:

Flexible Spending Account

A exible spending account (FSA) is funded by the employee and is not subject to federal, Social Security, or state taxes on the contributions. Employers may contribute a small amount to the plan. The spending account accumulates interest for one calendar or benet year, but unused money is returned to the employer at the end of that period. The

people age 65 or older people under age 65 with certain disabilities people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant) people of all ages with amyotrophic lateral sclerosis (Lou Gehrigs disease). Medicare offers four parts:

part Ahospital insurance part Bphysician services

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part CMedicare Advantage, in which patients can elect to have part A and B services provided through an HMO provider with reduced copayments and outof-pocket expenses part Dprescription drug services.

Medicare is nanced by a portion of the payroll taxes paid by workers and their employers. It is also nanced in part by monthly premiums deducted from Social Security checks. The program helps with the cost of health care, but it does not cover all medical expenses or the cost of most long-term care. Patients can elect to buy long-term care insurance, which will cover expenses of nursing facilities and home care. The Centers for Medicare and Medicaid Services is in charge of the Medicare program. Patients apply for Medicare at their Social Security ofce. The physician must decide if she is going to participate in the Medicare program. If the physician chooses to participate, Medicare will send payments directly to the physicians ofce, rather than to the patient. Medicare distributes a copy of its fee contract to every medical ofce each November in paper or electronic format. Medicare also posts this fee system, or schedule, online at its website, listed by region. Medicare will pay 80% of the posted fee, and the patient or her supplemental insurance pays the remaining 20% of the allowed amount. Also, if the physician participates in Medicare and the patient has a Medigap plan, a supplemental plan that picks up what Medicare does not pay, Medicare will automatically forward the claim on to the Medigap payor for payment. Although a nonparticipating physician must still le Medicare claims, Medicare will send the payment directly to the patient, who is then responsible for paying the physician. If a patient also has Medigap insurance, the nonparticipating physicians ofce must le the Medigap insurance claim for supplemental payment. In addition, the Medicare payment is 5% less for a nonparticipating physician than a participating physician. Pharmacies and laboratories are required to accept Medicare assignment and cannot elect to be a nonparticipating provider. (See Services not covered by Medicare.)

inpatient hospital services outpatient hospital services prenatal care vaccines for children physician services nursing facility services for persons age 21 or older family planning services and supplies rural health clinic services home health care for persons eligible for skilled-nursing services laboratory and x-ray services pediatric and family nurse practitioner services nurse-midwife services federally qualied health-center (FQHC) services, and ambulatory services of an FQHC that would be available in other settings early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21.

States may also receive federal matching funds to provide certain optional services. The most common of the currently approved optional Medicaid services are:

diagnostic services clinic services intermediate-care facilities for the mentally retarded prescribed drugs and prosthetic devices optometrist services and eyeglasses nursing facility services for children under age 21 transportation services rehabilitation and physical therapy services home and community-based care to certain persons with chronic impairments.

Although individual states vary, people are generally eligible for Medicaid if they are members of the following groups:

Medicaid
Title XIX of the Social Security Act is a federal and state entitlement program that pays for medical assistance to certain individuals and families with a low income and limited resources. This program, known as Medicaid, became law in 1965 as a cooperative venture jointly funded by federal and state governments to assist states in furnishing medical assistance to eligible people. Medicaid is the largest source of funding for medical and health-related services for Americas poorest people. Every state has different criteria for billing Medicaid, but the federal government institutes standards for states to obtain matching funds for the program. To obtain federal funding, a states Medicaid program must include medical coverage for the following:

children under age 6 whose family income is at or below 133% of the federal poverty level (FPL) pregnant women whose family income is below 133% of the FPL (services to these women are limited to those related to pregnancy, complications of pregnancy, delivery, and postpartum care) recipients of Supplemental Security Income (SSI), which is a federal program that supplements the income of persons who have disabilities, providing money for basic needs (Some states use more restrictive Medicaid eligibility requirements that predate SSI.) recipients of adoption or foster care assistance under Title IV of the Social Security Act special protected groups (typically, individuals who lose their cash assistance due to earnings from work or from increased Social Security benets, but who may keep Medicaid for a period of time)

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Patient Education

Services not Covered by Medicare

Sometimes Medicare patients will request services that may not be covered by Medicare. For example, if a patient wants to have his cholesterol checked every week, Medicare will say such measures are not medically necessary. If the patient still wants to have the test run, the medical assistant must require the patient to sign a notice called the advanced beneciary notice (ABN). This notice explains to the patient that, according to Medicare, the test is not needed; Medicare will not reimburse for it, and the patient agrees to pay for the test in full.

Patients Name:

Walter Simmons

Medicare # (HICN): ADVANCE BENEFICIARY NOTICE (ABN)

987-65-4321A

NOTE: You need to make a choice about receiving these health care items or services. We expect that Medicare will not pay for the item(s) or service(s) that are described below. Medicare does not pay for all of your health care costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor recommended it. Right now, in your case, Medicare probably will not pay for Items or services:

Acupuncture
Because:

Maximum number of visits allowed per calendar year has been met.
The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully. Ask us to explain if you dont understand why Medicare probably wont pay. 65.00 Ask us how much these items or services will cost you (Estmated cost: $ ____________________). PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE YOUR CHOICE.

Option 1. YES. I want to receive these items or services.

I understand that Medicare will not decide whether to pay unless I receive these items or services. Please submit my claim to Medicare. I understand that you may bill me for items or services and that I may have to pay the bill while Medicare is making its decision. If Medicare does pay, you will refund to me any payments I made to you that are due to me. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand I can appeal Medicares decision. Option 2. NO. I have decided not to receive these items or services. I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare wont pay.

07/30/08
Date

Walter Simmons
Signature of patient or person acting on patients behalf

NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our offices. If a claim is submitted to Medicare, your health information on this form may be shared with Medicare. Your health information which Medicare sees will be kept confidential by Medicare. OMB Approval No. 0938-0566 Form No. CMS-R-131-G (June 2002)

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all children born after September 30, 1983, who are under age 19 and come from families with incomes at or below the FPL.

Providers agreeing to participate in Medicaid must accept Medicaid payment rates as payment in full but may charge a copayment to some patients. The provider is not allowed to charge a copayment to Medicaid beneciaries who are pregnant women, children under age 18, and hospital or nursing home patients who are expected to contribute most of their income to institutional care. In addition, all Medicaid beneciaries are exempt from copayments for emergency services and family planning services. States may pay health care providers directly on a fee-forservice basis or through various prepayment arrangements, such as health maintenance organizations (HMOs). Each state, for the most part, has broad discretion in determining the payment methodology and payment rate for services within federally imposed upper limits and specic restrictions. Generally, payment rates must be sufcient to enlist enough providers to care for the needs of the patients in the geographic region. States must make additional payments to qualied hospitals that provide inpatient services to a disproportionate number of Medicaid beneciaries or other low-income or uninsured persons under what is known as the disproportionate share hospital (DSH) adjustment.

with Tricare Standard. There is no fee charged to the individual to use Tricare Extra benets. Tricare Prime, which is an HMO-style plan, requires the beneciary to choose a PCP and obtain referrals for specialty care. However, it charges lower copayments to the patient. The patient is charged an annual enrollment fee for Tricare Prime.

CHAMPVA
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a health benets program in which the Department of Veterans Affairs (VA) shares the cost of certain health care services and supplies with eligible beneciaries. CHAMPVA operates like an indemnity plan; patients choose their own physicians and deductibles and copayments may apply. CHAMPVA pays providers on a fee-for-service basis in which fees are determined by a formula using UCR and federal guidelines. In general, the CHAMPVA program covers most health care services and supplies that are medically necessary. To be eligible for CHAMPVA, patients cannot be eligible for Tricare (CHAMPUS) and must be in one of these categories:

CHAMPUS
The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) was enacted by Congress in 1956. The purpose of CHAMPUS was to provide civilian health care to dependents of military service members. The plan covered care supplemental to that available in military facilities. It provided authorized inpatient and outpatient care from civilian physicians and hospitals when deemed medically necessary. All CHAMPUS beneficiaries who have retired from the military are moved to the Medicare program at age 65. In keeping with the cost savings associated with HMO plans, CHAMPUS was revised in 1993 to offer lower-cost options to patients in the form of Tricare. Tricare offers three programs to eligible participants:

spouse or child of a veteran who has a disability rating determined by a Veterans Administration (VA) regional ofce of permanently and totally disabled for a serviceconnected disability surviving spouse or child of a veteran who died from a VA-rated service-connected disability surviving spouse or child of a veteran who was, at the time of death, rated permanently and totally disabled surviving spouse or child of a military member who died in the line of duty, not due to misconduct. (In most of these cases, these family members are eligible for Tricare [CHAMPUS], not CHAMPVA).

Workers Compensation
Every state mandates that employers carry workers compensation insurance. This insurance covers medical costs related to injuries or illnesses sustained by employees as a result of their job. Employers pay premiums to an insurer based on the risk of injury or illness to employees. A construction company whose workers use power tools and must climb onto roofs will pay higher premiums than a company whose workers sit at a desk all day. Physicians who treat patients under workers compensation must register annually with their state Workers Compensation Board. Services are reimbursed to physicians on a fee-forservice basis and no copayment or deductible is charged to the patient. A workers compensation claim must include a rst report of injury notice, which describes the accident or injury and its date, time, and location. (See Figure 16-4.) This notice is initiated by the employer and sent to the physician. The

Tricare Standard, which most resembles an indemnity plan, allows beneciaries to use any civilian health care provider who is eligible under Tricare regulations. The beneciary is responsible for payment of an annual deductible and coinsurance. There is no fee for enrollment in Tricare Standard. Tricare Extra, which is a PPO-style plan, allows a beneciary to elect to use civilian providers within a regional contractors provider network. Fees are paid to providers on a fee-for-service basis at HMO (discounted) rates. The coinsurance for the patient is at least 5% less than

CHAP TER 16

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Form 122
For your protection Connecticut Law requires notice that workers compensation fraud is a crime. Please see next page for the full fraud statement

WORKERS COMPENSATION EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS STATE OF CONNECTICUT - THE LABOR COMMISSION - DIVISION OF INDUSTRIAL ACCIDENTS HARTFORD, CT 06555
EMPLOYER (Name & Address Incl. Zip) CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA CASE/FILE # REPORT PURPOSE CODE

G E N E R A L

Barry Manufacturing 2589 Industrial Drive Presley, CT 06001

JURISDICTION

JURISDICTION CLAIM NUMBER

INSURED REPORT NUMBER

87TYM5673472
EMPLOYERS LOCATION ADDRESS (IF DIFFERENT) LOCATION #

SIC CODE

EMPLOYER FEIN

Same

Same
PHONE #

860-123-3876
CARRIER (NAME, ADDRESS & PHONE #) POLICY PERIOD TO CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE #)

C A R R I E R

C Worker Compensation Fund L A P.O. Box 1195 I Presley, CT 06001 M S Telephone: 1-800-123-4786 A D CARRIER FEIN M I N AGENT NAME & CODE NUMBER

12/31/10

CHECK IF APPROPRIATE SELF INSURANCE POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN

Baldwin Insurance Agency, Code #96360

NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE

E M ADDRESS (INCL ZIP) P L 42 Wilshire Ave. O Blueville, CT 06100 Y E E

PHONE RATE

Hansen, Craig, William

12/30/71
SEX

000-00-0000
MARITAL STATUS UNMARRIED SINGLE/DIVORCED

01/14/98
OCCUPATION/JOB TITLE

active

MALE FEMALE UNKNOWN

machinist
EMPLOYMENT STATUS

MARRIED SEPARATED UNKNOWN

active
NCCI CLASS CODE

860-543-2100 $680.00
DAY PER: WEEK DATE OF INJURY/ILLNESS MONTH

# OF DEPENDENTS

W A G E

# OF DAYS WORKED/W EEK

TIME EMPLOYEE X AM BEGAN WORK 8:00 PM

09/15/08

OTHER: TIME OF OCCURRENCE

FULL PAY FOR DA Y OF INJURY? DID SALARY CONTINUE? DATE EMPLOYER NOTIFIED

4:22 X

AM PM

LAST WORK DATE

09/15/08

09/15/08

YES X NO DATE DISABILITY BEGAN

YES

NO

09/15/08

CONTACT NAME/PHONE NUMBER

O C C U R R E N C E

Henry Watanabee 860-555-7400 ext 43

DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES?

TYPE OF INJURY/ILLNESS

lower back sprained

PART OF BODY AFFECTED

Lower back

TYPE OF INJURY/ILLNESS CODE

PART OF BODY AFFECTED CODE

YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

Loading dock
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

dolly
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

unloading boxes from truck

shipping

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED, DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE

slipped on water on loading dock while carrying heavy box

IF FATAL, GIVE DATE OF DEATH WER E THE Y USED?

DATE RETURN(ED) TO WORK

10/22/08
T R E A T M E N T O T H E R
PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)

WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?

X X
INITIAL TREATMENT

YES

YES

NO NO

HOSPITAL (NAME & ADDRESS)

Robert Greer, MD 15 Main Street Blueville, CT 06100 860-555-3212

WITNESS (NAME & PHONE #)

Hartell Memorial 773 Carson Street Blueville, CT 06100 X

NO MEDICAL TREATMENT MINOR: BY EMPLOYER

MINOR CLINIC/HOSP EMERGENCY CARE HOSPITALIZED >24 HRS

Sarah Kramer
DATE ADMINISTRATOR NOTIFIED

860-555-7868
DATE PREPARED

FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED PREPARER'S NAME & TITLE PHONE NUMBER

09/16/08

09/16/08

Rebecca Stavola, Legal Counsel

860-555-7400 ext 62

White: Labor Commission

Yellow: W.C. Insurance Carrier

SEE NEXT PAGE FOR IMPORTANT INFORMATION Pink: Employee Goldenrod: Employers File

FIG 16-4 First report of an injury.

230

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physicians ofce must include a copy of this report with all claims sent to the insurance carrier for payment. In addition to covering the cost of medical care, workers compensation insurance must cover the cost of lost wages while the patient is unable to work. If an employee dies as a result of a work-related accident or illness, the employees dependents become eligible for payment of benets. Some limitations apply to workers compensation coverage. Thus, submission of a claim for workers compensation must be agreed to by the employer and employee. (See Workers compensation claims below.) Employees are not covered if they are reckless in their job performance, arrive at work drunk, use illicit drugs, injure themselves purposely, or ght at work. Employees who fail to use safety equipment, such as steel-tipped boots or protective eyewear, may also forfeit their benets.

Multiple Insurance Policies

Patients may have more than one health insurance policy and payment can be obtained from a primary (billed rst) and a secondary policy. When gathering insurance information, the medical assistant should ask the patient which insurance is primary and which is secondary. Minor children covered by two policies of their parents are covered using the birthday rule. The birthday rule states that the primary coverage for children is the policy of the parent with the birthday that is rst in the calendar year. For example, if Mary is born on January 12 and John is born on March 8,

the mothers policy (Marys) is primary for all of the children. The parents can elect, however, to have primary coverage with either policy. So, in the example, if Johns coverage had better obstetric services than Marys, she could elect to use Johns policy as her primary policy. However, she would have to use that policy as primary for all medical coverage, not just obstetrics. John would have to pay for the primary coverage for his wife, Mary, through his employer. Multiple insurance policies require that the medical assistant have an understanding of coordination of benets. Coordination of benets means that the medical ofce bills the primary insurance company and then the medical assistant notes the amount paid on the bill sent to the secondary insurance company. The secondary insurance company then pays all or a portion of the remaining bill. Medicare will forward claims to a secondary insurance company for claims from participating providers. All other secondary claims must be led by the physicians ofce. The patient pays a copayment at the time of the ofce visit (if applicable) and is responsible for the unpaid portion after all insurance companies have paid their portions.

COBRA
In 1986, Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA). This act provides continuation of group health insurance coverage for subscribers and their dependents when they leave employment. Prior to the act, an individual and his family would be without health insurance coverage upon termination of employment by the employer or the employee. COBRA coverage allows a subscriber and his dependents to stay on the group health insurance of the employer for a maximum of 18 months after termination of employment. Many people use COBRA coverage to ensure that they and their dependents are not without medical insurance for any period of time between jobs. The COBRA coverage is subject to the following restrictions:

Patient Education

Workers Compensation Claims

If the employer and employee cannot agree on the nature of an injury, the physicians ofce cannot le the claim as workers compensation. The medical assistant should explain to the patient that he must discuss the status of the injury with his employer and come to an agreement so that the medical ofce can le his claim appropriately. When a claim has been established as a work-related injury, the medical assistant should make sure that the patient keeps a copy of the rst report of injury for his records. If the employee is unable to work, the physician will provide him with a notice of limitation to show his employer. When the physician determines that the patient is able to return to work, he will issue a return-to-work order. The medical assistant must make copies of the physicians order, placing one copy in the medical record and giving two copies to the patient (one for the patient to give to his employer and another for the patient to keep for his records). Without the return-to-work order, the employer will not allow the patient to return to his job.

The originating health insurance plan must provide coverage for 20 or more employees. Private-sector and state government employers must provide coverage, but federal government and some church-related organizations are exempt. The employer must allow the former employee and his dependents to remain on the group plan at the group rates. However, the employer is no longer obligated to pay any portion of the premium.

Under COBRA, a group health insurance plan is dened as a plan providing medical benets to employees through insurance, such as an HMO (any form) or an indemnity policy. Medical benets under the plan may include:

physician care inpatient and outpatient hospital care

CHAP TER 16

Coding and Insurance

231

surgery prescription drug benets dental and vision care.

Self-Pay Patients
Although most people have some form of insurance that covers a portion of their health care costs, some patients do not have any insurance coverage. A patient who does not have health insurance through their employer may not be eligible for a government health insurance plan. In 2007, the reported number of uninsured Americans varied from 8.2 million, according to the Kaiser Family Foundation, to 47 million, as reported by the National Coalition on Healthcare. Some patients may be temporarily without health insurance during job changes or divorce. Uninsured patients can be seen by the physician and a payment plan can be arranged to spread the cost of care over several months. Many physicians will offer services at a reduced rate to help their uninsured patients. Each physician practice will have policies regarding payment arrangements for self-pay patients.

2. 3.

Insurance Claims
Processing an insurance claim is a central operation in a medical ofce. Many guidelines, restrictions, and requirements are involved in such a procedure.

HIPAA
One of the most important requirements in ling an insurance claim involves the Health Insurance Portability and Accountability Act (HIPAA), a law passed in 1996 that protects the privacy and security of a patients protected health information (PHI). HIPAA allows disclosure of PHI only for the purposes of treatment, payment, and operations (TPO) of the medical practice and mandates that all other disclosures be specically authorized by the patient. Under these rules, insurance claims can be led for payment without additional authorization from the patient. (For more information on HIPAA, see Chapter 7, HIPAA and a Patients Rights, page 71.)

4.

Life Cycle of an Insurance Claim

The medical assistant must gather information from the patient and the physician to process insurance claims for payment. From the point that a patient enters the physicians office until the bill is finally paid, the medical assistant must take steps to gather the necessary information and submit the claim accurately to ensure fast payment. The cycle of processing an insurance claim follows these steps: 1. A new patient enters the ofce for treatment and begins the registration process, which involves lling out a new

5. 6. 7. 8.

patient registration form with his personal and insurance information. The registration form aids in the collection of demographics, which is information that the medical assistant needs to complete the claim. Demographic information includes the patients address, telephone number, employer, and insurance coverage information. For children, information also includes the names and addresses of both parents. (See Figure 16-5.) The patients or guardians signature on the registration form authorizes the release of the patients demographic information for the purposes of TPO. After the patient is registered, the medical assistant should collect the insurance copayment from the patient, because a patient might not stop back to see the front desk after completing the visit. When the payment is collected, the medical assistant should give the patient a receipt. The medical assistant creates a medical record for the patient and inserts the new patient intake form. The medical assistant makes a photocopy of the medical insurance card provided by the patient and keeps the copy in the patients medical record. The insurance card contains the details about the patients insurance policy, including the insurance identification number, the group number (if there is one), and the amount of the copayment. The back of the card contains the claim address, phone numbers to verify coverage and benefits and, possibly, a website address for the insurance company. At this point, it is extremely important for the medical assistant to collect all the information relating to the patients insurance. One of the major reasons for nonpayment of insurance claims is incorrect information, such as transposed numbers or misspelled names. Copying the insurance card helps eliminate some of these problems and ensures that the patients name, identification number, and group number are accurate. (See Figure 16-6.) The medical assistant veries the patients benets. Verication is conrming with the insurance company that the patient is covered by the policy and determining the extent of the patients benets under that policy. Verifying benets prior to providing services to the patient can avoid nonpayment of a claim by the patient. Because of long hold times on the phone, many front desk personnel will use the insurance companys website to verify benets. A password and identication number are required to access the data. The physician examines the patient. The physician provides the diagnosis and treatment for the service, commonly on the superbill. The medical assistant uses the information on the superbill to complete the CMS-1500 form for reimbursement. The medical assistant lls out the CMS-1500 form by using a billing software program and submits the claim

232

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CONFIDENTIAL PATIENT INFORMATION

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CT 860-555-3212 Name Michelle Calabrese Address 88 West Road Home phone 123-9674 Insured name self Insured employer Aloisio Advertising Associates Insurance carrier United Health Systems HEALTH HISTORY Have you ever suffered from: Asthma Fainting Diabetes Anxiety High blood pressure Bleeding disorder X Migraine headaches Constipation Fatigue X Stress Cancer (If so, what kind?) Date of birth 6/21/1984 Full time student Yes City Presley, CT Cell phone 203-998-5633 Insured date of birth 01/11/1984 Relationship to patient self Employer address 33 Park Ave, Presley, CT ID# XGA00443 Group # 4488

X No

Muscle weakness

X Difficulty sleeping
Allergies

X Stomach upset
Mental disorder

Lower back pain Difficulty swallowing Neck pain or stiffness Diarrhea Infection

none

Chronic pain (If so, where?)

neck and right shoulder

FAMILY HISTORY X Cancer (Who?) mother X High blood pressure (Who?) father, mother X Diabetes (Who?) father, grandmother MEDICATIONS AND SUPPLEMENTS

What type?

breast cancer (died last year)

Do you take any medications? Do you take any nutritional supplements? If so, please list (include dosages): If so, please list: none _____________________________________________ ________________________________________________________ Tylenol for headaches _____________________________________________ ________________________________________________________ Synthroid - 5 mg a day _____________________________________________ ________________________________________________________ _____________________________________________ ________________________________________________________ _____________________________________________ ________________________________________________________ REASON FOR TODAYS VISIT X Check up Physical for school, sports, or employment X Other (please explain) painful urination Women only Date of last menstrual period Number of pregnancies 0 Number of children 0

4/2/09

Miscarriages? 0 Difficult or painful menstruation?

sometimes

Men only Have you ever had erectile difficulty? Do you get up at night frequently to urinate?

Prostate problems?

I understand that Blueville Family Medicine will file my insurance for payment of services rendered. I also understand that I am responsible for any amount due Blueville Family Medicine if my insurance is denied. Signature of patient or guardian Relationship to patient Robert Greer, MD Sharon Piecek, APRN Hector Rodriguez, MD Henry Lee, MD Anne Wilson, MD

Michelle Calabrese

Date

04/15/09

FIG 16-5 New patient registration form.

CHAP TER 16

Coding and Insurance

233

United Health Systems

ID#: XGA00443 Group #: Name: MICHELLE CALABRESE Copays: $5 OV, $10 CHIRO, $50 ED 4488

Visit us at: www.UHSystems.com Member services 1-800-800-1767 Network provider services 1-800-800-1777 Out of network providers 1-800-800-1799 For medical emergencies please dial 911 or go to the nearest emergency room. Please contact your PCP or member services within 24 hours. For all other care, please contact your PCP. Refer to your benefit package for coverage descriptions. Mail Claims to:

RX:

$5

UHS, Inc., Claims Department 470 Commerce Park Blueville, CT 06100

UHS rev 12/08

FIG 16-6 Front and back of insurance card.

electronically or via U.S. mail. (See Figure 16-7.) This process is also referred to as posting the claim. 9. The insurance company processes the claim and sends payment for services to the provider.

In addition to the electronically submitted claim, Medicare may ask that the medical office mail a copy of the CMS-1500 form if it contains any surgical claims for unusual services (identied by the modier 22).

Submitting a Claim
When a claim is ready, the medical assistant will submit, or post, the claim. This process is made simple by computer billing software. In the billing software, dictionaries are set up to hold all the data that is referenced over and over again. There are dictionaries to hold physician billing information as well as a listing of all the physicians who might refer patients to the practice. There are dictionaries that hold all of the CPT codes, another one for modiers, and another for ICD-9-CM codes. Insurance companies are in another dictionary. An ofce will also usually create a master patient index and add to it every new patient when the patient registers. The report function of the billing software includes the CMS-1500 form. It also includes management reports that the ofce manager and billing supervisor can use to track payments, denials, and outstanding bills. The medical assistant will usually submit the days claims in batches. When a batch is completed, or closed, the claims are ready to submit. Some software will allow you to submit the claims through an edit check. The edit check looks for incorrect data and will print out a report that lists incorrect claims that the medical assistant must x before submitting them. Once the claims pass the edit check, they are ready to be submitted to the insurance company. The medical assistant may have to submit some claims by paper, most commonly third-party liability claims, such as workers compensation and motor vehicle accidents. Billing software typically allows the user to print these claims by agging them in the program. Once printed, the medical assistant can mail the claims to the insurance company. Insurance companies generally require the medical ofce to submit copies of ofce visit notes along with these claims.

Electronic Claim Submission

The majority of medical practices le claims electronically. After keying claims, the medical assistant sends the claims via an encrypted claims submission program. Some practices send claims directly to the insurance company; other practices use a clearinghouse. The clearinghouse is a company that processes the claims through additional edits, or scrubs, to make sure the claims contain no errors, designated as clean. Once the claims are determined to be error-free, the clearinghouse submits them to the various insurance carriers for processing and payment. (See Procedure 16-2: Submitting a CMS-1500 form to a third-party payor, page 235.)

TIP Effective Communication Effective communication with insurance companies and patients helps obtain quick, accurate payment. Establishing direct and reliable contacts with insurance provider representatives may help the medical assistant get answers to complex questions. A medical assistant who chooses to be friendly and helpful when assisting patients through difcult claims can also help obtain payment as well as satisfy patients.
Obtaining Referrals
A referral is a request by a PCP for the patient to be seen by a specialist. Most HMOs, PPOs, workers compensation plans, and Tricare (Extra and Prime) plans require a referral for specialty care to be considered for payment. The medical assistant working in the primary care physicians ofce will commonly be asked to forward a referral to a specialist. The medical assistant working in a specialty ofce must typically ask the patient for a referral prior to the patients visit. The referral can
(Text continues on page 237.)

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Administrative

HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

THE INSURANCE ID # IDENTIFIES THE EMPLOYEE OR BENEFICIARY.

PICA

THE PATIENTS NAME 1. MEDICARE MEDICAID TRICARE CHAMPUS MUST MATCH THE ID CARD #) (Medicaid #) (Sponsors SSN) (Medicare EXACTLY. 2. PATIENTS NAME (Last Name, First Name, Middle Initial)
CALABRESE MICHELLE
5. PATIENTS ADDRESS (No., Street)

PICA

CHAMPVA

(Member ID#)

GROUP HEALTH PLAN (SSN or ID)

FECA BLK LUNG (SSN) SEX M F

OTHER 1a. INSUREDS I.D. NUMBER

(For Program in Item 1)

(ID)

XGA00443
4. INSUREDS NAME (Last Name, First Name, Middle I le Initial)

3. PATIENTS BIRTH DATE MM DD YY

01 11 1984 X
Spouse

CALABRESE MICHELLE
7. INSUREDS ADDRESS (No., Street)

6. PATIENT RELATIONSHIP TO INSURED Self STATE Child Other

88 WEST ROAD

88 WEST ROAD PRESLEY

ZIP CODE

INFORMATION ON THE PRESLEY CT PATIENTS CONDITION ZIP CODE IN TELEPHONE (Include Area Code) BOX #10 IS NEEDED TO 06100 ( 860 ) 123 9674 DETERMINE IF THE CLAIM INSUREDS NAME (Last Name, First Name, Middle Initial) 9. OTHER IS TO BE FILED AS A a. OTHER WORKERS COMPENSATIONINSUREDS POLICY OR GROUP NUMBER OR OTHER LIABILITY POLICY.
b. OTHER INSUREDS DATE OF BIRTH MM DD YY M c. EMPLOYERS NAME OR SCHOOL NAME SEX F

Single

X X

Married Full-Time Student

Other Part-Time Student

CT

Employed

10. IS PATIENTS CONDITION RELATED TO:

TELEPHONE (Include Area Code) THE INSUREDS NAME IS ( 860 ) 123 9674 06100 THE EMPLOYEE WHO HOLDS 11. INSUREDS POLICY GROUP OR FECA NUMBER THE CONTRACT.

4488

a. EMPLOYMENT? (Current or Previous) YES b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES

X X X

REDS a. INSUREDS DATE OF BIRTH MM DD YY

SEX M F

NO PLACE (State) NO

01 11 1984

b. EMPLOYERS NAME OR SCHOOL NAME

ALOISIO ADVERTISING ASSOCIATES

c. INSURANCE PLAN NAME OR PROGRAM NAME

NO

UNITED HEALTH SYSTEMS

PLAN? d. IS THERE ANOTHER HEALTH BENEFIT P
YES

d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. RESERVED FOR LOCAL USE E

NO

If yes, re s return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment y below. SIGNED

SIGNATURE ON FILE
ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP)

DATE 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. NT GIVE FIRST DATE MM IRST DD YY
17a.
17b. NPI

14. DATE OF CURRENT: MM DD YY

10 19 08

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

THE DIAGNOSIS POINTER LINKS THE DIAGNOSIS CODE IN BOX 21 TO THE SIGNED SIGNATURE ON FILE PROCEDURE CODE IN BOX PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 16. DATES PATIE DD YY MM MM DD 24D. LINKING THESE YY CODES TO FROM IS REQUIRED TO RECIEVE HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 18. HOSP MM DD YY MM DD YY PAYMENT. FROM TO F
20. 2 OUTSIDE LAB? YES $ CHARGES NO

PERSONS SIGNATURE I authorize 13. INSUREDS OR AUTHORIZED P payment of medical benefits to the undersigned physician or supplier for services described below.

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) Relate 1.

722.52

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER

3.

INCLUSION OF THE 1 MEDICAL PRACTICES 10 22 08 10 22 08 11 FEDERAL TAX ID NUMBER 2 IS MANDATED BY THE IRS FOR THE INSURANCE 3 COMPANY TO PROCESS CHECKS TO PHYSICIANS.

YY

B. C. PLACE OF SERVICE EMG

E. DIAGNOSIS POINTER

F. $ CHARGES

DAYS OR UNITS

G.

EPSDT ID. Family Plan QUAL.

H.

I.

J. RENDERING PROVIDER ID. #

99204

1,2

85.00

NPI

5 6
25. FEDERAL TAX I.D. NUMBER AL SSN EIN S 26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
(For

CHECKING YES TO ACCEPT NPI ASSIGNMENT INDICATES TO THE INSURANCE NPI COMPANY THAT THE NPI CHECK SHOULD BE SENT DIRECTLY TO THE NPI PHYSICIAN.
NPI
govt. claims, see back)

28. TOTAL CHARGE $

29. AMOUNT PAID $

30. BALANCE DUE $

865623498

703

YES

NO

85 00

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS EES (I certify that the statements on the reverse me apply to this bill and are made a part thereof.)

32. SERVICE FACILITY LOCATION INFORMATION

33. BILLING PROVIDER INFO & PH #

INCLUSION OF THE PHYSICIANS NATIONAL a. b. NPI SIGNED DATE PROVIDER ID NUMBER WAS TYPE PLEASE PRINT OR NUCC Instruction Manual available at: www.nucc.org REQUIRED BY APRIL 2007.

HECTOR RODRIGUEZ, MD

HECTOR RODRIGUEZ, MD 15 MAIN STREET BLUEVILLE CT 06100 a. 1077358914 b. NPI

( 860 ) 555

85 00 3212

APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)

FIG 16-7 CMS-1500 claim form.

PHYSICIAN OR SUPPLIER INFORMATION

2. 729.1 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD

4. SUPPLIES D. PROCEDURES, SERVICES, OR SUP (Explain Unusual Circumstances) MODIFIER CPT/HCPCS MODI

PATIENT AND INSURED INFORMATION

CITY

8. PATIENT STATUS

CITY

STATE

CARRIER

1500

THE PATIENTS DATE OF BIRTH IS WRITTEN IN MM/DD/YYYY FORMAT.

CHAP TER 16

Coding and Insurance

235

PROCEDURE 16-2

Submitting a CMS-1500 form to a third-party payor

Task Complete and submit a CMS-1500 form to a third-party payor in electronic or hard copy format. Conditions Patient medical record Superbill CMS-1500 forms in printer (for mailed claims) Computer with CMS-1500 software Standards In the time specied and within the scoring parameters determined by the instructor, the student will accurately complete and submit a claim for payment using CMS-1500compatible software or by referring to the patients medical record. Performance Standards 1. Refer to the patients medical record (containing the patient registration form and photocopy of the patients insurance card) or the patient database to insert the name, address, telephone number, and insurance information into the CMS form (lines 1 through 13). 2. Recheck all information for accuracy to prevent a denial of the claim due to inaccurate data. 3. Refer to the superbill to ll out the following lines of the CMS form: a. #14illness (rst symptom) OR injury (accident) b. #15date patient has had same or similar illness (if applicable) c. #16dates unable to work (if applicable) d. #17referring provider and that providers national provider identication number (NPI) (if applicable) e. #18dates of hospitalization (if applicable) f. #21diagnosis code(s), using the ICD-9-CM codes from the superbill. (Enter the codes in spaces 1, 2, 3, and 4.) g. #24 Adate of service h. #24 Bplace of service code. (The physicians ofce code is 11.) i. #24 DCPT codes from the superbill with modiers (if applicable) j. #24 Fcharge for the procedure listed k. #24G1 in the days/units column to indicate that the procedure was performed once. l. #25federal tax identication number or physician Social Security number (as determined by ofce policy) to provide the insurance company with a record for federal and state income tax purposes m. #26patients account number (as designated by the practice) n. #27check in box to accept (yes) or reject (no) assignment, as designated by ofce policy (Checking yes sends payment directly to the physicians ofce.) o. #28total charges for the procedures entered p. #29amount paid by the patient (if any) q. #30balance due r. #31indication of physicians signature on le. (The medical assistant must include a signature or designation of signature on le on each claim she submits for it to be eligible for payment.) s. #33billing provider name, address, and phone number to ensure that payment is submitted to the correct ofce t. #33 aphysicians NPI to ensure that the claim is eligible for payment 4. Save and print the claim form. 5. Make a copy of the completed form for the patients medical record so that, if the claim is lost, the ofce can resend it in a timely manner. 6. If ling the claim electronically, save the claim and send it via electronic claims submission protocols. (The password-protected software encrypts the data for secure transmission.) If ling by mail, address the envelope to the claims department, enclose the CMS1500 form, and seal the envelope to ensure privacy. 7. Document the date of submission of the claim to maintain a record in case of a delay in payment. 8. Back up the data onto a separate data storage device, such as a USB drive, to ensure that data is not lost in case of damage to the computers memory.
Visit us at: www.UHSystems.com Member services 1-800-800-1767 Network provider services 1-800-800-1777 Out of network providers 1-800-800-1799 For medical emergencies please dial 911 or go to the nearest emergency room. Please contact your PCP or member services within 24 hours. For all other care, please contact your PCP. Refer to your benefit package for coverage descriptions. Mail Claims to: RX: $5 UHS, Inc., Claims Department 283 Commerce Park Drive Blueville, CT 06100 UHS rev 12/08

United Health Systems

ID#: XXHL129973534 Group #: Name: MARY OLESNEVICH Copays: $5 OV, $10 CHIRO, $50 ED 678844

Continued

236

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PROCEDURE 16-2contd

CONFIDENTIAL PATIENT INFORMATION

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CT 860-555-3212 Name Mary Olesnevich Address 277 Weston Road Home phone 555-7736 Insured name self Insured employer Blueville Family Services Insurance carrier United Health Systems HEALTH HISTORY Have you ever suffered from: Asthma Fainting X Anxiety Diabetes High blood pressure Bleeding disorder X Migraine headaches X Constipation Fatigue X Stress Cancer (If so, what kind?) Date of birth 07/17/1974 City Blueville, CT Cell phone 203-977-8033 Insured date of birth 07/17/1974 Employer address 115 Washington ID# XXHL129973534 Full time student Yes

X No

Relationship to patient

Street, Blueville, CT Group # 678844

self

Muscle weakness

X Difficulty sleeping X Allergies X Stomach upset

Mental disorder

X Lower back pain

Diarrhea Infection

Difficulty swallowing

X Neck pain or stiffness

none

X Chronic pain (If so, where?) neck, lower back

What type?

FAMILY HISTORY X Cancer (Who?) father X High blood pressure (Who?) father X Diabetes (Who?) grandmother, uncle MEDICATIONS AND SUPPLEMENTS

lung (died in 2005)

Do you take any medications? Do you take any nutritional supplements? If so, please list (include dosages): If so, please list: _____________________________________________ ________________________________________________________ Lipitor 5 mg/day Centrum multi _____________________________________________ ________________________________________________________ Zoloft 2 mg/day _____________________________________________ ________________________________________________________ Allegra 10 mg/day (not every day) _____________________________________________ ________________________________________________________ Prilosec 5 mg/day _____________________________________________ ________________________________________________________ REASON FOR TODAYS VISIT Check up Physical for school, sports, or employment X Other (please explain) extremely tired, my Women only Date of last menstrual period Number of pregnancies 3 Number of children 2

neck and back hurt

2/15/09
Miscarriages? 1 Difficult or painful menstruation?

sometimes

Men only Have you ever had erectile difficulty? Do you get up at night frequently to urinate?

Prostate problems?

I understand that Blueville Family Medicine will file my insurance for payment of services rendered. I also understand that I am responsible for any amount due Blueville Family Medicine if my insurance is denied. Signature of patient or guardian Relationship to patient Robert Greer, MD

Mary Olesnevich
Hector Rodriguez, MD

Date

03/12/09

self
Sharon Piecek, APRN Henry Lee, MD Anne Wilson, MD

CHAP TER 16

Coding and Insurance

237

PROCEDURE 16-2contd
Blueville Family Medicine 15 Main Street Blueville CT 860-555-3212 Patient Name: Date:

Mary Olesnevich March 8, 2009

Provider:

X
CPT-4 Codes Examinations Exam brief (New Pt) Exam intermediate (New Pt) Exam detailed (New Pt) Exam comprehensive (New Pt) Exam comp, high complex (New Pt) Exam brief (Est Pt) Exam intermediate (Est Pt) Exam detailed (Est Pt) Exam comprehensive (Est Pt) Exam comp, high complex (Est Pt) X-rays Chest - one view Chest - 4 views Spine - single view (specify level) X-ray - shoulder 1 view X-ray elbow X-ray wrist (2 views) X-ray hip (1 view) X-ray knee X-ray ankle (3 views) X-ray foot (2 views)

Robert Greer, MD Hector Rodriguez, MD Anne Wilson, MD Sharon Piecek, APRN Henry Lee, MD

99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 71010 71030 72020 73020 73085 73100 73500 73560 73610 73620

Laboratory Urinalysis Pregnancy test UA volume Allergy test - skin extracts Allergy - biologicals Allergy - patch test PTT Hematocrit Hemoglobin Diff WBC Occult blood Throat culture ECG ECG - 24-hour monitor

X X

81000 81025 81050 95004 95010 95044 85002 85014 85018 85004 82270 87650 93270 93224

Physical Medicine Acupuncture Acupuncture with ES Nutritional counseling (initial exam) Nutritional counseling (subsequent) Myofascitis Sinusitis Tonsillitis Otitis media Otitis externa Otitis interna Urinary tract infection Conjunctivitis Angina COPD

97780 97813 97802 97803 729.1 473.9 474.0 382.9 380.10 386.30 599.0 077.99 413.9 496

ICD-9-CM Codes Well-child visit Prenatal visit Prenatal visit - high risk Allergy exam Anemia Lower back pain Neck pain Hypertension Fatigue HF

V20.2 V22 V23 V72.7 285.9 724.2 723.1 642.2 789.79 428.0

be faxed to the specialists ofce or given to the patient to present at the time of the ofce visit. The referral must include:

name and NPI of the referring PCP type of service(s) requested by the PCP (for example, evaluation by an endocrinologist, psychologist, or nephrologist)

date of the referral, because referrals expire (although expiration times vary among insurance carriers). (See Figure 16-8.)

When the specialist sees a patient for a referred service, the medical assistant ling the CMS-1500 form must

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Blueville Family Medicine 15 Main Street Blueville CT 860-555-3212 Outpatient Services Referral Blueville Family Medicine 15 Main Street Blueville CT 860-555-3212 Patient: Robert Greer, MD Hector Rodriguez, MD Anne Wilson, MD Sharon Piecek, APRN Henry Lee, MD

Kaitlin Hartley 11/02/1958 Universal HMO

Gender Group #: Referral #:

Date of Birth:

female 3448 87995443

Insurance Carrier: ID#:

XRV86712984400

Referred to: Facility address: Facility phone:

Rebecca Roberts, MD Endocrinology Associates 17 Main Street, Blueville CT 860-555-9087

First appointment date

10/16/09
Reason for referral

increased thirst, excessive urination, enlarging examination for diabetes and thyroid function

mass in neck
Physician orders

testing

FIG 16-8 Specialty referral.

include the referring PCPs name and NPI number on lines 17 and 17b. (See Figure 16-9.)

Payment Systems
Insurance carriers use several methods to determine payment rates. Because HMOs require providers to enroll as participating physicians in order to provide care to their beneciaries, rates of payment must be attractive for physicians to apply. Government plans cannot mandate that physicians participate in programs such as Medicare, Medicaid, Tricare,

or CHAMPVA; but they also must attract physicians to participate in their programs. While all of the insurers need to attract physicians, they also need to control costs, offering the lowest possible premiums and deductibles to stay competitive. All of these factors add to the complexity of payment calculations. Methods for determining payments include:

usual, customary, and reasonable (UCR) fee-for-service (FFS) resource-based relative value scale (RBRVS) capitation.

CHAP TER 16

Coding and Insurance

239

14. DATE OF CURRENT: MM DD YY

03 20 09

ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP)

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. NT GIVE FIRST DATE MM IRST DD YY
17a. 17b. NPI

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

LOUISE RENSHAW MD

7690859444

FIG 16-9 Lines 17 and 17b from CMS-1500 form.

Usual, Customary, and Reasonable

The usual, customary, and reasonable (UCR) payment method is employed in some of the more expensive indemnity plans. It is based on prevailing rates determined by the insurance company. To determine these rates, the insurance company examines typical fees charged by physicians and other medical specialists in the same region or orders a study of a specic region to show the prevailing rates in that area.

a password, based on participation as a provider with the company.

Capitation
HMOs that offer capitation systems base payment to physicians on the number of patients who are signed up with the physician, called a panel. The insurance company pays the physician a set fee each month for each patient in the panel. This fee is referred to as the per member per month (PMPM) rate. For example, if a physician is the primary care physician for 2,500 patients enrolled with an insurance company, the insurance company will calculate a rate that ts the age and nature of the panel (depending on the history of usage, or claims, submitted by that group of patients and severity of illness in the patient base). So, if the insurance company agrees to pay the physician $12.85 per member each month, the physician will receive a at rate of $32,125 per month to provide care for all 2,500 patients. Thus, this system encourages physicians to be judicious when ordering diagnostic tests and treatments for patients. Although $32,125 per month may seem like a substantial sum of money, a physician who is not judicious will quickly lose money. An insurance company may pay for some services in addition to the PMPM rate. These services may include an annual physical and additional procedures that the physician has contracted to exclude from the PMPM rate, such as a primary care physician who also provides gynecological services.

Fee-for-Service
In the fee-for-service payment method, the insurance company looks at each line item submitted on the CMS-1500 claim form. It determines eligibility and makes payments for each line item based on an agreed-upon fee schedule (HMO rates) or on the UCR data that are available.

Resource-Based Relative Value Scale

Medicare uses the resource-based relative value scale (RBRVS) to determine payment to providers. An RBRVS system is made up of a set of formulas that take into account the resources needed to provide services. There are three factors considered in determining this need:

work necessary to provide the service expense incurred by the practice in relation to the service malpractice insurance expenses.

In addition, a geographical adjustment factor is included for each region. Medicare will supply the fee schedule for each procedure code, but that is only part of the system. The payment rules associated with RBRVS also include:

Payment Processing
Although some medical ofces may receive payments automatically (from the insurance company directly into the practices bank account), most ofces still process payments in the form of checks. Larger practices may use lock boxes that are arranged with a bank. The practice indicates payments should be sent to the lock box, and bank personnel deposit the checks and then send the explanation of benets (EOB) directly to the physicians ofce. (See Anatomy of an EOB, page 240.) Billing personnel in the medical ofce then post the payments to the patients accounts, following the itemized information on the EOB, called remittance advice. In addition to recording in the patients account any payments received, the medical assistant must apply any adjustments. Such an adjustment includes a contractual write-off, which is the difference between the amount billed by the physician and the amount allowed by the insurance

Medicare will allow a physician to bill for an evaluation on the same day as a major surgical procedure, but only if the claim includes the modier 57 with the evaluation procedure code. Medicare wont pay for supplies separately, because the value of most of these supplies has already been included in the RBRVS under the practice expense portion of the formula. The codes listed in the surgery section include references to the number of follow-up days included in the surgical procedure itself. The days listed will be 0, 10, or 90 days.

Many of the commercial (nongovernment) carriers have also used the RBRVS and adapted it by adding their own reimbursement rules. Rules for those insurance companies are outlined in the providers billing handbook, usually available on the companys website. Some of these sites require

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Anatomy of an EOB
Every health insurer is required to provide the subscriber with an explanation of benets (EOB), which outlines the response to medical claims led for reimbursement. The only exception to this rule is that health maintenance organizations (HMOs) are not required to provide an EOB to the patient for services provided by a participating provider who receives full reimbursement directly from the insurer. Even so, the HMO is required to provide an EOB for any payment if the patient requests it. The EOB must include: name of the service provider dates of service identication of the service by CPT-4 code providers charge amount or percentage payable after deductibles, copayment, and any other reduction of the amount claimed explanation of any reduction in or denial of reimbursement for the amount claimed telephone number or address where the insured person may obtain clarication information on how to le an appeal of a claim denial and a deadline for submission.

United Health Systems

United Health Systems 283 Commerce Park Drive PO Box 6978 Blueville, CT 06100 Claims 1-800-555-1212 EXPLANATION OF BENEFITS THIS IS NOT A BILL Patient name: Steven E. Muzinski United Health Systems ID# XGA00658 Group # 4388 Provider: Hector Rodriguez, MD NPI # 12244559988 Patient name Muzinski, Steven E. DOS 04/23/09 CPT 99215 Charge 95.00 Paid 80.00 Allowed 90.00 Code Pt res 10.00

Reason code

To file an appeal of a denial of a claim, send explanation to: UHS, Inc., Claims Department 283 Commerce Park Drive PO Box 6978 Blueville, CT 06100

CHAP TER 16

Coding and Insurance

241

company according to the contract. (See Why charge more?.) The billing staff must also apply copayments as well as any insurance deductibles. When the billing staff member nishes posting the payment and determines that all insurance companies have paid, she must bill the patient for any remaining balance.

Payment Denials and Appeals Process

Payment of a claim submitted by a medical ofce may be denied by an insurance carrier for many reasons. If the insurer denies a claim, that insurer must provide an appeals process. An appeals process involves an opportunity for the medical ofce to provide additional information regarding the claim to further support the medical necessity for the procedure. Commonly, the narrative notes of patient care will support the treatment and must be submitted to the insurance carrier. The medical assistant must read and refer to the EOB for the denial rationale in order to initiate the appeal process. (See Procedure 16-3: Communicating with a third-party payor, page 242.)

could be identified as fraud or abuse and the medical office may be forced to pay penalties to the insurance company. The U.S. Department of Justice denes health care fraud as the purposeful misrepresentation or misstatement regarding a medical services type, scope, or nature that could lead to incorrect payments made to the provider. Victims of health care fraud include private insurance companies as well as Medicare, Medicaid, workers compensation, and others. Examples of health care fraud include:

using another persons insurance card to obtain services changing dates of service to coincide with dates of insurance coverage soliciting or offering a kickback, such as payment for a referral of patients in exchange for ordering diagnostic tests or covered medical equipment coding more expensive procedures than those actually performed billing for services or equipment never provided separate bills for services that should be combined in one fee.

Fraud and Abuse

There are two forms of improper claims submission: fraud and abuse. Because the ultimate goal of billing and coding claims is to generate revenue, the medical assistant must be aware of the rules of compliance associated with claim submission. Every claim that leaves the physicians office should be a true, accurate reflection of the services provided to the patient. Claims that are coded improperly so that payment is too high can result in increased scrutiny by insurance companies, possibly inhibiting timely payment on all claims. Alternatively, such improper coding

Medicare denes abuse as reimbursement for services where medical necessity is not established. It is not necessarily an intentional act. Examples of insurance abuse include:

upcoding, in which the severity of the diagnosis is exaggerated in order to support the CPT-4 code. (The physician or coder may not realize that a lesser diagnostic code would be more appropriate.) services provided in excess of medical need, such as repeated reevaluations or excessive physical or occupational therapy treatments. (The provider or coder does not necessarily know that the charges are excessive.)

Penalties for fraud and abuse can be imposed on the medical practice by the insurance carrier that made excessive

Why charge more?

Physicians ofces can choose to charge whatever they want for a service, but insurance companies decide what amount they will pay. For example, if a physician charges $100 for a vitamin B12 injection, but Medicare allows only $60 for the injection, Medicare will pay 80% of $60 (or $48). The patient or the patients secondary insurance will pay $12 (the remaining 20% of the $60 approved by Medicare). A Medicareparticipating physician is not allowed to bill the patient the remaining $40, and must write off the balance. So why do physicians ofces bill at the higher price? Physicians are obligated to bill a service at the same price to all patients. Another insurance company may pay $75 for the same B12 injection, while yet another may allow $80. If the physician charged only the $60 price approved by Medicare, he would lose money by discounting the service to companies that allow a higher reimbursement for that service. In addition, if a physicians ofce were to charge varying prices based on the insurance company billed, billing could become very complicated. The medical assistant creating the claims would have to keep up with any changes in allowed charges for all insurance companies. So, to simplify the process, most ofces charge a little more than the highest allowed reimbursement for that service across all insurance companies with which they have contracts.

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PROCEDURE 16-3

Communicating with a third-party payor

Task Write a letter to a third-party payor requesting an appeal for a denied claim. Conditions Patient medical record CMS-1500 claim form sent to third-party payor for payment Denial notication from third-party payor Ofce letterhead Computer Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully write a letter of appeal for payment of a denied claim. Performance Standards 1. Read information from the patients medical record (below) so that you can understand the claim completely.
Date 03/24/09; 11:15 a.m. Pt complains of neck pain, stiffness, sensitivity to light, and severe right-sided temporal pain. She has been unable to sleep due to pain, did not go to work yesterday or today. Ibuprofen, Tylenol offer limited relief. Points stimulated w/ES- GB 20, GB 21, B11, Si 13, Liv3, Li4, H9, Gv20, Li 18 -- for 20 minutes. Pt states pain and sensitivity to light decreased immediately. Tx plan 2x per week for 4 weeks, then re-eval. -------- Henry Lee, MD Pt states that she was able to sleep for the past 2 nights, head pain reduced from 10 to 6 on 10 scale. Went to work today, by the end of the day experienced light sensitivity Tx as 3/24 ------------------------ Henry Lee, MD Pt states pain at 6 on 10 scale, she drank wine last night and headache increased. Suggested no alcohol until pain subsides. Tx as above, increased sensitivity at Liv3 ------------------------------------------------------------ Henry Lee, MD Pt states no change in symptoms, Tx as above ------------------------------------------------------------------ Henry Lee, MD Pt states pain 4 on 10 scale, sleeping better, went to gym today, feeling well, Tx as above ---------- Henry Lee, MD

2. Reread the CMS-1500 form originally submitted (below) to check for errors. 3. Read the denial notication on the explanation of benets (below). 4. Compose a letter requesting payment of the claim based on medical necessity as proven by the patients medical record. Be sure to refute the reasons given for denial of the claim. 5. Reprint the CMS-1500 form because the insurance company will only accept an original form when receiving a resubmitted claim. 6. Sign the letter and submit it to the insurance company (your instructor).

03/26/09; 11:30 a.m.

03/30/09; 9:15 a.m.

04/02/09; 4:00 p.m. 04/06/09; 4:30 pm

United Health Systems

ID#: XGA00778 Name: CARA COHELO Copays: $5 OV $10 CHIRO $50 ED Group #: 4488

Visit us at: www.UHSystems.com Member services 1-800-800-1767 Network provider services 1-800-800-1777 Out of network providers 1-800-800-1799 For medical emergencies, please dial 911 or go to the nearest emergency room. Please contact your PCP or member services within 24 hours. For all other care, please contact your PCP. Refer to your benefit package for coverage descriptions. Mail Claims to:

RX:

$5

UHS, Inc., Claims Department 283 Commerce Park Drive Blueville, CT 06100

UHS rev 12/08

CHAP TER 16

Coding and Insurance

243

PROCEDURE 16-3contd

CONFIDENTIAL PATIENT INFORMATION

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CT 860-555-3212 Name Cara Cohelo Address 127 West Road Home phone 123-8888 Insured name self Insured employer Aloisio Advertising Associates Insurance carrier United Health Systems HEALTH HISTORY Have you ever suffered from: Asthma Fainting Diabetes Anxiety High blood pressure Bleeding disorder X Migraine headaches Constipation Fatigue X Stress Cancer (If so, what kind?) Date of birth 6/21/1984 City Presley, CT Cell phone 203-111-2223 Insured date of birth 6/21/1984 Employer address 33 Park Ave, ID# XGA00778 Full time student Yes

X No

Relationship to patient

Presley, CT
Group #

self

4488

Muscle weakness Difficulty sleeping Allergies X Stomach upset Mental disorder

Lower back pain Difficulty swallowing X Neck pain or stiffness Diarrhea Infection

none

Chronic pain (If so, where?)

neck and right shoulder

FAMILY HISTORY Cancer (Who?) X High blood pressure (Who?) grandmother Diabetes (Who?) grandfather MEDICATIONS AND SUPPLEMENTS

What type?

Do you take any medications? Do you take any nutritional supplements? If so, please list (include dosages): If so, please list: _____________________________________________ ________________________________________________________ Clarinex, not every day Fem essentials (multi) _____________________________________________ ________________________________________________________ Ibuprofen occasionally for headaches _____________________________________________ ________________________________________________________ _____________________________________________ ________________________________________________________ _____________________________________________ ________________________________________________________ REASON FOR TODAYS VISIT Check up Physical for school, sports, or employment X Other (please explain) severe headaches Women only Date of last menstrual period Number of pregnancies 0 Number of children 0

03/14/09
Miscarriages? 0 Difficult or painful menstruation?

sometimes

Men only Have you ever had erectile difficulty? Do you get up at night frequently to urinate?

Prostate problems?

I understand that Blueville Family Medicine will file my insurance for payment of services rendered. I also understand that I am responsible for any amount due Blueville Family Medicine if my insurance is denied. Signature of patient or guardian Relationship to patient Robert Greer, MD Sharon Piecek, APRN Hector Rodriguez, MD Henry Lee, MD Anne Wilson, MD Continued

Cara Cohelo

Date

03/27/09

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PROCEDURE 16-3contd

HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA 1. MEDICARE MEDICAID TRICARE CHAMPUS (Sponsors SSN) CHAMPVA GROUP HEALTH PLAN (SSN or ID) FECA BLK LUNG (SSN) SEX M F OTHER 1a. INSUREDS I.D. NUMBER PICA (For Program in Item 1)

(Medicare #)

(Medicaid #)

(Member ID#)

(ID)

XGA00778
4. INSUREDS NAME (Last Name, First Name, Middle I le Initial)

2. PATIENTS NAME (Last Name, First Name, Middle Initial)

COHELO CARA M
5. PATIENTS ADDRESS (No., Street)

3. PATIENTS BIRTH DATE MM DD YY

06 21 1984 X
Spouse

COHELO CARA M
7. INSUREDS ADDRESS (No., Street)

6. PATIENT RELATIONSHIP TO INSURED Self STATE Child Other

127 WEST ROAD

CITY

127 WEST ROAD PRESLEY

ZIP CODE

PRESLEY
ZIP CODE

CT
TELEPHONE (Include Area Code)

Single

X X

Married Full-Time Student

Other Part-Time Student

CT
TELEPHONE (Include Area Code)

06100

( 860 )

123 8888

Employed

06100 4488

( 860 )

123 8888

9. OTHER INSUREDS NAME (Last Name, First Name, Middle Initial)

10. IS PATIENTS CONDITION RELATED TO:

11. INSUREDS POLICY GROUP OR FECA NUMBER

a. OTHER INSUREDS POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous) YES

X X X

REDS a. INSUREDS DATE OF BIRTH MM DD YY

SEX M F

NO PLACE (State) NO

b. OTHER INSUREDS DATE OF BIRTH MM DD YY M c. EMPLOYERS NAME OR SCHOOL NAME

SEX F

b. AUTO ACCIDENT? YES c. OTHER ACCIDENT? YES

06 21 1984

b. EMPLOYERS NAME OR SCHOOL NAME

ALOISIO ADVERTISING ASSOCIATES

c. INSURANCE PLAN NAME OR PROGRAM NAME

NO

UNITED HEALTH SYSTEMS

PLAN? d. IS THERE ANOTHER HEALTH BENEFIT P
YES

d. INSURANCE PLAN NAME OR PROGRAM NAME

10d. RESERVED FOR LOCAL USE E

NO

If yes, re s return to and complete item 9 a-d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment y below. SIGNED

PERSONS SIGNATURE I authorize 13. INSUREDS OR AUTHORIZED P payment of medical benefits to the undersigned physician or supplier for services described below.

SIGNATURE ON FILE
ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP)

DATE

SIGNED

SIGNATURE ON FILE

14. DATE OF CURRENT: MM DD YY

03 20 09

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIE NT PATIENT UNABLE TO WORK IN CURRENT OCCUPATION DD YY MM MM DD YY GIVE FIRST DATE MM IRST DD YY TO FROM
17a.
17b. NPI

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

LOUISE RENSHAW MD
19. RESERVED FOR LOCAL USE

7690859444

HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 18. HOSP MM DD YY MM DD YY FROM TO F 20. 2 OUTSIDE LAB? YES $ CHARGES NO

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line) Relate 1.

346.01

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER

3.

MM

DATE(S) OF SERVICE From To DD YY MM DD

YY

B. C. PLACE OF SERVICE EMG

E. DIAGNOSIS POINTER

F. $ CHARGES

DAYS OR UNITS

G.

EPSDT ID. Family Plan QUAL.

H.

I.

J. RENDERING PROVIDER ID. #

1 2 3 4
5

03 27 03 29 04 01 04 04 04 06

09 09 09 09 09

03 27 03 29 04 01 04 04 04 06

09 09 09 09 09

11 11 11 11 11

97813 97813 97813 97813 97813

1 1 1 1 1

65.00 65.00 65.00 65.00 65.00

1 1 1 1 1

NPI

NPI

NPI

NPI

NPI

6
25. FEDERAL TAX I.D. NUMBER AL SSN EIN S 26. PATIENTS ACCOUNT NO. 27. ACCEPT ASSIGNMENT?
(For

NPI
govt. claims, see back)

28. TOTAL CHARGE $

29. AMOUNT PAID $

30. BALANCE DUE $

865623498

1296

YES

NO

325 00

31. SIGNATURE OF PHYSICIAN OR SUPPLIER EES INCLUDING DEGREES OR CREDENTIALS me (I certify that the statements on the reverse apply to this bill and are made a part thereof.)

32. SERVICE FACILITY LOCATION INFORMATION

33. BILLING PROVIDER INFO & PH #

SIGNATURE ON FILE
SIGNED DATE a.

NPI

b.

HENRY LEE MD 15 MAIN STREET BLUEVILLE CT 06100 a. 8700334239 b. NPI

( 860 ) 555

325 00 3212

NUCC Instruction Manual available at: www.nucc.org

PLEASE PRINT OR TYPE

APPROVED OMB-0938-0999 FORM CMS-1500 (08-05)

PHYSICIAN OR SUPPLIER INFORMATION

2. 24. A.

4. SUPPLIES D. PROCEDURES, SERVICES, OR SUP (Explain Unusual Circumstances) MODIFIER CPT/HCPCS MODI

PATIENT AND INSURED INFORMATION

8. PATIENT STATUS

CITY

STATE

CARRIER

1500

CHAP TER 16

Coding and Insurance

245

PROCEDURE 16-3contd

United Health Systems

United Health Systems 283 Commerce Park Drive PO Box 6978 Blueville, CT 06100 Claims 1-800-555-1212 EXPLANATION OF BENEFITS THIS IS NOT A BILL Patient name: Cara Cohelo United Health Systems ID# XGA00778 Group # 4488 Provider: Henry Lee, MD NPI # 8700334239 Patient name Cohelo, Cara Cohelo, Cara Cohelo, Cara Cohelo, Cara Cohelo, Cara Reason code A12 further documentation needed to process claim To file an appeal of a denial of a claim, send explanation to: UHS, Inc., Claims Department 283 Commerce Park Drive PO Box 6978 Blueville, CT 06100 DOS 03/27/09 03/29/09 04/01/09 04/04/09 04/06/09 CPT 97813 97813 97813 97813 97813 Charge 65.00 65.00 65.00 65.00 65.00 Paid 0.00 0.00 0.00 0.00 0.00 Allowed 0.00 0.00 0.00 0.00 0.00 Code A12 A12 A12 A12 A12 Pt res 65.00 65.00 65.00 65.00 65.00

payments. Penalties can include revocation of participating provider status (HMO) or participating physician status (Medicare, Medicaid, Tricare). Other penalties include recovery of overpayments and withholding of pending payments. In cases of fraud, where intentional misrepresentation is evident, criminal prosecution and jail sentences are possible.

Chapter Summary

Because health insurance products vary, the medical assistant must be aware of the various products and be aware of changes to policies.

There are various forms of payment to physicians for services, including fee-for-service, UCR, RBVS, and capitation. Gathering demographic information from a patient at the rst visit is necessary for complete claims submission. A patient can elect to self-pay upon arrangement with the physician. Medicare patients electing to self-pay for an uncovered procedure must sign an advance beneciary notice (ABN) before receiving care. Copayments, where applicable, should be collected prior to patient examinations. Coding procedures and diagnoses are learned skills that require the medical assistant to understand coding procedures and be aware of coding changes.

246

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The medical assistant must be able to include referral information on CMS-1500 forms for specialist payment when specialty care requires a referral. If claims for payment are denied, the medical assistant can appeal the decision by providing further documentation to support the need for services. Fraud and abuse are the intentional or unintentional coding of claims for excessive payment. The medical assistant must have a working understanding of current codes to avoid coding in error. Fraud can be prosecuted with civil and criminal penalties; abuse can be prosecuted with civil penalties.

Case Studies
1. Leona Jensen has been a patient for many years. She has just turned 65 years old and has retired from her job as a police dispatcher. She comes in for a visit to see Dr. Rodriguez. What information should you obtain from Mrs. Jensen? 2. Ralph Sawyer, a 38-year-old construction worker who was injured at work, calls the ofce. He tells you that he must return to work because his compensation benets are not enough for his family to live on and his wife recently lost her job. He has been out of work for the past 2 weeks, and his salary benets from workers compensation have yet to arrive. He is agitated and tells you that he is behind in paying his mortgage. He is scheduled to see Dr. Greer tomorrow. What should you tell Ralph?

Team Work Exercises

1. Divide into groups of four to six students each. Each group must choose one type of medical ofce: a. pediatrics b. obstetrics and gynecology c. family practice d. orthopedics e. dermatology f. cardiology. Each group must create a superbill for their practice, including the procedures and diagnoses that the group thinks are most commonly used. Using the CPT-4 and ICD-9-CM coding texts, nd the codes to include on your superbill. Ask the other groups to comment on your choices. 2. Divide into teams of six to nine students. Each team must create a computer or poster presentation on one of the following topics and present it to the class: a. life cycle of an insurance claim b. steps for coding a procedure c. steps for coding a diagnosis d. response to denied claims.

Resources

American Academy of Professional Coders: www .aapc.com American Health Information Management Association: www.ahima.org CMS programs and information: www.cms.gov Complete U.S. Government rules for HSAs: www.treas .gov/ofces/public-affairs/hsa/pdf/all-about-HSAs_051807.pdf Healthcare Billing and Management Association: www .hbma.com Medicaid eligibility: www.cms.hhs.gov/MedicaidGenInfo Professional Association of Health Care Ofce Management: www.pahcom.com Types of managed care: www.sbhcs.com/hospitals/ monmouth_medical/managed/types.html

CHAPTER

Billing and Collections

Learning Objectives
After reading this chapter the student will be able to: dene the key terms presented in the glossary explain the importance of timely billing and collections in the physicians ofce list the key components of a patient statement describe monthly and cycle billing describe the various options for collecting overdue accounts apply HIPAA principles to billing and collections. General Competencies Patient Instruction
Explain general ofce policies

17
Billing Procedures
Aging of Accounts Computerized Billing and Account Transactions Monthly and Cycle Billing Monthly billing Cycle billing

ABHES Competencies
Administrative Duties
Perform billing and collection procedures

Credit and Collections

Policies and Procedures Extending Credit Collections Collection strategies Telephone collections Collection agency

Instruction
Orient patients to ofce policies and procedures

Procedures
Explaining ofce nancial policies to a patient Creating a collection letter

CAAHEP Competencies
Administrative Competencies Perform Bookkeeping Procedures
Perform accounts receivable procedures Perform billing and collection procedures

Chapter Outline
Patient Billing Determination of Fees
Explaining Fees to the Patient

Chapter Summary Team Work Exercises Case Studies Resources

247

Key Terms
aging accounts

Patient Billing
Billing patients in an ambulatory setting is a necessary task of the administrative medical assistant. Effective billing practices promote a healthy cash flow, the amount of money a business must maintain to ensure that patients can be cared for and overhead expenses and salaries can be paid. While most offices are now computerized, some may still use a manual, or pegboard, system. Regardless of the billing system, accurate, timely billing promotes trust and understanding among staff, patients, and physicians.

Method used to identify how long an account is overdue

cash ow

Amount of available cash that a business maintains to cover expenses

collection agency

Business that recovers bad debts for a percentage of the debt or a xed fee
copayment

Amount of money a patient pays out-of-pocket for each ofce visit

cycle billing

Method of billing that divides patients into groups to which billing statements are mailed at various times throughout the month
monthly billing

Determination of Fees
Providers of health care have many different arrangements with insurance carriers regarding the determination of fees. Providers within an HMO network agree to a fee schedule of services and how much (if any) money can be collected directly from the patient in the form of a copayment, or copay. Providers outside of an HMO network may receive a reduced portion of the total fee or no fee at all from the insurance carrier. However, they may bill the patient for the remaining balance.

Method of billing in which all patients are mailed billing statements on the same date, usually the rst of the month

Explaining Fees to the Patient

Comprehensive communication and understanding of fees between staff and patients will encourage timely payments. It is the responsibility of the administrative medical assistant to explain to the patient:

which portion of the total bill the patient is responsible for and when this money is due when ofce charges are owed and how much is owed fees charged for missed appointments, telephone consultations, copying of reports, and other charges that the patient may be unaware of.

The medical assistant can use various tools to help explain these fees and policies. She can refer to a brochure that outlines the nancial policies of the ofce. (See Figure 17-1.) To explain insurance charges, many ofces have a chart at the front desk that shows the names of various insurance plans with their respective copayment amounts, covered services, and exclusions. (See Figure 17-2.) From this chart, the medical assistant can compile and provide a brief outline of the covered services to a patient for clarication. (See Figure 17-3.) The medical assistant can refer to the chart when speaking to a patient on the phone or in person. (See Procedure 17-1: Explaining ofce nancial policies to a patient, page 251.)

CHAP TER 17

Billing and Collections

249

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CONNECTICUT 06000 860-555-3212

Robert Greer, MD Family Medicine Hector Rodriguez, MD Family Medicine Anne Wilson, MD School and Sports Physicals Sharon Piecek, APRN Nutritional Counseling and Weight Loss, Diabetes Management Henry Lee, MD Acupuncture

Blueville Family Medicine Financial Policies Copayments Copayments are due at time of visit. Please come to your appointment with your copayment in cash, a personal check, or credit card. Returned check policy A charge of $20 will be incurred for any check returned for insufficient funds in addition to any charges from the bank. The office reserves the right to deny checks from patients who have had returned checks previously. Lack of health insurance If you have little or no health insurance, you can speak with Dr. Rodriguez or Kelly Manera in the billing department about an affordable monthly payment schedule. Past-due bills Bills are considered past-due after 30 days of nonpayment. The office bills patient balances each month. Bills that are 90 days late are sent to a collection agency.

FIG 17-1 Ofce nancial policies brochure.

Billing Procedures
Adequate cash ow in the physicians ofce depends on accurate, timely billing practices. If the total amount of unpaid patient balances increases over time, the practice may not be able to meet the costs of running the ofce. Physicians ofces usually bill a patients insurance company rst, while the patient pays only a copayment at the time of the

visit. After the ofce receives reimbursement from the insurance company, it balance bills the patient, that is, bills for the outstanding balance of unpaid charges.

Aging of Accounts
Aging of accounts begins when the patient receives the first bill. The first bill the medical office sends to a patient is considered new. It does not age until it remains unpaid

250

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Administrative

Insurance plan

Copay

Covered services OV, X-rays, Mamm, PAP, Well Child, UA, Hct, Immunizations, TC OV, X-rays, Mamm, PAP, Well Child, UA, Hct, Immunizations, TC OV, X-rays, Mamm, PAP, Well Child, UA, Hct, Immunizations, TC OV, X-rays, Mamm, PAP, Well Child, UA, Hct, Immunizations, TC OV, X-rays, Mamm, PAP, Well Child, UA, Hct, Immunizations, TC

Exclusions/limitations

Blue Cross & Blue Shield POE

$5

1 checkup per year

Blue Cross & Blue Shield POS

$10

2 checkups per year

HealthNet

$10

Need referral for x-ray; 1 checkup per year

Physicians Health Network

$15

1 checkup per year

Carpenters Health Fund

$10

Will pay for ultrasound breast examination in lieu of mammography with Rx from physician

FIG 17-2 Insurance plans and patient fees chart.

Blueville Family Medicine

15 Main Street Blueville CT Your copayment for office visits is $5

860-555-3212 ask for Kelly Manera for billing inquiries

Your plan is: Blue Cross & Blue Shield POE (Point of Enrollment)

Your plan covers office visits (2 checkups per year), mammography, pap smears, urinalysis, routine immunizations, and throat cultures. X-rays and most blood tests that we run in the office are covered. If you need to see a specialist, we will write the appropriate referral form but it is your responsibility to confirm coverage of services with the specialist.

FIG 17-3 Outline of covered services.

for 1 month. If the patient does not pay the bill within the first month, it is considered 30 days old. If the office bills each month, bills can age from 30 days to 60 days and even 90 days and beyond. In general, the longer a patient does not pay a bill, the greater the likelihood that he will never pay it.

patient bills. As with a manual billing system, a computerized patient bill should include:

Computerized Billing and Account Transactions

A vast array of computer software is available to help run a medical ofce. Most of these software packages can generate

patients name and address insurance plan name, identication number, and plan code dates of service description of services (in words as well as codes) payment made by the insurance company (received or pending) amount due from the patient instructions on how to submit payment, including the address of the practice.

CHAP TER 17

Billing and Collections

251

PROCEDURE 17-1

Explaining ofce nancial policies to a patient

Task Explain the ofce nancial policies to a new patient Conditions Ofce brochure Financial policies document Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully explain the nancial policies of the ofce to the patient as outlined in the nancial policies document. Performance Standards 1. Introduce yourself to the patient and ask her to read the ofce nancial policies brochure. 2. Ask the patient if she has any questions regarding the ofce policies listed in the brochure to ensure understanding. 3. Ask the patient to sign the nancial policies document (below) to document patients understanding of nancial policies. 4. Place the signed nancial policies document in the patients medical record to provide a record of the patients understanding of nancial policies.

Financial Policies Statement

I, , have read and understand Blueville Family Medicines financial policies as outlined in the office brochure.

The ofce can generate bills according to the patients last name, physician, account number, or other identifying information. The method used is signicant because it could dictate when the ofce can send patient bills. The medical assistant can record payments in the computerized system by inputting the patients name and the amount of the payment. If a patient makes a partial payment, recording the payment will ensure that the next months bill reects the new balance. Recording these account transactions provides a complete record of payments received.

and mailing statements are generally accomplished in an afternoon or a day. The schedule of the billing staff must accommodate the task of sending out all of the bills. A medical assistant who normally works on insurance claims or telephoning insurance companies for payment may suspend these activities to devote time to billing patients. Monthly billing is sometimes generated and mailed on the 26th or 27th of each month so that patients receive billing statements on the 1st or 2nd of the next month.

Monthly and Cycle Billing

A medical ofce commonly determines when to generate and send bills to patients based on the size of the practice and the schedule of the billing staff. The two most common billing systems are monthly billing and cycle billing.

Cycle Billing
A larger practice may use a cycle billing system, which divides patient bills throughout the month. Because the practice needs a printer to generate the bills, dividing monthly billing into smaller, more frequent batches can free printers for other tasks throughout the day. Systems for cycle billing can vary and include:

Monthly Billing
Monthly billing is a system of generating bills for all patients at the same time each month. Such a system is convenient for a small practice. In a monthly billing system, billing

dividing patient accounts by an alphabet system: bill patients with last names beginning with A to F in week 1

252

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Administrative

bill patients with last names beginning with G to L in week 2 bill patients with last names beginning with M to R in week 3 bill patients with last names beginning with S to Z in week 4 dividing patients by physician: bill for physician 1 in week 1 bill for physician 2 in week 2 bill for physician 3 in week 3 bill for physician 4 in week 4 dividing by account numbers: bill even account numbers in week 1 bill odd account numbers in week 2 dividing by ofce location (for large practices with multiple locations).

Front ofceBack ofce connection

Answering Billing Questions

Most commonly, the administrative medical assistant answers a patients billing questions. However, a patient may ask a clinical medical assistant about a bill while in the examination room. Thus, the clinical medical assistant should have an understanding of the payment policies of the ofce. Clinical medical assistants should ask the billing personnel how to read the various documents, such as explanations of benets (EOBs) from insurance companies and statements generated from the ofce. The clinical medical assistant should be able to answer patient billing questions as they arise.

A good credit and collection policy will address: How is credit extended to a patient? The ofce manager or physician may arrange a credit extension to patients or develop a minimum monthly payment system for a patient with high balances. When are payments due from the patient? Copayments may be due at each visit. For frequent visits, the ofce and patient may agree upon a maximum outstanding copayment balance. What types of payments are accepted? Cash and personal checks are the most common forms of payment from patients. Some ofces accept credit cards. If a patient pays with cash, the medical assistant should give the patient a receipt for his records. (See Figure 17-4.) When is a patient balance considered overdue? An ofce can conduct account aging in 30-, 60-, and 90-day increments, with a bill generated each month to the patient. The ofce can print past-due messages on bills to prompt patient payment. (See Figure 17-5.) How will patients be reminded of overdue accounts? In addition to the past-due message on printed patient bills, the office may contact the patient by letter or phone. In a collection letter, the medical assistant should use language that is firm, yet polite. If the account is only 30 days overdue, the medical assistant should refrain from mentioning a collection agency, because it is possible that the patient will make some sort of payment arrangement. If a patient has ignored a bill for 90 days, however, the medical assistant should consider his account as more likely to be sent to the collection agency. (See Figure 17-6.) Depending on the office policy, accounts that are 90 or 120 days past due are usually considered for collection proceedings. (See Procedure 17-2: Creating a collection letter, page 256.)

Whatever cycle billing system is used, the billing staff must know when patients have received bills in order to accomplish accurate account aging. If the patient fails to pay the balance of the bill within 30 days, it may be considered late. Office policies regarding overdue accounts vary.

Credit and Collections

Unfortunately, sometimes a patients clear understanding of a balance due does not prompt payment. If a patient ignores a bill, the practice may use a collection agency, which is a business hired by the practice to recover bad debts, that is, to collect on overdue accounts. Other times, a patient is temporarily unable to pay the bill because of his own cash ow issues. In such a case, the practice may choose to extend credit to the patient.

Policies and Procedures

Policies and procedures for extending credit and collecting debts should be established by the physician employers or office manager. The role of the administrative medical assistant is to enforce the policies as directed by the physicians or management. Even so, all members of the health care team should be able to assist patients with basic billing questions. (See Answering billing questions.) The medical assistant may be required to write a letter asking for payment to avoid collection proceedings. Established guidelines for credit and collections enables the medical assistant to deal confidently with a patient regarding past-due balances.

CHAP TER 17

Billing and Collections

253

03101 BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CONNECTICUT 06000 860-555-3212 Received from: Amount:

Date:

January 28, 2009

Sandy Chen $ 10.00 dollars

check number

cash

check

Signed

C. Smith, CMA

03102 BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CONNECTICUT 06000 860-555-3212 Received from: Amount:

Date:

cash

check

check number

Signed

03103 BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CONNECTICUT 06000 860-555-3212 Received from: Amount:

Date:

cash

check

check number

Signed

FIG 17-4 Cash receipt.

Extending Credit
Physicians may provide special arrangements for patients with nancial difculties or give professional courtesy discounts to colleagues. Patients who cannot pay copayments or pay for uncovered services may reach an agreement with the physician to pay a reduced rate or use a prolonged schedule of payments. Although rare, a physician may agree to a barter system with a housecleaner or lawn care provider or for other services the physician can use to offset the unpaid charges.

Collections
There are numerous ways to collect payment for services provided. Many involve making the payment process as immediate or easy for the patient as possible. Sometimes, however, notifying the patient of a past-due balance is best done over the phone.

Collection Strategies
The best way for a medical ofce to avoid the stress of collecting on overdue accounts and having to confront angry

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Administrative

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CONNECTICUT 06000 860-555-3212

IF THIS BILL IS NOT PAID WITHIN 15 DAYS OF RECEIPT, IT WILL BE TURNED OVER TO ABC COLLECTION AGENCY.

Austin McNally 122 Mason Road, Apt #17 Blueville, CT 06100

Date 12/07/07 01/22/08 01/30/08 02/24/08 02/01/08 03/01/08 04/01/08

Service office visit Health Services check acupuncture & ov Health Services check patient billed patient billed patient billed

Charge 85.00 0.00 150.00 0.00 0.00 0.00 0.00

Paid 0.00 72.00 10.00 80.00 0.00 0.00 0.00

Balance 85.00 13.00 153.00 73.00 73.00 73.00 73.00 PLEASE PAY THIS AMOUNT.

FIG 17-5 Past-due message on a patient bill.

patients is to collect money owed as soon as possible. Bills that are not overdue do not cause stress for the patient or the staff. One way the medical assistant can obtain prompt payment is to ask the patient how she will be paying, not if she will be paying. For example, at the front desk, the medical assistant says, Ms. Clifford, your copayment today is $15; will you be paying with cash or check? In this statement, the medical assistant does not offer the patient the option of not paying. Another strategy is to include a return envelope with every bill when mailing bills to patients. If the ofce includes an addressed envelope with the bill, it is easier for the patient to write the check and simply place it in the envelope. Some ofces will actually stamp the return envelope in an effort to increase collections. However,

including a stamp in every bill is costly, so ofces should use this strategy sparingly.

Telephone Collections
Calling patients with past-due accounts can be stressful but is commonly effective. A patient who is experiencing nancial problems may be embarrassed about the status of her account. Another patient may have simply forgotten to pay or thought he mailed a check. These patients are commonly eager to explain their circumstances and come to an amiable resolution. If a patient is unwilling or unable to pay, however, he may become rude or even verbally abusive. Regardless of the patients demeanor, the administrative medical assistant must remain respectful and courteous. She should never

CHAP TER 17

Billing and Collections

255

DICINE MILY ME VILLE FA TREET BLUE S 6000 15 MAIN TICUT 0 ONNEC VILLE, C -3212 BLUE 860-555

February

5, 2 0 0 6

Jones Ms. Lynn treet Main S 123 , CT Blueville D e ar M s If you are e g overdue. 30 days that we can arran is now $ 203.45 t me so 555 -1444. I look contac o u nt of Your acc ay in full, please n be reached at p nable to of payments. I ca u le a schedu your call. forward to . J o nes, , Sincerely

er Kelly Man

nera Kelly Ma ager n illing Ma B

BLUE
April

BLUE

3 , 20 06 M s. Lynn 123 Jone M Blue ain Stre s ville, e CT t D e ar M s. Jone s, Your ac c o requ unt w e to re sts for p ith our o a a your ch you b yment h f fice is 9 0 av bala y tele pro c nce pho e been days pa o e at 55 edings. f $ 203.4 ne to dis ignored. st due. P I c 5 r 5 -14 44. f you hav by April uss this I have be evious m e an Sinc y qu 20 th to a at ter. P en unable erely estio le v , ns, p oid colle ase pay lease ction Kelly c o nt M an e ac t m ra e Kelly M an Billin g M a era n ag e r

VILL EF 15 M AMILY M AIN ED VILL E, CO STREE ICINE T NNE C 860555- TICUT 0 3212 6000

FIG 17-6 Examples of collection letters.

256

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Administrative

PROCEDURE 17-2

Creating a collection letter

Task Create a collection letter for a past-due account. Conditions Record of patients account Computer Ofce letterhead Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully create a letter to a patient regarding his past-due account. Performance Standards 1. Refer to the patients nancial account (below) to see how old the account is and how much the patient owes. 2. Determine the appropriate collection agency to use (as provided by your instructor or using your local telephone book). 3. Compose a letter to the patient, explaining that his account will be sent to the collection agency (use name in letter) if it remains unpaid. 4. Make a copy of the letter and place it in the patients medical record to provide a record that the notice of collection was sent to the patient.

Henry Paulson 22 Pinecrest Lane Blueville, CT April 12,2007 April 19, 2007 May 11, 2007 May 22, 2007 June 8, 2007 July 1, 2007 August 1, 2007 August 20, 2007 September 1, 2007 September 18, 2007 October 1, 2007 November 1, 2007 December 1,2007 January 2, 2008 February 1, 2008 March 3, 2008 April 1, 2008 OV, stress test payment personal ck Ins payment OV, med ck Ins payment Patient billed payment personal check OV, x-ray, meds Patient billed Insurance no pay, patient called Patient billed Patient billed Patient billed Patient billed Patient billed Patient billed Patient billed
called pt he will send payment this month called pt he will send payment this month called pt he will send payment this month

140.00 10.00 110.00 85.00 60.00

140.00 130.00 20.00 105.00 45.00

20.00 330.00

25.00 365.00 365.00 365.00 365.00 365.00

payment 20.00 called pt no answer called pt no answer called pt no answer

345.00 345.00 345.00 345.00

CHAP TER 17

Billing and Collections

257

threaten a patient with collection proceedings over the phone; this information must always be conveyed in writing. If the patient is abusive or threatening, the medical assistant must notify the physician or ofce manager of the patients behavior. She should also document the phone call and the patients comments in the patients medical record. Financial matters require the same privacy protection as any medical information. The medical assistant should place collection calls in a private area of the ofce to ensure the condentiality of the call. She should also refrain from discussing specic patient nancial situations with anyone who does not need to know. Finally, she must always document collection calls in the patients le.

policies. Create an informational brochure for an ofce that outlines the patient responsibility for ofce visits, routine physicals, mammograms, ECGs, well-child visits, and global surgical packages. Post the brochures in the classroom and discuss your ndings with the class. 2. Divide into groups of three to ve students. Discuss ways that you might increase patient payments in the medical ofce. What strategies have you seen employed by your own physicians ofce? Which ones do you think work, and which do not? Create some guidelines for an ofce based on your discussion. A representative from each group must present the top four strategies for collections that the group feels are most effective.

Collection Agency
A medical ofce can hire a private collection agency to recover past-due payments for a at fee or a percentage of the recovered amount. Therefore, the ofce should consider referring only large accounts when hiring a collection agency because the agency charges a minimum fee for its services. In addition, sending a patients account to collections inhibits a full and open physicianpatient relationship that is essential for proper patient care. Thus, the medical assistant should always consult with the physician or ofce manager before initiating collection proceedings. When an ofce is considering collections for a patient account, the medical assistant should mail a nal warning to the patient stating that the delinquent account will be sent to collections if no payment is received within a given time period. Because collection proceedings impact credit ratings, this notice will usually prompt the patient to pay the pastdue amount before her credit is affected.

Case Studies
1. Lynn Jones has a 90-day past-due account with the ofce. On the phone, she states that she is unable to pay because she is going through a divorce and has yet to collect any child support from her ex-husband. Later the same week, you see Lynn at your hairdressers getting an expensive manicure and acrylic nail set. What should you do? What are the appropriate places to discuss Lynns overdue account? 2. Mr. Wallace is a retired brick mason who comes into the ofce for his physical. He is a great guy and the ofce staff and physicians all enjoy seeing him. He tells you that he forgot his $10 copayment but he brought in a bag of tomatoes from his garden. He asks that you forgive the copayment. What should you do?

Resources

Chapter Summary

Effective billing practices in an ambulatory setting promote healthy relationships between patients and the ofce staff. Consistent, effective billing ensures proper patient care and prompt payment of ofce expenses, such as employee salaries. Billing systems require accuracy and consistency, yet leave room for special arrangements as needed. The medical assistant may contact a patient with a delinquent account by letter or telephone. She must always document such contact with the patient.

Information for patients on understanding medical bills: www.aafp.org/fpm/20040300/monitor_boxc.html Collection agencies: www.bad-debts.net, www .collectionscheap.com, and www.abccompanies.com Caplan, S.: Streetwise Credit and Collections: Maximize Your Collections Process to Improve Your Protability. Avon, MA: Adams Media Corporation, 2007. Stanley, K. (ed.): Maximizing Billing and Collections in the Medical Practice. Chicago: AMA Press, 2007. HCPro (Firm) Staff: Improve Billing and Collections: Get the Money You Deserve Now. Marblehead, MA: HCPro, 2006.

Team Work Exercises

1. Divide into teams of four to six students. Research local insurance carriers and their copayment and payment

CHAPTER

Accounting and Banking

Learning Objectives
Upon completion of this chapter, the student will be able to: dene key terms presented in the glossary describe the importance of accurate, complete accounting records in the ambulatory care setting describe how cost analysis and cost ratios can be used to make nancial decisions describe the importance of complete, accurate bookkeeping practices describe how payroll is calculated, including deductions be able to balance a business checking account against a bank statement.

18
Chapter Outline
Financial Management Accounting Practices
Fixed and Variable Costs Cost Ratio Income Statement Balance Sheet Bookkeeping Ledger cards Adjustments NSF checks Accounts Receivable Ratio Collection Ratio Accounts Payable Deliveries and supplies Writing checks Payroll Preparing payroll checks Apply computer concepts for ofce procedures Prepare a bank statement and deposit record Reconcile a bank statement Post entries on a day sheet Perform billing and collection procedures Prepare a check Establish and maintain petty cash fund Post adjustments Process credit balance Process refunds Post NSF funds Post collection agency payments

ABHES Competencies
Administrative Duties

Financial Management
Use manual and computerized bookkeeping systems Manage accounts payable and receivable Maintain records for accounting and banking purposes Process employee payroll

Banking Practices
Reconciling Bank Statements Making Bank Deposits Petty Cash

CAAHEP Competencies
Administrative Competencies Perform Bookkeeping Procedures
Prepare a bank deposit Post entries on a day sheet Perform accounts receivable procedures Perform billing and collection procedures Post adjustments Process a credit balance Process refunds Post nonsufcient fund (NSF) checks Post collection agency payments

Chapter Summary Team Work Exercises Case Studies Resources

Procedures
Preparing a bank deposit slip Reconciling a bank statement Posting entries, adjustments, and collection agency payments on day sheet Processing credit balances Processing a refund Posting an NSF check

General Competencies Operational Functions

Utilize computer software to maintain ofce systems

259

Key Terms
accounts payable

Financial Management
Comprehensive nancial management of the physicians ofce is an important function of the administrative medical assistant or ofce manager. Having complete and accurate records of what money is coming in and what money is going out allows managers and physician-owners to understand the overall nancial health of the practice. Such an analysis gives physician-owners the information needed to make nancial decisions, such as expansion of the practice, new equipment purchases, and new employee hiring.

Amount of money the practice owes to outside vendors, rent or mortgage, supplies, salaries, and so forth
AU: No bold term in chapter Set bold in chapter text or delete form key term list.

accounts receivable

Amount of money owed to the practice for patient services performed

accounts receivable ratio

Comparison of the amount of money charged to a practice and the amount collected by the practice
assets

Property owned by a business, such as equipment, supplies, and accounts receivable

balance sheet

Statement of nancial condition that contains itemized assets, liabilities, and owners equity
collection ratio

Accounting Practices
Accounting practices can be divided into two main categories: nancial and managerial. Financial accounting provides data for outside entities such as the federal government. Analysis of net prot provides information needed to pay federal and state taxes. The practices accounting rm will provide forms for administrative staff to ll out, including total money collected and business expenses, such as salaries, ofce and medical supplies, license fees, and continuing education expenses. The accounting rm will then use this information to determine what the practice owes for federal and state taxes. The administrative staff should keep copies of receipts in case of an audit. Managerial accounting provides information for the managers or physician-owners. Where is money being spent? What are the best returns on investment procedures? What does it cost to perform particular services? The practice can determine whether to continue providing certain services or drop them, depending on how costly they are to perform and how much income they generate. Services that generate a larger income and cost less generate a good return on investment and should be offered by the practice.

Comparison of outstanding debt amount and amount collected

cost ratio

Comparison of total expenses to number of procedures

nancial accounting

Process of tracking monetary expenditures and income for outside entities, such as the federal government
xed costs

Expenses that do not depend on the number of patients being seen in a practice
income statement

Report of itemized monthly expenses and prots

liability

Money owed to a creditor

managerial accounting

Process of tracking monetary expenditures and income for a practices managers or physician owners
owners equity

Amount by which business assets exceed business liabilities; also called net worth
variable costs

Expenses that increase with an increase in the number of patients seen

Fixed and Variable Costs

For the ofce manager to analyze where the practice is spending money and how it is generating income, she must conduct a cost analysis of xed and variable costs. A xed cost does not vary by the number of patients being seen in the practice. Such expenses as rent or mortgage, equipment leases, or payments are examples of xed costs. Variable costs depend on the number of patients seen in a practice and can include clinical supplies and staff salaries. As patient volume increases, the average cost of treating a patient declines because xed costs per patient decline. (See Fixed costs and prots.)

Cost Ratio
By conducting a cost ratio analysis, which compares the practices total expenses to the number of procedures and services provided, an ofce manager can predict how many

CHAP TER 18

Accounting and Banking

261

Fixed costs and prots

The following table shows how an increasing volume of patients decreases the xed cost per patient and, therefore, increases the prot per patient. It is important to note that in the example above, the additional staff needed to see 100 more patients, from
Rent or mortgage on building Equipment leases Staff salaries Clinical and office 6,400 1,100 49,000 1,350

1,300 to 1,400 patients, actually reduces the prot per patient. The ofce manager should consider how busy the ofce should be to be protable and when the busy ofce actually decreases prot per patient.

FIXED COSTS

6,400 1,100 49,500 1,400 58,400 1,000 75,000 58.40 16.60

6,400 1,100 51,000 1,450 59,950 1,100 82,500 54.50 20.50

6,400 1,100 55,000 1,500 64,000 1,200 90,000 53.33 21.67

6,400 1,100 59,000 1,550

6,400 1,100 67,000 1,600

6,400 1,100 69,000 1,700

VARIABLE COST BECAUSE IT INCREASES WITH AN INCREASE IN PATIENT VISITS TOTAL EXPENSES TOTAL NUMBER OF PATIENTS

supplies Total expenses 57,850 Patient visits per month 900 Monthly income ($75 67,500 average charge/patient) Cost per patient 64.28 Profit per patient 10.72 Monthly net profit

68,050 76,100 78,200 1,300 1,400 1,500 97,500 105,000 112,500 52.35 22.65 54.36 20.64 52.13 22.87

$9,648 $16,600 $22,550 $26,004 $29,445 $28,896 $34,305

$75.00 AVERAGE CHARGE COST PER PATIENT

PROFIT PER PATIENT NUMBER OF PATIENTS

patients the ofce must see to generate adequate income (net monthly income) to cover expenses. If the practice must expand by hiring new staff, buying more equipment, or buying or renting a larger ofce suite, such a cost ratio analysis can show the manager how many more patients must be seen to cover the increase in expenses. In addition, such an analysis reveals the cost-effectiveness of certain procedures and services. (See Cost ratio analysis: X-ray department, page 262.)

Owners equity is the total assets minus the liabilities. For example, if the x-ray machine is worth $20,000 and the practice owes $8,000, the owners equity for the x-ray machine is $12,000. The balance sheet is updated by adding credit and debit entries. Increases in assets are recorded as debits; increases in liabilities and owners equity are recorded as credits. (See Figure 18-2.)

Income Statement
If an ofce manager wishes to assess the total prot and expenses for a month of services, she can use an income statement. (See Figure 18-1.) This statement is an overall picture of monthly nancial obligations and revenue that can be used to predict future earnings and monitor increases or decreases in prots.

Bookkeeping
More than one person in the medical office can do bookkeeping, the day-to-day financial record-keeping. The front desk staff normally records patient procedure charges and payments, in addition to scheduling appointments. Computerized medical office management systems include insurance billing, patient billing, and appointment scheduling functions as well as functions for payroll, accounts payable, and productivity reporting. Most medical offices use a computerized management system for financial records; however, staff can perform all functions manually if necessary. Each day, the medical assistant must record patient visits, charges, and payments. The medical assistant bills the insurance company by sending a completed CMS-1500 form electronically or via the mail. The insurer sends the medical ofce reimbursement (payment), usually in the form of a check. The insurance company check commonly

Balance Sheet
A balance sheet shows the value of the office at a given date. It lists the assets, liabilities, and owners equity of the office. Assets are the values of all of the property owned by the practice. Items considered assets include furniture, equipment, and computers as well as the building if owned by the practice. Liabilities are the total money owed to creditors. For example, if the practice owes $8000 in payments for the x-ray machine, that $8000 is a liability.

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Cost ratio analysis: X-ray department

A medical ofce has its own x-ray machine and technician. The ofce manager wants to conduct a cost ratio analysis to determine the cost-effectiveness of the x-ray department. To do so, the ofce manager must compare the total expenses of the x-ray department to the total number of x-rays (or x-ray services) performed each month. The cost ratio analysis above indicates that the x-ray departments cost per procedure is low. Thus, the x-ray department has the ability to generate signicant income for the practice. If, however, insurance reimbursement for x-rays in the ofce were reduced and, therefore, the number of x-rays taken each month were to drop to 60, the ratio becomes $43.33 per procedure ($2600 60). This increased cost ratio may cause the physician-owners and managers to decide to stop offering x-rays in the ofce and, instead, refer patients to another facility for x-ray services.

X-Ray Department Expenses X-ray technician salary $1500 Lease/loan on machine $ 800 Supplies (film, developer, fixative) $ 300 Total Expenses: $2600 Total number of x-ray procedures per month = 250 Cost Ratio: $10.40/procedure

Date 10/01/08 10/03/08 10/03/08 10/03/08 10/03/08 10/15/08 10/16/08 10/16/08 10/16/08 10/16/08 10/16/08 10/17/08 10/21/08 10/0110/31 10/0110/31

Profit description Carpenters Local 896 check Allied Health Services check Medicare check Aetna Life check Guardian Life check Carpenters Local 896 check Allied Health Services check Medicare ceck Aetna Life check Guardian Life check Mutual of Omaha check Casino Workers Local 445 check ABC Collection Corporation Front desk cash/check copayments Patient balances paid by personal checks

Amount 2,477.08 17,344.99 7,990.44 4,337.01 8,907.45 3,551.98 11,445.07 3,221.08 6,997.07 2,407.09 1,104.56 874.22 1,456.02 8,800.00 1,759.30 82,673.36

Date 10/01/08 10/01/08 10/01/08 10/21/08 10/21/08 10/21/08

Expense description Amount Henderson Realty office rent 6,400.00 Office supplies 435.00 Clinical supplies 1,550.00 Telephone bill and advertising in Yellow Pages 683.44 Payroll taxes 16,433.07 45,488.58 Total payroll for October 70,989.58 $82,673.36 $70,989.58 $11,683.78

Total income for October 2008 Total expenses for October 2008 Net profit for October 2008

FIG 18-1 Income statement.

CHAP TER 18

Accounting and Banking

263

ASSETS Current Assets Cash Accounts receivable (less doubtful accounts) Inventory Temporary investment Prepaid expenses Total Current Assets 82,000 27,000 < 3,000> 11,000 0 0 117,000

LIABILITIES Current Liabilities Accounts payable Short-term notes Current portion of long-term notes Interest payable Taxes payable Accrued payroll Total Current Liabilities Long-term Liabilities Mortgage Other long-term liabilites Total Net Fixed Assets 700 0 0 0 14,000 12,000 26,700

Fixed Assets Long-term investments 5,000 Land 0 Buildings 0 (less accumulated depreciation) 0 Plant and equipment 14,000 (less accumulated depreciation) < 3,000> Furniture and fixtures 11,000 (less accumulated depreciation) < 1,000> Total Net Fixed Assets 26,000 TOTAL ASSETS 143,000

0 0 0

TOTAL LIABILITIES

26,700

FIG 18-2 Balance sheet.

represents payment for services provided to many patients. The medical assistant must use the explanation of benets (EOB) that the insurance company sends with the payment to apply the payments to the appropriate patient accounts. The medical assistant will also collect copayments from patients at the time of their visits. She must record all payments in the computerized accounting program or on a day sheet. (See Entering charges and payments on a day sheet, page 264.)The medical assistant can then generate reports of daily, weekly, monthly, and quarterly charges and payments.

manual ledger card system, the medical assistant must also record the transactions on the day sheet. If a practice uses a computerized accounting system, individual account statements can be printed that show the same charges and payments as a ledger card.

Adjustments
Adjustments to account balances are write-offs of money that the medical practice does not expect to collect, even though it charged the fee. Because a medical practice contracts with many insurance companies and Medicare that have various fee schedules, physicians expect the insurance company to adjust the payment for the service so that it is in line with their contracted fee. Thus, although the practice charges the full fee, it will not collect the full amount. The practice must then make adjustments on the patients ledger card to discount the fee by the specied amount. (See Procedure 18-1: Posting charges, adjustments, and payments, page 264.)

TIP Check the Numbers Computerized systems calculate accounts receivable balances based on what is keyed into the system. The medical assistant should always review her records for accuracy. In addition, if the medical assistant cannot balance the day sheet, she should check for transposed digits (such as 59 written as 95). If she still cannot get it to balance, she should ask a coworker to check her work. It is possible for anyone to repeatedly overlook a mistake, but a fresh eye can usually catch it.
Ledger Cards
A medical practice may use ledger cards, which are used to record each patients charges and payments. The medical assistant records on the patients ledger card any charges and copayments she received at the time of service and the date of service. When the practice receives insurance or patient payments in the mail, the medical assistant must also record these payments on the ledger card. If a practice uses a

NSF Checks
When a patient pays with a check, the practice may receive that check back from the bank marked NSF for not sufcient funds. This designation means that there is not enough money in the checking account to pay the amount of the check. Usually, such a situation arises unintentionally and the patient will pay the money owed. Ofce policy may dictate that the patient pay a ne for a returned check. The medical assistant should check her state law regarding returned check nes before imposing a ne. A bank will generally charge a
(Text continues on page 267)

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Administrative

Entering charges and payments on a day sheet

Entering charges and payments into a computerized or manual day sheet helps the medical assistant keep track of the payments received and services provided at the medical ofce each day. The following example of a computerized
Patient name Description

day sheet shows how a day sheet tracks patient visits and services provided, charges for those services, and payments received from patients and insurance companies.

Charges Payments 150.00 180.00 210.00 .00 540.00 15.00 10.00 15.00 415.00 455.00

New Balance 155.00 340.00 195.00 0.00 690.00

Old Balance 20.00 170.00 0.00 415.00 605.00

Joe Smith OV, X-ray Mike Connors OV, UA, X-ray Maria Sanchez New Pt OV Insurance payment --------Tina Sawyer TOTALS

THE AMOUNTS RECEIVABLE, OR AMOUNT OF MONEY OWED TO THE PRACTICE, WENT FROM $605.00 TO $690.00

A computerized day sheet will include built-in formulas that compute the totals automatically. However, if the

medical assistant uses a manual day sheet, she can check the accuracy of the totals by using this formula:
605.00 + 540.00 1145.00 455.00 690.00

Old balances + charges = (subtotal) payments = New balance

PROCEDURE 18-1

Posting charges, adjustments, and payments and balancing a day sheet

Task Post charges, adjustments, and payments from an insurance company, patients, and a collection agency to a day sheet and balance the day sheet. Conditions Computer and printer or manual day sheet Checks (from insurance companies and patients) Collection agency payment Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully post charges, adjustments, and payments and balance a day sheet. Performance Standards 1. Post charges and payments to the ledger cards (below) for these patients, who visited the ofce on April 22, 2008: a. Andrew Stevenson came in for an ofce visit ($40 charge) and paid a $10 copayment in cash. b. Jenna Collins came in for an ofce visit and urinalysis (combined charge of $75) and paid a $15 copayment by check (#534). c. Barry Chen came in for an x-ray ($75 charge) and paid a $25 copayment in cash. d. John Rivera came in for an ofce visit and urinalysis and paid a $10 copayment by check (#1766). e. Hannah Martin came in for an ECG (charge $105). 2. Create a computerized day sheet according to the format of the daysheet or use a manual day sheet (provided by your instructor). 3. Post entries on the day sheet according to the activities listed above. 4. Post the insurance payment (check below) from United Health Systems to the day sheet and apply payments to the patient accounts on the ledger cards. 5. Apply the amount allowed from the insurance companys explanation of benets, adjusting the patient balances to reect only the amount allowed.

CHAP TER 18

Accounting and Banking

265

PROCEDURE 18-1contd

6. Post the collection agency payment (check below) from ACME Collections, Inc., on the patient ledger card and day sheet. 7. Include the following adjustments to the day sheet and the appropriate patients ledger card:
Andrew Stevenson 167 Main Street, Colbrush, CT 860-123-0932 Date Procedure

a. Hannah MartinMedicare adjustment $15.00 b. John RiveraHMO adjustment $15.00 c. Barry ChenHMO adjustment $47.00 8. Balance the day sheet.

Charge

Payment

Balance

Balance brought forward -----------------------------------------------------------------------03/06/2008 office surgery 650.00 25.00

170.00 795.00

Hannah Martin 36 Gratuity Way, Blueville, CT 860-555-9778 Date Procedure Charge Payment Balance

Balance brought forward ------------------------------------------------------------------------03/08/2008

Jenna Collins 14 Wayside Drive, Blueville, CT 860-555-9778 Date Procedure Charge Payment Balance

0.00 105.00

ECG

105.00

0.00

Balance brought forward -------------------------------------------------------------------------03/08/2008 OV-exp, x-ray, LBP, PT, Acu 404.00 15.00

150.00 539.00

John Rivera 83 Pinecrest Road, Blueville, CT 860-555-7695 Date Procedure Charge Payment Balance

Balance brought forward ------------------------------------------------------------------------03/08/2008

Barry Chen 762 Elm Street, Blueville, CT 860-555-6823 Date Procedure Charge Payment Balance

50.00 188.00

PE, stress test

153.00

15.00

Balance brought forward -------------------------------------------------------------------------03/07/2008 office surgery

Gary Travini 11 Appleton Drive, Blueville, CT 860-555-7833 Date Procedure

100.00 485.00

410.00

25.00

Charge

Payment

Balance

10/20/2007 11/22/2007 12/01/2007 12/13/2007 01/05/2008 02/05/2008 03/05/2008 04/01/2008

Balance brought forward --------------------------------------------------------------------------office surgery 404.00 20.00 OV, UA, stress test 185.20 20.00 check returned NSF 20.00 patient check 69.00 patient billed patient billed patient billed final notice to collect account sent to ACME collections

0.00 384.00 549.00 569.00 500.00

500.00
Continued

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PROCEDURE 18-1contd

United Health Systems 283 Commerce Park Drive P.O. Box 6978 Blueville, CT 06100 PAY TO THE ORDER OF

2349786799943

April 16, 2008

DATE

Blueville Family Medicine

1,453.00

One thousand four hundred fiftythree and -------------------------------------------------------------no/00

DOLLARS

FOR

2349786799943

000000188

111111883301

Patient Jenna Collins Andrew Stevenson John Rivera Barry Chen

ID# X1J100990077 XDD269873888 XLK798639922 XRS689812544

Date of service 03/08/2008 03/06/2008 03/08/2008 03/07/2008

Amount charged $404.00 $650.00 $153.00 $410.00

Copay 15.00 25.00 15.00 25.00

Amount allowed 390.00 610.00 148.00 385.00 Total

Amount paid 375.00 585.00 133.00 360.00 1,453.00

ACME Collections, Inc. 456 Underhill Road Granville, CT 23456 860-234-3456 PAY TO THE ORDER OF

45978

April 18, 2008

DATE

Blueville Family Medicine

107.55

One hundred seven and ------------------------------------------------------------------------------------- 55/00

DOLLARS

FOR

045978

000000106

111111338801

Patient Gary Travini Collection fee @ 10% Check amount

Account balance 500.00

Payment 118.30 10.75 $107.55

CHAP TER 18

Accounting and Banking

267

$15 or $20 processing fee to the practice for every NSF check that it processes. Many ofces charge the same fee to the patient to recover that cost. To record an NSF check returned by the bank, the medical assistant should add the check amount (plus any penalty per ofce policy) to the account as a charge, returning the patients balance to the amount owed before the payment.

Collection ratio evaluation

An ofce manager may want to determine a collection ratio for several reasons. One possibility is when a new physician is hired and, thus, more services are provided to more patients. With the increase in services billed, the billing department is challenged to keep up with collections. To determine the collection ratio, the medical assistant must determine the total monthly charges and the total amount collected after adjustments (and unpaid patient portions) using this formula:
Total montly charges: Managed care adjustments: Medicare adjustments: Total monthly collections: $210,397 $10,945 $7,833 $191,619

Accounts Receivable Ratio

The accounts receivable ratio is a formula the medical ofce can use to measure the time it takes for bills to be paid. The formula compares the total charges to the monthly collections. (See Accounts receivable ratio formula.)

Collection Ratio
A medical assistant can also evaluate accounts receivable by determining the collection ratio, which is a comparison of an outstanding debt amount to the amount collected. Simply stated, how much of the money billed is actually paid. The goal of the collection ratio for a medical ofce should be 0.85 to 0.90. (See Collection ratio evaluation.)

TIP Rewarding High Collections Collection ratios that are 90% or higher are a reection of the hard work of the billing staff. The physician or ofce manager may offer bonuses, a day off, or a gift certicate to motivate continued success.

Of the $210,397 in charges, $191,619 is collectable in real dollars, which provides a collection ratio of 0.91 (191,619 210,397). The formula above assumes that all patients will pay copayments and balances on outstanding bills. If the ofce determines that there will be an additional $3,000 that will remain uncollected from patients, the ratio drops to 0.896, or (191,619 3,000 188,619 210,397). This ratio is still within the acceptable range for a collection ratio.

Accounts Payable
Accounts payable are nancial obligations of the practice to outside vendors or patients and include xed and variable

costs. Accounts payable procedures include receiving and tracking deliveries and other supply purchases for payment, writing checks, and managing payroll.

Deliveries and Supplies

Accounts receivable ratio formula

The medical practice tracks the total amount charged for services in a given month as well as the total amount collected in payments from patients and insurers. These totals are used to determine the accounts receivable ratio using this formula:
Total accounts receivable (how much money was charged?) Monthly receipts (how much money was collected?) $210,397 (charges) = 2.03 $103,455 (collected)

The accounts receivable ratio is 2.03. Thus, payment turnaround time is approximately 2 months for account payments. An accounts receivable ratio that is 2 or less indicates that the practice collects on outstanding charges in 2 months or less. Such a ratio shows that the ofce is keeping up with billing and collections.

To ensure a good relationship with suppliers, the medical office should pay bills upon receipt. Clinical and office suppliers may deliver supplies to the office, or office staff may pick them up at local suppliers. Items shipped to the office should include a packing slip. The packing slip will identify items (and quantities) sent. Upon receipt of the packages, the medical assistant should check items received against the packing slip to ensure that the delivered items match the items charged to the office. (See Figure 18-3.) When the medical assistant veries that all items on the packing slip are included in the package, she can send the packing slip to the accounts payable department. In addition, some bills, such as utilities, ofce rental or mortgage, and some supply bills, will arrive at the ofce in the mail. The medical assistant can forward these items to the accounts payable department as well.

Writing Checks
The medical assistant must record all checks written, whether to vendors or employees, in the check register.

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Administrative

PACKING SLIP
TriCounty X-ray 1867 Commerce Parkway Presley, CT 06001 Ship to Attn: Cindy Smith, CMA Blueville Family Medicine 15 Main Street Blueville, CT 06000 869-555-3212 Bill to Blueville Family Medicine 15 Main Street Blueville, CT 860-555-3212

Order Date 10/02/08

Order Number 78963

Shipped Via UPS

Tracking Number 89BXZ767687134

Quantity 2 3

Description Box 100 12 x 14 plain film x-ray Box 50 10 x 10 plain film x-ray Subtotal Tax Shipping TOTAL

Unit Price $42.95 $31.95 $181.75 $12.75 $11.45 $205.95

FIG 18-3 Typical packing slip.

The check register is a log of expenses that the medical office can later use for cost analysis, comparing vendor prices, proof of payment, and balancing the checkbook. The check register can be computerized, manual, or both. (See Figure 18-4.) Items to record in the register include:

returning the account balance to zero. (See Procedure 18-2: Processing a credit balance and refund and posting an NSF check, page 272. )

Payroll
Paying employees on a weekly or biweekly basis is usually the job of an office manager. The office manager should give all employees a Withholding Exemption (W-4) form at the onset of employment. (See Figure 18-6.) The W-4 shows the total amount of deductions the employee claims and affects the federal taxes withheld from each paycheck.

name of vendor or patient amount of check date of check items received or packing slip number (if vendor). (See Figure 18-5.)

Occasionally, a patient may pay the practice for services and then the patients insurance company reimburses the practice for the same service. The patient may do so because he assumes that the service is not covered or that he has not yet met a deductible. In such a case, the medical assistant must refund the money to the patient. A refund to a patient should be processed as soon as the insurance check arrives at the office. The medical assistant should record the payment from the insurance company, noting the credit balance. She must then refund the patient any excess money previously paid to the account,

Preparing Payroll Checks

The ofce may pay employees at an hourly rate or a salary rate. Salaried employees earn the same amount of money each week and may be paid for overtime, depending on their agreement with the physician-owners. Hourly employees must keep track of hours worked by using a time sheet, time card, or computer log-in system. Regardless of how the hourly information is gathered, the ofce manager calculates the amount of the paycheck by multiplying the number of

CHAP TER 18

Accounting and Banking

269

Number

Date 12/20/08 12/21/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08

Description of Transaction Previous balance Payroll taxes Payroll- Robert Greer Payroll- Hector Rodriguez Payroll- Ann Wilson Payroll- Henry Lee Payroll- Sharon Piecek Payroll- Kelly Manera Payroll- Cindy Smith Payroll- Shelly Gonzalez Deposit- insurance & personal checks Patterson Office Supply Henderson Realtyoffice rent Jan 09 Yellow Page.com- advertising

Debit ()

Credit (+)

Balance $78,590.34 $77,001.79 $73,987.40 $71,944.18 $70,618.85 $69,372.18 $68,637.66 $68,313.55 $67,702.12 $67,225.84 $89,989.05 $89,852.93 $83,452.93 $82,202.93

11032 11033 11034 11035 11036 11037 11038 11039 11040

$1588.55 $3014.39 $2043.22 $1325.33 $1246.67 $734.52 $324.11 $611.43 $476.28 $22,763.21 $136.12 $6400.00 $1250.00

11041 11042 11043

FIG 18-4 Check register.

hours worked by the hourly rate. Commonly, the ofce manager will use a payroll worksheet to make these calculations. (See Figure 18-7.) When she has calculated the paycheck amount, she can write the paychecks by hand or in a computer software system. Payroll checks should show the employee all deductions and hours worked. In addition, they should include:

gross salary itemized tax deductions, including federal income tax, Social Security tax (FICA), and state taxes (if applicable) other itemized deductions, such as health insurance and retirement savings net salary (gross earnings minus taxes and deductions). (See Figure 18-8.)

name of the employee number of hours worked (regular, if hourly, and overtime) dates of pay period (beginning date and ending date) date of check

TIP On Time or Early Always pay employees on the same day of the week or every 2-week period. If a payday is changed due to a holiday, pay employees a day early. The employees will appreciate it!

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CT 06000 860-555-3212 PAY TO THE ORDER OF

11041 November 1, 2008

$ DATE

Patterson Office Supplies

136.12
DOLLARS

One hundred thirty six and ---------------------------------------------------------------------------12/100 BLUEVILLE SAVINGS BANK

FOR

patient files, alpha stickers

011041 000000105

Hector Rodriguez, MD
111111333301

FIG 18-5 Business check.

270

UNIT 2

Administrative

Cut here and give Form W-4 to your employer. Keep the top part for your records.
Form

W-4

Employees Withholding Allowance Certificate

Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. Last name 3 2

OMB No. 1545-0074

Department of the Treasury Internal Revenue Service

2008

Type or print your first name and middle initial. Home address (number and street or rural route)

Your social security number

Single Married Married, but withhold at higher Single rate. Note. If married, but legally separated, or spouse is a nonresident alien, check the Single box.

City or town, state, and ZIP code

4 If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card.

5 6 7

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 6 Additional amount, if any, you want withheld from each paycheck I claim exemption from withholding for 2008, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here 7

Employees signature
(Form is not valid unless you sign it.)
8

Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Date
9 Office code (optional) 10 Employer identification number (EIN)

Employers name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

FIG 18-6 W-4 form.

Employee Robert Greer, MD Hector Rodriguez, MD Anne Wilson, MD Henry Lee, MD Sharon Piecek, APRN Kelly Manera Jennifer Morgan Carol Chapin Wendy Jones Shelly Gonzalez Cindy Smith

Hourly rate salary salary salary salary salary $14.00 $14.00 $15.50 $13.00 $15.50 salary

Hours worked --------------------32 38 25 20 42 -----

Gross salary $3300.00 $2400.00 $1500.00 $1400.00 $950.00 $448.00 $532.00 $387.00 $260.00 $666.50 $750.00

Withholding 4 5 3 4 4 2 1 2 0 2 3

Health insurance 49.33 81.63 40.18 49.33 49.33 24.07 24.07 0 0 24.07 40.18

Retirement $165.00 $120.00 $77.50 $70.00 $50.00 $22.40 $26.60 $19.38 $13.00 $33.32 $37.50

40 HOURS @ REGULAR TIME ($15.50/HR) + 2 HOURS @ 1 TIME ($23.25/HR) FIG 18-7 Payroll worksheet.

CHAP TER 18

Accounting and Banking

271

BLUEVILLE FAMILY MEDICINE EMPLOYEE NAME DATE GROSS AMOUNT DEDUCTIONS

001687
NET PAYABLE

Sharon Piecek

04/22/08

$950.00

Federal State SS 401K

$ 103.22 $ 16.61 $ 45.65 $ 50.00

CHECK NO.

001687

TOTALS

$950.00

TOTALS

$215.48

$734.52

THE FACE OF THIS DOCUMENT HAS A COLORED BACKGROUND ON WHITE PAPER

Blueville Family Medicine 15 Main Street Blueville, CT 06000 860-555-3212

PAY TO THE ORDER OF

BLUEVILLE SAVINGS BANK BLUEVILLE, CT

001687 04/22/08
AMOUNT

80-162 02

DATE

$734.52

Sharon Piecek
DOLLARS

Seven hundred thirty-four and 52/100

George A. Lowry
SIGNATURE
SECURITY FEATURES INCLUDED. DETAILS ON BACK.

SIGNATURE

FIG 18-8 Paycheck.

The medical ofce must have a federal tax reporting number in order to process payroll checks. On a quarterly basis, the ofce must pay all federal and state taxes withheld using the appropriate reporting forms. The ofce manager can use a computer software program to calculate federal and state payroll taxes and determine the amount to deposit in the bank tax account as mandated by federal law. Although this account is just a place to hold tax funds until the practice makes its required quarterly tax payments, the bank does not allow access to this account for any other reason than to pay taxes at the specied payment periods. At the end of each calendar year, the medical ofce must generate Wage and Tax Statement (W-2) forms for each employee. (See Figure 18-9.) This form shows total wages, federal income tax withheld throughout the year, Social Security wages and taxes withheld, and Medicare wages and taxes withheld. An employee needs this form to le her personal tax returns. The ofce manager should give the W-2 form to employees no later than January 31st so that each employee has ample time to meet the April 15th deadline for income tax ling.

Banking Practices
In addition to the many accounting practices performed by the medical assistant or ofce manager, running a medical ofce requires an extensive understanding of proper banking practices. Some of the most common and most essential banking practices are:

reconciling bank statements making bank deposits managing petty cash.

Reconciling Bank Statements

The bank in which a medical practice keeps its accounts will send a monthly statement to the practice. Many banks also offer online bank statements as an alternative. The ofce manager can use the account number and password to log in and view the statement. She can also print statements to check against the ofces records. On the statement, the bank records all deposits and withdrawals and includes the balance at the end of the statement period. In addition, most ofces

272

UNIT 2

Administrative

PROCEDURE 18-2

Processing a credit balance and refund and posting an NSF check

Task Process a credit balance, process a refund, and post a not sufcient funds (NSF) check. Conditions Day sheet Checks (insurance and patient checks) Collection agency payment Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully process a credit balance and a refund and post an NSF check. Performance Standards 1. Post the insurance check for Irina Sharapova to her ledger card. 2. Write a refund check to Mrs. Sharapova and record her balance as zero. 3. Post the returned check (below) from Ariana Klieger on the day sheet (from previous procedure) and on the patients ledger card (below).

Universal HMO 1 Vista Boulevard Regionville, NY 04321 800-888-8765 PAY TO THE ORDER OF

0088678721

April 20, 2008

DATE

Blueville Family Medicine

30.00

Thirty and -------------------------------------------------------------------------------------------------------- 00/100

DOLLARS

FOR

0088678721

000000886

771117354301

Name Irina Sharapova

Procedure 99204

Amount charged 85.00

Allowed 70.00

Copay 40.00

Paid 30.00

Irina Sharapova 211 Elm Street, Blueville, CT 860-555-1129 Date Procedure Charge Payment Balance

Balance brought forward --------------------------------------------------------------------------03/07/2008 03/07/2008 OV exp Payment, personal check #859 85.00 15.00 (writeoff) 50.00

0.00 70.00 20.00

CHAP TER 18

Accounting and Banking

273

PROCEDURE 18-2contd

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CT 06000 860-555-3212 PAY TO THE ORDER OF

11432
DATE

DOLLARS

BLUEVILLE SAVINGS BANK

FOR

011432

000000105

111111333301

Arianna Klieger 769 Elm Street Blueville, CT 06000

772 April 7, 2008

DATE

PAY TO THE ORDER OF

Blueville Family Medicine

45.00 no/100
DOLLARS

Forty-five and

Presley Savings and Loan

MEMO

Arianna Klieger
960130629721 1000

044008804

Arianna Klieger 769 Elm Street, Blueville, CT 860-555-9733 Date Procedure Charge Payment Balance

Balance brought forward -------------------------------------------------------------------------04/07/2008 office surgery 410.00 45.00

0.00 365.00

274

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Administrative

a Control number

00000000

OMB No. 1545-0008 1 Wages, tips, other conpensation 2 Federal income tax withheld

b Employer identification number (EIN)

99-9999999
c Employers name, address, and ZIP code

49400.00
3 Social security wages 4 6 8

7728.36
Social security tax withheld

Blueville Family Medicine 15 Main Street Blueville, CT 06000

49400.00
5 Medicare wages and tips

3380.37
Medicare tax withheld

49400.00
7 Social security tips

790.57
Allocated tips

d Employees social security number

9 Advance EIC payment Last name Suff. 11 Nonqualified plans 13

Statutary employee Retirement plan Third-party sick pay

10 Dependent care benefits 12a See instructions for box 12 12b 12c 12d

123-45-6789
e Employees first name and initial

Sharon L.

Piecek X
14 Other

C o d e C o d e C o d e C o d e

Employees address and ZIP code

1406 Long Pond Road Blueville, CT 06000

16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc.

15 State

Employers state ID number

19 Local income tax

20 Locality name

CT
Form

5555-5555

49400.00

1275.04

49400.00

Blueville

W-2

Wage and Tax Statement FIG 18-9 W-2 form.

Department of TreasuryInternal Revenue Service

have a computerized nancial management system that can report all deposits and withdrawals as well as the account balance for the statement period. (See Reconciling ofce and bank records.) Whether the ofce has computerized or manual records, the ofce manager should compare the bank records to the ofce records to reconcile them, or ensure that the check and deposit amounts on both statements match and that the account balances match. (See Procedure 18-3: Reconciling a bank statement, page 277 to 278.)

TIP Online Banking Banks send statements at the end of each month. Most banks, however, also offer online banking information that an ofce manager can access at any time. If questions arise, the online banking information can be useful in answering questions in a timely manner. Usually, the information is accessible using the checking account number and is secured by a pass word.

make bank deposits daily, a few times per week, or once per week. The ofce manager is usually in charge of bank deposits; however, she may ask a medical assistant to prepare the deposit or take it to the bank. Many ofces require the medical assistant to make photocopies of checks for deposit to be kept in a le in case of a discrepancy between the amount of the check and the deposit amount recorded by the bank. Because the medical assistant must write the check number on the deposit slip along with its amount, she can easily identify the check if a discrepancy with the bank occurs. Cash is listed separately on the deposit slip. (See Figure 18-10.) The medical assistant should count cash twice to ensure accuracy. The medical assistant should be sure to get a slip from the bank, conrming the deposit, and le it with the photocopies of checks for complete records. (See Procedure 18-4: Preparing a bank deposit, page 279.)

Making Bank Deposits

The ofce manager or medical assistant must record and deposit into the practices checking account checks from insurance companies and personal checks and cash from patients. Depending on the size of the practice, staff may

TIP Adding Machines Some adding machines can produce a printable paper receipt. The office manager can use this capability to print out the computations she has entered to review them for accuracy.
(Text continues on page 282)

CHAP TER 18

Accounting and Banking

275

Reconciling ofce and bank records

The ofce manager should reconcile each monthly bank statement with the ofce records for that month. To do so, she must print out the ofce accounting record for that month (commonly called a deposit and withdrawal report) and compare it with the bank statement. The ofce manager should check off the withdrawals and deposits that appear on the deposit and withdrawal report and the bank statement, and then look for items that do not appear on the bank statement to account for any difference in the nal balance. Checks written at the end of the month may be missing from the bank statement if they have not been processed, or cleared, by the bank by the statement closing date. When comparing the two statements, the ofce manager would nd in this case that the nal balances do not match. Checks numbered 11041 and 11044 were not yet cashed by the recipients. In addition, check number 11046 does not appear on the statement. To reconcile the statements, then, the ofce manager must subtract the outstanding withdrawals (in this case, checks 11041, 11044, and 11046) from the bank statement balance. Using an adding machine with printable tape, the ofce manager can add the total amount of money from the checks not yet cashed and subtract it from the ending bank balance. That amount should be equal to the ofce accounting.

Deposit and Withdrawal Report December 2008

Number Date Description of Transaction Previous balance New England Telephone Deposit insurance & personal cks CT Light & Power AMA- conference fee Deposit insurance & personal cks Withdrawal cash- office party supplies Payroll taxes Payroll- Robert Greer Payroll- Hector Rodriguez Payroll- Ann Wilson Payroll- Henry Lee Payroll- Sharon Piecek Payroll- Kelly Manera Payroll- Cindy Smith Payroll- Shelly Gonzalez Payroll- Jennifer Morgan Payroll- Wendy Jones Payroll- Carol Chapin Deposit insurance & personal cks Patterson Office Supply Henderson Realty- office rent Jan 09 Yellow Pages.com advertising C Debit () Credit (+) Balance $56,315.12 $55,644.79 $66,876.23 $66,564.33 $65,814.33 $78,590.34 $78.390.34 $76,801.79 $73,787.40 $71,744.18 $70,418.85 $69,172.18 $68,437.66 $67,853.55 $67,242.12 $66,765.84 $66,273.28 $65,797.41 $65,503.28 $88,266.49 88,130.37 $81,730.37 $80,480.37

11029

12/05/08 12/10/08 12/10/08 12/15/08 12/18/08 12/19/08

$670.33 $11,231.44 $311.90 $750.00 $12,776.01 $200.00 $1588.55 $3014.39 $2043.22 $1325.33 $1246.67 $734.52 $584.11 $611.43 $476.28 $492.56 $475.87 $294.13 $22,763.21 $136.12 $6400.00 $1250.00

11030 11031

11032 11033 11034 11035 11036 11037 11038 11039 11040 11041 11042 11043

12/19/08 12/19/08 12/19/08 12/19/08 12/19/08 12/19/08 12/19/08 12/19/08 12/19/08 12/19/08 12/19/08 12/19/08 12/19/08 12/22/08 12/22/08 12/22/08

11044 11045 11046

Continued

276

UNIT 2

Administrative

Reconciling ofce and bank recordscontd

Blueville Savings Bank 122 Main Street Blueville, CT 06000 Statement Account# 6869750033 Blueville Family Medicine 15 Main Street Blueville, CT 860-555-3212 Bank Statement January 1, 2009 Beginning balance $56,315.12 Ending balance $82,359.05 Check # 11029 11030 11031 Date of Transaction 12/15/08 12/19/08 12/19/08 12/19/08 11032 11033 11034 11035 11036 11037 11038 11039 11040 11041 11042 11043 11044 11045 Totals 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08 12/22/08
missing in sequence

860-555-1298 www.bluevillesavings.com

Average balance $72,625.42 Deposit Amount $11,231.44

Withdrawal $670.33 $311.90 $750.00 $200.00 $1588.55 $3014.39 $2043.22 $1325.33 $1246.67 $734.52 $584.11 $611.43 $476.28

Deposit Date 12/10/08

12/18/08

$12,776.01

12/19/08

$22,763.21

12/22/08 12/22/08
missing in sequence

$475.87 $294.13

12/24/08 checks and withdrawals

$6400.00 $20,726.73 deposits and $46,770.66 interest

CHAP TER 18

Accounting and Banking

277

Reconciling ofce and bank recordscontd

BANK STATEMENT END OF PERIOD BALANCE

82,359.05+ 492.56 136.12 1250.00 80,480.37

CHECK #11041

CHECK #11044

CHECK #11046

THIS TOTAL SHOULD MATCH THE BALANCE IN THE DEPOSIT AND WITHDRAWAL REPORT.

PROCEDURE 18-3

Reconciling a bank statement

Task Reconcile the monthly deposit and withdrawal report with a bank statement. Conditions Computerized monthly deposit and withdrawal report Bank statement Adding machine Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully reconcile the deposit and withdrawal report with a bank statement. Performance Standards 1. Using the bank statement dated April 1, 2008, and the deposit and withdrawal report for that same period (below), compare the totals and note the difference in the amounts, if any. 2. Compare each withdrawal and deposit on the bank statement to the report. 3. In comparing each item, be sure to determine if the amounts on the statement and the report match to prevent discrepancies in totals. 4. For each matching item, make a check mark next to the item on the report and the corresponding item on the bank statement to track your progress and ensure no items are missed. 5. Draw a circle around any item on the report that is not also included on the bank statement as well as any item on the statement that is not on the report to determine outstanding checks, uncredited deposits, or errors. 6. Using the adding machine, add all circled withdrawals. Then add all circled deposits on the report. 7. Subtract the total outstanding withdrawals from the bank statement ending balance. 8. Add the total outstanding deposits to the bank statement ending balance. 9. Conrm that the resulting amount matches the balance of the deposit and withdrawal report.

Continued

278

UNIT 2

Administrative

PROCEDURE 18-3contd
Blueville Savings Bank 122 Main Street Blueville, CT 06000 Statement Account s#6869750033 Blueville Family Medicine 15 Main Street Blueville, CT 860-555-3212 Bank Statement April 1, 2008 Beginning balance $59,008.31 Ending balance $57,778.19 Check # 11733 11734 11735 11736 11737 11738 11739 11740 11741 03/09/08 03/09/08 11742 11743 11744 11745 11746 Totals 03/21/08 checks and withdrawals 03/09/08 03/09/08 03/09/08 Date of Transaction 03/08/08 03/09/08 03/09/08 03/09/08 03/09/08 03/09/08 03/09/08 Withdrawal $458.25 $611.90 $734.47 $1248.22 $3019.39 $2033.22 $1338.33
missing in sequence

860-555-1298 www.bluevillesavings.com

Average balance $55,715.89 Deposit Amount $8,231.44

Deposit Date 03/14/08

03/21/08

$11,772.11

$324.11 $250.00 $475.88 $294.11 $1585.55

missing in sequence

$6400.00 $18,773.43 deposits and $20,003.55 interest

Deposit and Withdrawal Report March 2008

Number Date Description of Transaction Previous balance Payroll- Kelly Manera, CMA Payroll- Cindy Smith, CMA Payroll- Sharon Piecek, APRN Payroll- Henry Lee, MD Payroll- Robert Greer, MD Payroll- Hector Rodriguez, MD Payroll- Ann Wilson, MD Payroll- Shelly Gonzalez, CMA Payroll- Jennifer Morgan, CMA Payroll- Wendy Jones Payroll- Carol Chapin Payroll taxes Cash withdrawal for office party supplies Patterson Office Supply Deposit insurance & personal cks Henderson Realty- Office rent for April 2008 Deposit insurance & personal cks Deposit insurance & personal cks C Debit () Credit (+) Balance $59,008.31 $58,550.06 $57,938.16 $57,203.69 $55,955.47 $52,936.08 $50,902.86 $49,564.53 $49,208.45 $48,884.34 $48,408.46 $48,114.35 $46,528.80 $46,278.80 $46,142.68 $54,374.12 $47,974.12 $11,772.11 $9,763.07 $59,746.23 $69,509.30

11733 11734 11735 11736 11737 11738 11739 11740 11741 11742 11743 11744

03/07/08 03/07/08 03/07/08 03/07/08 03/07/08 03/07/08 03/07/08 03/07/08 03/07/08 03/07/08 03/07/08 03/07/08 03/09/08 03/11/08 03/14/08

$458.25 $611.90 $734.47 $1248.22 $3019.39 $2033.22 $1338.33 $356.08 $324.11 $475.88 $294.11 $1585.55 $250.00 $136.12 $8,231.44 $6400.00

11745

11746

03/16/08 03/21/08 03/31/08

CHAP TER 18

Accounting and Banking

279

CENTS

DEPOSIT TICKET
Blueville Family Medicine 15 Main Street Blueville, CT 860-555-3212

DOLLARS

Date
200033
LIST CHECKS INDIVIDUALLY

CURRENCY

Total from other side

TOTAL

COIN

PLEASE ENTER TOTAL

Blueville Savings Bank 122 Main Street Blueville, CT 06000 860-555-1298 www.bluevillesavings.com

PLEASE BE SURE ALL ITEMS ARE PROPERLY ENDORSED

001001

6869750033

12345678

ADDITIONAL CHECK LISTING SPACE

CENTS

10

11

12

13

14

15

15

16

17

18

19

20

21

22

23

24

25

26

27

FIG 18-10 Deposit slip.

PROCEDURE 18-4

Preparing a bank deposit

Task Prepare a bank deposit. Conditions Bank deposit form Checks (insurance and patient checks) Cash received Ofce checkbook register Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully prepare a bank deposit and record the deposit in the ofce checkbook register. Performance Standards 1. Using the personal checks from patients (below), the United Health Systems check from Procedure 18-1 on page 264, and the bank deposit form in Figure 18-10 enter the check numbers and amounts of all checks on the deposit slip. 2. Total the cash received from the day sheet on page 264 and enter the amount on the deposit slip in the appropriate section. 3. Total the amount of the checks and cash using an adding machine. Recheck your total to avoid errors. 4. Write the total amount of the deposit in the total column. 5. Write the amount of the deposit in the ofce checkbook register (below) and add it to the previous balance. 6. Recheck your math before writing the new balance in the register to ensure accuracy.

28

TOTAL

ENTER TOTAL ON FRONT

DOLLARS

Continued

280

UNIT 2

Administrative

PROCEDURE 18-4contd

Brenda Capshaw 1 Circle Drive Redtown, CT 06111

PAY TO THE ORDER OF

457

April 19, 2008

$

DATE

Blueville Family Medicine

Fifteen and
Blueville Trust Blueville, CT Michael McGuinniss 7125 Main Street Blueville, CT 06101
PAY TO THE ORDER OF

15.00 no/100

DOLLARS

Brenda Capshaw
3239

April 19, 2008

$

DATE

Blueville Family Medicine

20.00
DOLLARS

Twenty and
Blueville First Bank Blueville, CT
FOR

no/100 Michael McGuinniss

123 456 7

123456780

0301

Charles Ayers 1719 Lake Avenue Green Lake, CT 06088

PAY TO THE ORDER OF

466

April 19, 2008

$

DATE

Blueville Family Medicine

15.00
DOLLARS

Fifteen and
1st Green Lake Bank Green Lake, CT Alicia Carter 43 East End Avenue Redtown, CT 06111
PAY TO THE ORDER OF

no/100 Charles Ayers

337

April 19, 2008

$

DATE

Blueville Family Medicine

20.00
DOLLARS

Twenty and
1st Green Lake Bank Green Lake, CT
FOR

no/100 Alicia Carter

456 7

123456780

0301

123

Kirsten Tremblay 231 Purple Place Blueville, CT 06000

PAY TO THE ORDER OF

199

April 19, 2008

$

DATE

Blueville Family Medicine

15.00 no/100
DOLLARS

Fifteen and
Blueville National Bank Blueville, CT
FOR

Kirsten Tremblay
456 7

123456780

0301

123

CHAP TER 18

Accounting and Banking

281

PROCEDURE 18-4contd

10549 Date To 4/16/08

Amount Deposit $66,387.45

10550 4/16/08 Date To Clinic One Supply $136.12 $66,251.33 $89,017.54

Amount

Deposit $22,766.21

10551 4/22/08 Date To Henderson Realty Office rent May 2008 Amount $6,400.00 Deposit $82,617.54

10552

4/22/08 Date To Yellow Page.com advertising Amount $1,250.00 Deposit $81,367.54

10553 Date To

BLUEVILLE FAMILY MEDICINE 15 MAIN STREET BLUEVILLE, CT 06100 860-555-3212

PAY TO THE ORDER OF

10553
DATE

$
DOLLARS

Amount Deposit BLUEVILLE SAVINGS BANK

FOR

010553

000000105

111111333301

282

UNIT 2

Administrative

Petty Cash
Patients who pay a copayment at each visit may require change for large bills. Having a petty cash drawer will allow front desk staff to take a $20 bill and give $10 change. The medical assistant can also use petty cash to pay for postage-due items received or supplies that are needed immediately. The medical

assistant should reconcile the petty cash drawer each day by using a computerized or manual log. (See Figure 18-11.) When the ofce manager or medical assistant makes the bank deposit, she can exchange large bills from petty cash for smaller bills (1-dollar bills and 5-dollar bills) so that the petty cash drawer will always have change when needed.

Date 04/10/08

Description Cash drawerbeginning of day COD delivery Dawson Medical Supply Total cash copays Office staff meeting lunches Deli delivery Take copay cash from drawer to deposit

Transaction amount $410.00

Total $410.00

Initials

CS, CMA CS, CMA CS, CMA

JM, CMA

04/10/08

$230.00

$190.00

04/10/08 04/10/08

$300.00 $73.00

$490.00 $417.00

04/10/08

$300.00

$117.00

CS, CMA

FIG 18-11 Petty cash log.

Chapter Summary

Accounting is an important component of any business, including the physicians ofce. Having an understanding of the nancial status of the practice, including how money is earned and how it is spent, enables long-term planning. Financial success of the business depends on using accounting information to make decisions regarding expenses and services offered. Complete, understandable bookkeeping practices ensure that money collected and spent is documented and appropriate. Federal and state taxes can be accurately assessed and paid only when complete documentation is available.

should receive a salary and some should be paid an hourly rate (plus overtime, possibly). After you have completed your time sheet, swap time sheets with others on the team and calculate the gross pay for the employee whose time sheet you have. Add a section for deducting 5% for retirement and a at rate (dollar amount indicated by your instructor) for health insurance coverage. Finally, calculate the gross pay amount to which you would apply federal taxes. 2. Divide into groups of three to ve students. Each group researches a different procedure for the physicians ofce to offer to patients. Research the cost of the equipment or supplies and the average charges for the procedure in your area. Create a cost ratio analysis of the procedure. Present your procedure to the class along with its cost ratio analysis.

Case Studies Team Work Exercises

1. Divide into teams of four to seven students and create a time sheet for each employee (student). Each employee should ll in the time sheet with hours worked, ranging from 18 to 45 hours, and choose a ling status (married or single and number of dependents). Some employees 1. Accounts receivable for your practice has increased over the past 6 months. Why might you see this type of trend? What corrective actions can be taken to increase revenues and therefore decrease accounts receivable? 2. X-ray lm costs have risen from $1.10 per 14 11 sheet to $2.00 per sheet. Assume a charge of $125.00 per x-ray

CHAP TER 18

Accounting and Banking

283

and salary and other supply costs per month of $2200. What is the cost ratio if the practice performs 150 x-rays per month? What is the cost ratio at the old lm cost? How many additional x-rays are needed to achieve the same cost ratio?

Brewer, P.C., et al.: Introduction to Managerial Accounting, 4th ed. New York: McGraw Hill, 2007. Payroll software: www.paycycle.com, www.adp.com, and www.surepayroll.com Up-to-date tax compliance rules: www.IRS.gov

Resources

American Medical Association: Maximizing Billing and Collections in the Medical Practice. Chicago: American Medical Association Press, 2007.

UNIT III
Clinical

CHAPTER

19 20 21 22 23 24

Infection Control and Medical Asepsis 285

CHAPTER

The Patient Interview 307

CHAPTER

Vital Signs 319

CHAPTER

Physical Examination 345

CHAPTER

Essentials of Medical Terminology 367

CHAPTER

Surgical Asepsis and Assisting with Minor Surgery 381

CHAPTER

25 26 27 28

Dermatology 411
CHAPTER

Neurology 435
CHAPTER

Cardiology and Lymphatics 461

CHAPTER

Pulmonology 495

CHAPTER

29 30 31 32 33

CHAPTER

40 41 42 43

Endocrinology 519
CHAPTER

Introduction to the Clinical Laboratory 849

CHAPTER

Gastroenterology 537
CHAPTER

Phlebotomy 867
CHAPTER

Urology and the Male Reproductive System 567

CHAPTER

Hematology and Coagulation Procedures 889

CHAPTER

Obstetrics and Gynecology 599

CHAPTER

Clinical Chemistry and Serological Procedures 903

CHAPTER

Pediatrics 641
CHAPTER

44 45 46 47 48 49

Urinalysis 919

34
CHAPTER

Geriatrics 683
CHAPTER

Microbiology 935

35
CHAPTER

Orthopedics 707
CHAPTER

Bioemergency Response and Preparedness 959

36
CHAPTER

Ophthalmology and Otolaryngology 745

CHAPTER

Ofce Emergencies 967

37
CHAPTER

Nutrition 777
CHAPTER

Radiology and Diagnostic Imaging 991

38
CHAPTER

Introduction to Pharmacology 805

CHAPTER

Externship and Career Strategies 1007

39

Dosage Calculation & Medication Administration 825

CHAPTER

Infection Control and Medical Asepsis

Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell the key terms presented in the glossary identify the role of the medical assistant in infection control identify disease-producing microorganisms list common infectious diseases identify the links in the chain of infection differentiate between the stages of disease describe the bodys defense mechanisms demonstrate the performance of hand washing with soap and water demonstrate the performance of hand sanitization with an alcohol-based hand rub explain standard precautions list common types of personal protective equipment describe strategies to increase health and safety in the workplace differentiate medical asepsis and surgical asepsis differentiate sanitization, disinfection, and sterilization demonstrate equipment and instrument sanitization demonstrate equipment and instrument disinfection demonstrate wrapping a pack for sterilization demonstrate the performance of sterilization using an autoclave educate patients regarding methods to reduce disease transmission.

19
Types of Infection Stages of Disease
Incubation Stage Prodromal Stage Acute Stage Declining Stage Convalescent Stage

CAAHEP Competencies
Clinical Competencies Fundamental Principles
Perform hand washing Wrap items for autoclaving Perform sterilization techniques Dispose of biohazardous materials Practice standard precautions

The Bodys Defense Mechanisms

Mechanical Defenses Chemical Defenses Cellular Defenses Inammatory response Immunity Active natural immunity Active articial immunity Passive natural immunity Passive articial immunity

General Competencies Patient Instruction

Provide instruction for health maintenance and disease prevention

ABHES Competencies
Clinical Duties
Apply principles of aseptic technique and infection control Wrap items for autoclaving

Standard Precautions
Personal Protective Equipment Disposal of Biohazardous Waste Vaccinations Exposure Control Bloodborne pathogen exposure Biohazard spill

Procedures
Washing hands with soap and water Sanitizing hands with an alcoholbased hand sanitizer Sanitizing equipment Disinfecting equipment Wrapping a pack for autoclaving Using an autoclave for sterilization

Asepsis
Sanitization Hand sanitization Sanitization of equipment and the environment Disinfection Sterilization Autoclave Chemical sterilization Types of Asepsis Medical asepsis Surgical asepsis

Chapter Outline
Infectious Disease Microorganisms and Pathogens
Bacteria Rickettsia Virus Fungus Protozoa

Chain of Infection
Pathogen Reservoir Host Means of Exit Mode of Transmission Means of Entry Susceptible Host

Chapter Summary Team Work Exercises Cases Studies Resources

287

Key Terms
antibody

purulent

Consisting of or containing pus Immunoglobulin produced by white blood cells in response to a specic antigen
antigen reservoir host

Organism that provides a hospitable environment in which pathogens can grow

Rickettsia

Marker that identies a cell as being part of the body (self) or not part of the body (nonself)
asepsis

Genus of bacteria that are intracellular parasites

sanitize

Practice of maintaining an environment free from pathogens

bacteria

To remove microorganisms from reusable equipment and surfaces by using chemicals, heat, or ionizing radiation
spores

One-celled organism, some of which are capable of producing disease

disease

Bacterial or fungal cells that are resistant to temperature extremes

symptomatic

Any condition characterized by subjective complaints, a specic history, clinical signs or symptoms, and laboratory or radiographic ndings
disinfection

Having symptoms, such as fever, sore throat, nausea, and vomiting

vector

Application of a substance to materials and surfaces to destroy pathogens

fomite

Carrier, usually an insect, that transmits a disease from an infected person to a noninfected person
virus

Any object that adheres to and transmits infectious material (such as a comb, countertop, or drinking glass)
fungi

Pathogen that can grow and reproduce only after infecting a host cell

Kingdom of organisms that includes yeasts, molds, and mushrooms and is usually not pathogenic to humans
incubation

Interval between exposure to infection and the appearance of the rst symptoms
infectious disease

Any disease caused by a microorganism that may be directly or indirectly transmitted between individuals, causing infection
microorganism

Living organism too small to be seen with the naked eye

normal ora

Organisms found on and in a persons body that do not cause disease

parasite

Pathogen requiring another living organism in order to survive

pathogen

Disease-producing microorganism
phagocytosis

Process in which specialized white blood cells (phagocytes) engulf and destroy microorganisms, foreign antigens, and cellular debris
prodromal

Interval between earliest symptoms and appearance of a rash or fever

protozoa

Organism mainly found in soil that is capable of producing disease

CHAP TER 19

Infection Control and Medical Asepsis

289

Infectious Disease
The health care environment is intended to be a place where people can nd help and healing. However, because it brings individuals together, many of whom have infectious diseases or weakened immune systems, it sets the stage for the very real possibility of disease transmission between patients and even health care staff. To prevent such transmission from happening, medical assistants must have an understanding of how disease is transmitted and how to take every reasonable precaution to reduce disease transmission in the medical ofce. A disease is any condition characterized by subjective complaints (sensations felt by the individual), a specific history, clinical signs, symptoms, and laboratory or radiographic findings. Infectious diseases, also called communicable diseases, are diseases caused by a microorganism that may be transmitted directly or indirectly between individuals, causing infection.

cocci (round-shaped) bacilli (rod-shaped) spirilla (spiral-shaped).

Rickettsia
Rickettsia are a genus of bacteria known as parasites, which are organisms that must live inside another living organism in order to survive. Rickettsia spread to humans via a vector, which is a disease carrier, that transmits a disease from an infected person to a noninfected person. Common vectors are insects, such as ticks, eas, mites, and lice. Examples of diseases transmitted by rickettsia are typhus and Rocky Mountain spotted fever.

Virus
A virus is a pathogen that can grow and reproduce only after infecting a host cell. There are more than 400 types of viruses and they usually act in a parasitic fashion by invading the individuals healthy host cells and taking them over. They then use the host cells RNA and DNA (genetic material) to reproduce. They are the smallest pathogens and are difcult to treat because the protein in their outer cell membrane prevents antibiotics from affecting them. Viruses cause such diseases as the common cold, hepatitis, chicken pox, and human immunodeciency virus (HIV).

Microorganisms and Pathogens

Microorganisms are microscopic living organisms, or living organisms too small to be seen with the naked eye. Many different types of microorganisms exist in the environment; however, not all are connected to disease. Those that normally live on and in the human body are known as normal ora. A healthy balance of these microorganisms normally exists and provides protection from those that are not part of the bodys normal ora. However when this balance is disturbed, a person becomes more vulnerable to illness and disease. Pathogens are microorganisms that are capable of producing disease. To grow and thrive, most pathogens require nutrients, moisture, warmth, and a suitable (usually neutral) pH environment. Thus, some parts of the human body tend to provide a more hospitable environment for pathogenic growth than others. Some, called aerobic, require oxygen; those that must have an oxygen-free environment are called anaerobic. There are ve main types of pathogens:

Fungus
A fungus is a simple, single-celled organism, such as yeast, or multicellular colonies, such as mold and mushrooms. Examples of the disease they cause in humans include tinea infections (athletes foot, ringworm, and so forth) and candidiasis (yeast infections). However, most fungi do not cause disease and are present in the bodys normal flora.

Protozoa
Protozoa are disease-causing microorganisms that live mainly in soil. They commonly infect persons with low immunity. Protozoan infections are spread through the fecal-oral route, by ingesting contaminated food or water, or by mosquitoes or other insects carrying the infection. Examples of common protozoan infections are malaria, Giardia, and a vaginal infection called trichomoniasis. (For more information on pathogenic microorganisms, see Chapter 45, Microbiology, page 937.)

bacteria Rickettsia virus fungus protozoa.

Bacteria
Bacteria are one-celled organisms that cause such diseases as Staphylococcus infection, Streptococcus infection (Strep throat), gonorrhea, and Lyme disease. There are three types of bacteria:

Chain of Infection
Understanding how microorganisms are spread and persons infected will help the medical assistant more effectively protect

290

UNIT 3

Clinical

herself and her patients. (See Preventing disease transmission.) This chain of infection is a series of steps that must occur for disease to spread. Infectious diseases can only spread if all of the links in the chain of infection are active. Therefore, a medical assistant can stop the spread of disease by breaking any link in the chain. The elements of the chain include:

Front ofceBack ofce connection

Preventing Disease Transmission

Microorganisms are introduced into the physicians ofce on a daily basis by ill patients who speak, cough, sneeze, and touch things with contaminated hands. By doing so, they spread pathogens throughout the reception area and examination rooms. To help break the cycle in the chain of infection, administrative and clinical medical assistants must team up in their efforts to keep the environment as clean as possible. Administrative medical assistants may be responsible for cleaning countertops, windows, and other surfaces in the reception area. Clinical medical assistants may be responsible for cleaning surfaces and equipment in the clinical areas between patients. However, preventing disease transmission is everyones job, so all members of the team should work together in a cooperative fashion. In addition, they can make sure hand sanitizers and tissues are available to patients in all areas and teach them the importance of hand washing.

pathogen reservoir host means of exit mode of transmission means of entry susceptible host. (See Figure 19-1.)

Pathogen
Pathogens are the rst link in the chain of infection. They exist in the everyday environment and usually thrive in warm, moist environments. Those that are present in the blood that can be transmitted through blood or body uids are called bloodborne pathogens. Examples of common bloodborne pathogens are HIV, hepatitis C, and hepatitis B. Those that are usually harmless but become pathogenic under specic circumstances, such as exposure to an immunocompromised host, are called opportunistic pathogens.

Reservoir Host
A reservoir host is an organism from which pathogenic organisms such as bacteria or viruses obtain their nourishment.

Thrives in warm, moist environment 1 Pathogenic microorganism 6 Susceptible host 2 Reservoir host

Weak immune system increases susceptibility

Nourishes pathogenic organism

Mucous membranes Wounds

5 Means of entry 4 Mode of transmission Direct or indirect Fomites Vectors Airborne FIG 19-1 Chain of infection.

3 Means of exit

Mucous membranes Blood and body fluids Wounds

CHAP TER 19

Infection Control and Medical Asepsis

291

It provides a hospitable environment in which the pathogen can grow. Living infected hosts may be symptomatic (having noticeable signs of disease) or may be asymptomatic (free of symptoms). The reservoir host is considered contagious and can spread the disease to others.

Patient Education

Breaking the Chain

To help patients avoid infectious disease, the medical assistant should teach these commonsense strategies to help them protect themselves against pathogens: Wash your hands frequently throughout the day, especially during cold and u season, as well as after using the toilet, after blowing your nose, and before eating. Teach children how to wash or sanitize their hands. Avoid crowds during cold and u season, if possible. Avoid others who are ill. Avoid going to work when ill. Do not send ill children to school. Cover coughs and sneezes with your arm, rather than your hand. Avoid sharing drink containers and eating utensils. Use hand sanitizer when warm water and soap are not available. Avoid unprotected sexual encounters. Avoid touching your eyes, nose, and mouth. Use hand sanitizers, if available, in medical ofces and grocery stores.

Means of Exit
A common way for pathogens to leave a reservoir hosts body is via the mucous membranes. Therefore, any opening of the body that is lined with mucous membranes becomes a potential exit site. Examples include the eyes, nose, mouth, throat, vagina, and rectum. Another exit site might be an interruption in the normal protective structures of the body, such as injury or surgery to the skin and underlying tissues. Pathogens can also exit the body via blood and such body uids as semen, vaginal secretions, urine, and feces.

Mode of Transmission
A pathogen can be transmitted to another person by direct or indirect contact. Examples of direct contact include skin-toskin contact such as hand shaking or kissing or the exchange of body uids such as with needle sharing or sexual contact. Pathogens may also be transmitted via indirect contact with inanimate objects called fomites. Virtually any object can be a fomite. Common examples include countertops, hairbrushes, combs, door knobs, drink containers, handles of shopping carts, and pencils. Another type of transmission occurs via vectors, which are usually insects or other arthropods such as eas, lice, ticks, and vermin that carry pathogens from infected to noninfected individuals. Airborne transmission, a form of indirect transmission, occurs when an infected individual sprays pathogens into the air by coughing or sneezing. Another individual then inhales the pathogen from the air and becomes infected. Tuberculosis is an example of a disease that is spread by airborne transmission.

use, excessive alcohol intake, and use of illicit drugs. (See Breaking the chain.)

Types of Infection
Infections can be categorized according to their general duration and whether they occur only once or recur repeatedly. There are three types of infection:

Means of Entry
Pathogens gain entry to the body in much the same way as they exit it, usually via contact with mucous membranes or a break in the skin. Therefore, potential entry sites include the eyes, nose, mouth, throat, vagina, and rectum as well as any wounds to the skin.

Susceptible Host
If a host is susceptible, pathogens will grow and multiply, eventually reaching an infectious level. There are a number of conditions that increase host susceptibility and most contribute to a weakened immune system. Common examples include poor hygiene, poor nutrition, stress, other underlying diseases or disorders, some medications, age (very young and very old), and self-destructive behaviors such as tobacco

Acute infections typically have a quick onset and short duration. There may or may not be a clear prodromal phase in which symptoms are generally nonspecic. The duration is usually 1 to 3 weeks. An example is the common cold. Chronic infections last for a long time, sometimes for years or even a lifetime. The patient may be asymptomatic or symptoms may uctuate. An example of a chronic infection is hepatitis C. Latent infections are those in which patients experience alternating periods of being symptomatic (relapse) with periods of being symptom-free (remission). The infecting organism, usually a virus, never leaves the body but lies dormant between relapses. A common example is the herpes viruses, which can cause intermittent outbreaks of oral lesions, genital lesions, and shingles.

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Stages of Disease
There are several stages in the disease process. The rst begins when pathogens rst come in contact with and gain access to the body and the last ends when patients are no longer ill and have fully recovered. The duration and severity of the entire process is highly variable. In some cases, it lasts a few short days and in other cases for weeks or even months. Some diseases are so disabling that infected individuals are bedridden, and others are so mild that infected individuals experience few symptoms and continue to carry out their normal daily activities. Stages of disease include:

temperature. Patients who are febrile (have a fever) also commonly complain of such generalized symptoms as malaise (feeling of discomfort), fatigue, weakness, and generally feeling unwell.

Acute Stage
The acute stage is when symptoms peak and the patient feels the worst. He continues to be contagious and should avoid others in order to prevent spreading the disease. He should heed medical advice, which commonly includes taking prescribed medications, resting, and drinking nonalcoholic and noncaffeinated beverages.

incubation prodromal acute declining convalescent. (See Figure 19-2.)

Declining Stage
The declining stage begins with the end of the acute stage. It is characterized by a continuation of the disease but a lessening of the symptoms. The patient notices that he is beginning to feel better and may wish to begin resuming normal activities.

Incubation Stage
The incubation stage, sometimes called the latent period, is the beginning stage of an infectious disease and starts at rst contact with the pathogen. During this stage, the patient may be asymptomatic but is commonly considered contagious. The incubation stage is the interval between exposure and the appearance of the rst symptoms. Incubation time varies from days to weeks or months, depending on the disease.

Convalescent Stage
The convalescent stage of disease is the recovery period. It begins when disease symptoms disappear and continues until the patient has regained full strength and returns to a normal state of health. The medical assistant should caution patients to avoid overexertion or prematurely discontinuing medical or other therapies during the declining and convalescent stages. Doing so could cause a relapse. (See Taking medications as prescribed.)

Prodromal Stage
The prodromal stage marks the interval between the earliest symptoms and the appearance of a rash or elevated

The Bodys Defense Mechanisms

Exposure Incubation stage Asymptomatic

The bodys natural protective mechanisms normally work amazingly well to protect human beings from pathogens. There are three main types of defense mechanism:

Pathogens multiply

Prodromal stage Symptomatic Fever or rash

May be contagious

mechanical chemical cellular.

Acute stage Symptoms peak

Mechanical Defenses
Mechanical defenses include certain structures and functions of the body. For example, the skin is a structure that protects a person from the external environment. Tiny hairs within the nasal cavity help lter the air by removing debris. The lower airways are lined with special membranes that have cilia (threadlike projections) that move in a wavelike fashion to propel debris upward so that it can be coughed out or swallowed. Protective reexes, such as coughing and sneezing, are triggered by the presence of foreign debris in the respiratory tract. A cough is a forceful expiratory effort

Declining stage Symptoms lessen

Convalescent stage Asymptomatic Return of strength and function FIG 19-2 The stages of disease.

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Patient Education

Taking Medications as Prescribed

Many patients who fail to take their medication as prescribed are labeled noncompliant by their health care providers. However, many patients may not understand why the medication should be taken a certain way. The medical assistant should strive to explain to patients why they should take medication as prescribed. If they understand, patients are more likely to comply with the treatment plan. Here are some common reasons why patients do not take medications as prescribed: Feeling better. Some patients think they no longer need the medication when they begin feeling better. In some cases, as with pain medication, this perception is accurate. However, the effectiveness of such medications as antibiotics depends on completion of the full course of treatment. Discontinuing early could cause a relapse and worsening of the illness. Furthermore, discontinuing medication early exposes the pathogens to the medication without fully destroying them. This brief but inadequate exposure is a major contributor to the rise in antibiotic-resistant organisms so prevalent today. Saving some for later. Some patients discontinue medication early so they will have some left for future use. This practice is dangerous, of course, because the current medication may not be the best choice for whatever future illness arises. Furthermore, having only a small amount of medication like antibiotics may be worse than having none at all, leading to relapse or drug resistance, as discussed. Fitting the schedule. Some patients change dosing times or frequencies to t better with their daily schedule. Changing dosing times is sometimes okay, but the medical assistant should encourage the patient to check with the physician before making any changes. Increasing the dose. Some patients take more than the prescribed dose hoping for an increased effect or a faster response. Doing so puts them at risk for drug toxicity but does not increase the healing benet. Reducing the effects or cost. Some patients take less than the prescribed dose, hoping to reduce unpleasant adverse effects, save money, or make the medication last longer. Doing so results in decreased effectiveness of the medication and provides no benets to the patient. If the patient feels the adverse effects of a drug are unacceptable, the medical assistant should encourage him to consult with the physician regarding possible solutions.

that is difcult, if not impossible, to suppress and can literally be lifesaving. When an individual sneezes, air is expelled forcefully though the nose and mouth by a spasmodic contraction of muscles that normally facilitate respiration. This action helps clear irritating debris and microorganisms from the nasal passages. Other physical protective mechanisms in the body include the ushing action of certain body uids. For example, the tear glands of the eyes produce a uid that continually bathes and cleanses the eyes. Because the eyes are extremely sensitive, when foreign particles enter them the tear glands respond by increasing production of tears to ush the debris away. Flushing action also occurs in the urinary tract where urine is produced in the kidneys and follows a one-way path through the ureters (long, narrow tubes) to the bladder and out of the body via the urethra. This one-way ow of uid helps prevent pathogens from moving upward through the urethra into the urinary tract, where they might cause infection.

Chemical Defenses
The body has some chemical barriers that help protect it from pathogens. For example, the skin contains sebaceous glands, which are present nearly everywhere except the palms of the hands and soles of the feet. These glands secrete an oily substance that not only helps keep skin supple and healthy but actually kills some types of pathogens. The uids in the stomach are normally very acidic, which effectively kills most swallowed pathogens. The uid in tears and the urinary tract is also somewhat acidic, which is generally not conducive to bacterial growth. In addition, the body produces a group of glycoproteins (compound of carbohydrate and protein), called interferons, that have antiviral activity. Some are produced by white blood cells in response to pathogen invasion, especially viruses. They help mark the invading pathogens for destruction. They also inhibit virus production within infected cells. Various types of interferons are used to treat diseases such as hepatitis B and C, Kaposis sarcoma, and multiple sclerosis. Also, some enzymes produced by the body protect against pathogens. A great example is lysozyme. This enzyme, which is present in tears, saliva, and other bodily secretions, acts to inhibit the growth of bacteria by damaging their cell walls.

Cellular Defenses
Various cells also act to protect the body from pathogens. These defenses include:

inammatory response cell-mediated immunity antibody-mediated immunity.

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Inammatory Response
The inammatory response is the bodys immediate immunological defense against injury, infection, or allergy. This response protects the body from invasion by foreign pathogens and sets in motion a series of events that repair tissue damage. In the inammatory response, tissue trauma causes the release of several chemicals that cause inammation:

Histamine is a chemical that causes a variety of responses, depending on the site of injury. In soft tissue, it causes the dilation of blood vessels, which helps improve circulation to the injured area and increases the arrival of white blood cells to the scene. Prostaglandins are hormones that are formed rapidly and act in the immediate area of the injury. They produce vasodilation, vascular permeability, and platelet aggregation and stimulate pain receptors. Kinin is a chemical that increases blood ow and the permeability of small blood capillaries. (See Figure 19-3.)

itself. For example, the increase in circulation and vessel permeability allows specialized white blood cells (phagocytes) to enter the injured area and begin engulng and desbroying microorganisms, foreign antigens, and cellular debris in a process known as phagocytosis. (See Figure 19-4.) Increased circulation also brings oxygen and nutrients to the area so that repair can occur. However, edema (swelling) can contribute to the patients discomfort. In addition, the chemicals that set the whole process in motion also cause increased pain perception. When the bodys natural defenses are unsuccessful in eliminating invading organisms, infection may occur. However, inammation and infection are not the same. Symptoms of localized infection are similar to those of inammation but may become more pronounced. In infection, such signs of inammation as redness, swelling, heat, and pain may be present along with fever and generalized malaise. Localized sites of injury may produce purulent, or pus-containing, drainage, which is rich in dead white blood cells, bacteria, and cellular debris.

As a result, localized inammation occurs, indicated by redness, swelling, heat, pain, and decreased function. Some of these changes indicate that the body is at work healing

Immunity
Immunity is dened as protection from infectious disease. Immunity is categorized as active or passive. Active and

Injury Skin 1 Injury

5 Heat, edema, pain

Phagocyte Bacteria 2 Release of histamine Histamine 4 Attraction of phagocytes to injured area

Blood vessel

3 Dilation and increased permeability of blood vessel

FIG 19-3 Inammatory response.

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Passive Natural Immunity

1. Phagocyte approaches bacteria

2. Phagocyte engulfs bacteria

4. Phagocyte returns to normal 3. Phagocyte eliminates bacteria

Passive natural immunity develops when already formed antibodies are passed from mother to fetus across the placenta during pregnancy. A pregnant woman has, through the course of her life, been exposed to a variety of pathogenic organisms and developed antibodies against many of them. Some of these antibodies cross the placenta to the fetus. After the infant is born, the antibodies continue to provide protection against disease for several months. In addition, if the woman breastfeeds the infant, additional antibodies are passed to the infant through breast milk. In both cases, the preformed antibodies passed to the infant help to protect him until his body begins developing his own antibodies.

Passive Articial Immunity

Passive articial immunity develops when preformed antibodies are developed in an animal or in another human and are then injected into an individual who has experienced a known exposure. This introduction of antiserum provides the individual with temporary passive immunity. Situations in which such an injection might be given include known exposures to rabies, botulism, venomous snakes or spiders, hepatitis, and diphtheria. (See Figure 19-5.)

FIG 19-4 Phagocytosis.

passive immunity are further categorized as acquired naturally or articially.

Standard Precautions
Safety in the medical ofce is of utmost importance, including protecting staff and patients from injury and disease transmission. Two organizations that play an important role in safety guidelines and regulation in medical ofces are the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA). In the 1980s, the CDC created a set of guidelines called universal precautions to instruct health care providers on how to minimize the risk of disease transmission when providing

Active Natural Immunity

Active natural immunity develops when the body is exposed to a pathogenic microorganism. All microorganisms contain antigens, which are markers that identify cells as being part of the body (self ) or not part of the body (nonself ). Antigens on the bodys own cells are called autoantigens and all others are foreign antigens. During the initial exposure to the pathogen, a person usually develops symptoms of disease. This initial exposure also stimulates white blood cells to develop antibodies, which are immunoglobulins specically tailored to that pathogens antigen. Those antibodies later combine with that antigen when it presents itself again (during a second exposure) to mark the microorganism for destruction by macrophages, another type of white blood cell.

Acquired immunity

Active immunity

Passive immunity

Active Articial Immunity

Active artificial immunity develops when an antigen is purposely introduced into a persons body in the form of a vaccine. Examples of vaccines include mumps, measles, and rubella (MMR) or oral poliomyelitis vaccine (OPV). Vaccines generally contain a live, altered (weakened) microorganism or all or part of a dead microorganism. The antigen in the vaccine has been altered in some way so that it will stimulate antibody formation without causing disease.
Natural Antigens enter the body by natural means. The bodys immune system responds by producing antibodies. Artificial Antigens are introduced into the body by means of a vaccine. Natural Antibodies are passed from a woman to her fetus through the placenta or her infant through breast milk. Artificial Already formed antibodies in serum are introduced into the body via injection.

FIG 19-5 Types of immunity.

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care. The CDC later revised the guidelines and renamed them standard precautions. The revision expanded the guidelines to cover more body uids and routes of exposure. In general, standard precautions advise health care providers about the handling of any blood or body uids (except sweat) that might contain blood or infectious organisms. Such body uids include semen, vaginal secretions, cerebrospinal uid (CSF), synovial joint uid, pleural uid (from the lining of the lungs), peritoneal uid (from the abdominal cavity), pericardial uid (from between the heart and its lining), amniotic uid, and any other body uid or substance that contains visible blood. The Occupational Safety and Health Administration (OSHA) is regulated by the U.S. Department of Labor to ensure safe, healthy working conditions for Americans. OSHA guidelines for bloodborne pathogens were developed to decrease the transmission of diseases in the workplace. Upon hire, medical assistants learn about OSHA guidelines relevant to medical ofce safety and must review them on a regular basis, usually annually. OSHA guidelines dictate that employers provide workers with personal protective equipment (PPE), supplies, and equipment required for the safe disposal of contaminated or dangerous items. Regulations also include mandatory vaccinations against communicable diseases and protocols to follow in the event of an exposure.

FIG 19-6 Personal protective equipment (PPE).

Personal Protective Equipment

The practice of standard precautions requires health care providers to wear PPE that is appropriate to each situation, depending on the degree of risk. In the medical ofce, common PPE includes such items as gloves, masks, eye protection, shoe covers, and gowns to wear during minor ofce surgeries and procedures when there is a risk of contact with blood or body uids. The medical assistant and other staff should wear PPE that ts adequately and should replace it if it becomes contaminated or damaged. She should appropriately discard gloves that have become contaminated, punctured, or torn and replace them immediately. Appropriate eye protection includes a face shield or safety glasses that prevent splashing into the eyes. (See Figure 19-6.) needles, scalpel blades, capillary tubes, and broken glass or slides. She must dispose of such items in puncture-resistant containers. Furthermore, the medical assistant should never recap an uncapped needle, especially one that is contaminated (used), and should carefully examine trays and work areas for needles or any sharp objects after procedures are completed. She can do so safely by sorting through instruments and supplies with a pair of forceps, rather than by hand. She can then use the forceps to pick up and discard items as needed.

Disposal of Biohazardous Waste

Containers that hold blood or body uids, such as those used to store or transport specimens, and containers with regulated waste are required to have the biohazard label. (See Figure 19-7.) Red leakproof bags are used for such contaminated supplies as gloves, gauze, bandages, gowns, and linens.

Sharps and Needlestick Safety

The medical assistant must develop careful habits regarding handling materials that are considered sharps, such as

BIOHAZARD
FIG 19-7 Biohazard symbol.

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Medical assistants must be in the habit of removing and replacing sharps and biohazard containers before they are full. This reduces risk of injury from trying to place items in a container that is too full. Furthermore, medical assistants must know the policy and procedure for disposal of biohazard waste at the facility in which they work. In the year 2000, the U.S. Congress signed into law the Needlestick Safety and Prevention Act in an effort to reduce the occupational exposure from sharps injuries. This act was a modication of OSHAs Bloodborne Pathogens Standard and provided more specic directives to employers to identify, evaluate, and implement safer medical devices and to maintain a sharps injury log. (See Protecting each other.)

Vaccinations
In most cases, a medical assistant must provide documentation of all necessary vaccinations prior to employment. Examples include the hepatitis B vaccination and testing for tuberculosis exposure. If the medical assistant has not completed certain vaccinations, the CDC requires the employer to provide them at no cost to the employee within 10 days of becoming employed. The hepatitis B vaccine is administered in a series of three injections; the second injection is administered 6 weeks after the rst, and the third injection is administered 6 months after the rst. An employee can decline to receive the immunization by completing and signing the proper paperwork, which the ofce manager will keep in her employee le. If the employee later requests the immunization, the CDC requires the employer to make it available.

Front ofceBack ofce connection

Exposure Control
In the event of exposure to a pathogen, the medical assistant must follow the facility policy, which is dictated by several guidelines and requirements set by government agencies. Most exposure control guidelines address exposure to a bloodborne pathogen or a biohazardous material spill.

Protecting Each Other

Accidents involving contaminated substances are common in health care. Many incidents where a health care worker suffers an injury are the result of the sloppy habits of coworkers. Here is a small sample of such events: A housekeeper is stuck by a contaminated needle left in a bundle of soiled linens. A medical assistant cleaning up after a procedure is stuck in the nger by a suture needle left on the tray. As a medical assistant reaches for an overowing biohazard container placed on an upper shelf in a dirty utility room, it opens and spills its contents over his face. A nurse pulls up a nearby chair to sit in while engaged in a conversation with a patient, not noticing the uncapped syringe and needle left there by the laboratory technician, and so sits on the contaminated needle. A laboratory technician retrieves a specimen left by a medical assistant. The specimen lid has come loose in transport and contaminated uid has spilled inside of the specimen bag and soaked the outside of the specimen cup. A kitchen worker in a local hospital is poked by a contaminated needle left on a meal tray by a nurse. What do these events have in common? Members of the health care team were needlessly endangered by the sloppy habits of their coworkers. The safety and wellbeing of all health care workers depends on each others good habits.

Bloodborne Pathogen Exposure

If a medical assistant or other staff member is exposed to a bloodborne pathogen, the employee must wash or ush the exposed area and then report the incident to the employer right away. OSHA guidelines require employers to develop exposure control plans and make these plans known to employees. The employee involved must document the event by completing an incident report. The employer is also required to follow up on the exposure incident by documenting the exposure and related circumstances and identifying the source individual and the status of the source individual if he consents to testing for human immunodeciency virus (HIV) or hepatitis B virus (HBV). The employer must offer the employee the option of having her blood tested for HIV and HBV as well as post-exposure treatment in accordance with the current recommendations from the U.S. Public Health Service. Furthermore, the employer must provide counseling to the employee regarding precautions she must take and what possible illness signs or symptoms to report.

Biohazard Spill
The medical assistant must be familiar with ofce protocol and CDC recommendations for responding to a biohazard spill. The rst priority is protecting herself by applying gloves and other PPE. Next, she should contain the spill with paper towels and then cover the entire spill with 10% bleach solution and let it stand for at least 20 minutes.

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When cleaning up the spill, she must use a mechanical device, rather than her hands. She should then place all items in a biohazard container and repeat the bleach application, waiting another 20 minutes. She must document the incident according to ofce policy.

Asepsis
Asepsis refers to a condition free from pathogens. There are three levels involved in asepsis:

microorganisms on the skin, and cause minimal skin irritation. They take less time to use than soap and water and require no towel drying. Additionally, allergic responses to these products are rare. (See Procedure 19-2: Sanitizing hands with an alcohol-based hand sanitizer, page 300.) The medical assistant must still wash her hands with warm water and soap after several hand sanitizer uses or whenever hands are visibly soiled. In either case, sanitizing the hands in view of the patient sets a good example and assures him that the medical assistant is using proper aseptic technique.

sanitization disinfection sterilization.

Sanitization of Equipment and the Environment

Sanitization decreases the number of microorganisms from reusable equipment and surfaces. To sanitize an instrument, the medical assistant will usually rinse it under cold water and scrub it with an enzymatic detergent. In some cases, the medical assistant might use an ultrasonic bath where sound waves cause vibrations to loosen debris from instruments. Sanitization allows the heat, gas, or sterilizing chemicals to penetrate all surfaces. It must occur before disinfecting and sterilizing can take place. When performing sanitization, the medical assistant should wear utility or heavy-duty gloves and other PPE, such as goggles, to reduce the risk of exposure to contaminated materials. She must rinse all instruments and equipment under cool running water. For increased efciency, the medical assistant should try to rinse instruments as soon as possible after use. After rinsing, the medical assistant should clean them by removing debris with a scrub brush. She must carefully scrub all parts of an instrument, including hinges, ratchets, and serrations. At this point, it is also best to check each piece of equipment to ensure it is in proper working order. The medical assistant should try to use detergents that produce no suds or low suds. To prevent self-injury, the medical assistant should point instruments with sharp edges away from her body while cleaning them. She should rinse items with hot water and dry them thoroughly, leaving hinged instruments in the open position. (See Procedure 19-3: Sanitizing equipment, page 300.) In addition to equipment, the medical assistant must sanitize the environment of the medical ofce, including such surfaces as countertops and examination tables. Such solutions as a combination of 10 parts water to 1 part household bleach are inexpensive, easy to use, and effective. Other commercial sanitizing solutions are available and effective as well. Regardless of the products used, the medical assistant should always take time to read the labels, follow the directions, and note the material safety data sheet (MSDS) information, which provides data about ingredients and measures to take in the event of a spill or exposure. This information is provided by the manufacturer of each substance and is included on the individual package labels. Each medical ofce must also keep copies of this information on-site.

Sanitization
Sanitization of an object or surface, or the removal of microorganisms using chemicals, heat, or ionizing radiation, is the rst line of defense in ensuring asepsis in the health care environment. The single most effective standard precaution practice that breaks the chain of infection and protects everyone is consistent, proper hand hygiene and sanitization. Proper sanitization of equipment and supplies is also essential.

Hand Sanitization
Standard precautions dictate cleaning the hands with soap and warm water or with an antiseptic agent prior to and immediately after any direct contact with patients, after any potential contact with pathogenic organisms, after using the toilet, and any time the hands become visibly soiled. Other times to sanitize the hands include the beginning of each work day, before and after placing patients in examination rooms, before and after cleaning examination rooms, before and after assisting the physician with procedures, before and after cleaning equipment, before putting on gloves, after removing gloves, before and after taking a break, before eating or drinking anything, and at the end of each work day. When washing her hands, the medical assistant must remember to cover all parts of her hands with soap and water, rub them together to create friction for at least 15 seconds, and then rinse well. (See Procedure 19-1: Washing hands with soap and water.) Alcohol-based hand sanitizers contain 60% to 95% ethanol or isopropyl alcohol. When the medical assistant uses an alcohol-based hand sanitizer, she should follow the manufacturers directions, which generally include covering all hand surfaces with the sanitizer, including the hands, the ngers, between the ngers, and the wrists. She should then allow her hands to air dry. There are several advantages to alcohol-based hand sanitizers. They act fast, signicantly reduce the number of

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PROCEDURE 19-1

Washing hands with soap and water

Task Perform hand washing. Conditions Sink Soap Timer Nail stick or brush Paper towels Waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform hand washing with soap and water. Performance Standards 1. Remove all rings and jewelry because jewelry harbors microorganisms and push your watchband up to expose your wrists. 2. Stand in front of the sink without touching the sink edge or countertop to prevent water or microorganisms from being transmitted to the front of your uniform. 3. Turn on the water to a comfortable temperature. 4. Apply soap to your hands (approximately 5 ml or 1 tsp) and work it into a lather, being sure to cover all parts of your hands and wrists. Using friction, continue to wash hands and wrists for 15 seconds. 5. Using an orange stick or a ngernail, clean under the edges of all of your ngernails to help remove microorganisms. 6. Pointing your hands and ngers down, rinse your hands under the running water.

Rinse your hands and ngers while pointing them down.

7. Dry your hands with a disposable towel, then discard the used towel in a waste container. 8. Use a dry, disposable towel to turn off the water to maintain infection control. 9. Dispose of the towel in a waste container.

Cover all parts of your hands and wrists.

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PROCEDURE 19-2

PROCEDURE 19-3

Sanitizing hands with an alcohol-based hand sanitizer

Task Sanitize hands using an alcohol-based hand sanitizer. Conditions Alcohol-based hand sanitizer Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform hand sanitization using an alcohol-based hand sanitizer. Performance Standards 1. Remove all rings and jewelry because jewelry harbors microorganisms and push your watchband up to expose your wrists. 2. Read the label of the alcohol-based hand sanitizer and verify that it contains 60% to 95% alcohol. 3. Apply enough sanitizer to cover all the surfaces of your hands and wrists. 4. Rub the sanitizer over the surfaces of your hands, ngers, ngernails, and wrists. 5. Allow your hands to air dry.

Sanitizing equipment
Task Perform sanitization of equipment. Conditions Sink Brush with stiff bristles Low-sudsing, chemical disinfectant soap Gown or apron with a plastic, leakproof backing Utility gloves Goggles Towels Soap Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully sanitize equipment for reuse. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Using soap, scrub all instruments with a bristle brush under running water to remove debris. 3. Clean all surfaces of the instruments and open any hinges to allow better exposure of instruments to hot water and air. 4. Rinse the instruments thoroughly with hot water. 5. Place the instruments on a towel for drying. 6. Remove your gloves and wash your hands to ensure infection control.

Disinfection
Although the medical assistant could disinfect instruments used in noninvasive procedures by placing them in boiling water at 212F (100C) for 15 minutes, doing so is not practical in most medical ofces. Thus, disinfection typically involves the application of a substance to equipment, surfaces, or other items to kill pathogenic microorganisms. The medical assistant should be sure to sanitize most instruments and equipment before disinfecting them. Other items a medical assistant should disinfect include surfaces, such as countertops and trays, some types of furniture, and even the skin. Disinfecting agents appropriate for instruments, surfaces, furniture, and equipment include chlorine, iodine, 70% isopropyl alcohol, hydrogen peroxide, or a 1:10 solution of household bleach and water (1 part bleach to 10 equal parts of water). Bleach solution must be prepared daily because it loses potency over time. Agents appropriate for the skin include povidone-iodine (Betadine), if the patient is not allergic to iodine, and 70% isopropyl alcohol. Many other disinfecting agents are too harsh for the skin. Regardless of the agents used, the medical assistant should be sure to read labels and use these agents according to directions. (See Procedure 19-4: Disinfecting equipment.)

Sterilization
In surgical asepsis, all instruments and supplies must be sterile. Although sanitization kills most microorganisms, it does not kill spores (bacterial or fungal cells resistant to temperature extremes). Sterilization eliminates all microorganisms from a surface or instrument through exposure to chemicals, ionizing radiation, dry heat, gas, or steam. Prior to sterilization, instruments must have been sanitized and disinfected. Some pathogens are easily destroyed; others, such as spores, are very resistant to temperature extremes and are difcult to destroy. However, the process of sterilization kills them. Examples of pathogenic organisms that produce spores are Clostridium tetani, which causes tetanus, and Clostridium botulinum, which causes food poisoning. Sterilization should take place in a part of the medical clinic specically set aside for this purpose. One area should be designated as the receiving area where nonsterile items are placed. Some of the supplies used by the medical assistant in this area include receiving basins, sterilization wrapping

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PROCEDURE 19-4

Disinfecting equipment
Task Perform equipment disinfection. Conditions Sink Disinfectant chemical solution Container for instruments Timer Water Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully disinfect equipment. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Put on utility gloves. 3. Sanitize all instruments prior to disinfecting. 4. Read the manufacturers instructions on the label of the disinfectant solution. 5. Prepare the disinfectant as directed. 6. Place the sanitized instruments into a container. 7. Apply the disinfectant to the instruments. 8. Soak the instruments for the required time, according to the manufacturers instructions. 9. Dry the instruments with towels. 10. Store the instruments appropriately for future use. 11. Remove your gloves and wash your hands to ensure infection control.

paper, sterilization indicator strips, sterilization tape, sterilization pouches, and gloves. When items have been sterilized, the medical assistant should place them in a different area designated as the receiving area for sterile supplies. Types of sterilization techniques include chemical, dry heat, steam, gas, and radiation. One of the most common methods of sterilizing reusable instruments in the medical ofce is by using an autoclave.

Prior to sterilization in the autoclave, the medical assistant should sanitize and, in some cases, disinfect instruments. She must then package or wrap them appropriately. Some packs contain single instruments and others contain a combination of items needed for a specic procedure. For sterilization to occur efciently, the surfaces of all objects must be subjected to the moisture, heat, and pressure of the autoclave. Therefore, the medical assistant must follow several guidelines for packaging and preparing items properly. For example, she must leave all hinged instruments open, pack items so they do not touch each other, and pack items loosely into the autoclave so that all parts of the instruments can be fully exposed to the steam and pressure. Many packs include disposable or reusable towels. Muslin cloth, a common reusable material used in sterile packs, is porous, allowing the steam to pass through and enabling the instruments to dry easily as well. Polypropylene autoclave bags are also available. (See Procedure 19-5: Wrapping a pack for autoclaving, page 302.) Surgical packs are commonly wrapped twice using two towels, one inside the other. When a medical assistant includes a large number of items in a pack, she should put them into trays so that the contents can be carefully organized. Regardless of the size or content of the pack, the medical assistant should always place a sterilization indicator strip inside the pack and use special tape to close the pack. These heat-sensitive items change color when sterilized to indicate that the sterilization process is successful. When the medical assistant has wrapped the items, she must identify the contents by labeling the outside of the pack, including the date and her initials. The medical assistant should always follow the manufacturers instructions that accompany the autoclave used in her ofce. However, some general guidelines apply to wrapping instruments and loading, operating, and unloading all autoclaves.

Wrapping Instruments and Loading the Autoclave

When wrapping instruments and loading the autoclave, the medical assistant should be sure to follow these guidelines:

Autoclave
An autoclave is a device that sterilizes items using steam pressure at a temperature of 250 to 270F (120 to 130C) with 15 lb of pressure for a specic amount of time, depending on the contents to be sterilized. Subjecting items to steam under pressure causes the proteins in microorganisms to coagulate; when the chamber cools, the condensation of the steam causes the explosion of the microorganism cells, ensuring their complete destruction.

Make sure all items were previously sanitized. Use only material approved for autoclaving to wrap instruments, and examine the wrap for holes or fraying before each use. Wrap and arrange all items to allow exposure of all surfaces. (Allow 1 to 3 between the pack and the walls of the autoclave.) Wrap hinged instruments open for best exposure. Wrap sharp instrument tips with gauze to prevent puncturing the wrap. Label packs using permanent marker with the contents, date, and her initials.

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PROCEDURE 19-5

Wrapping a pack for autoclaving

Task Wrap a pack for autoclaving. Conditions Disinfectant chemical solution Container for instruments Timer Water Sanitized instruments to be sterilized Wrapping towels (2) Sterile indicator strips and tape for securing contents Marker pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully wrap a pack for sterilization. Performance Standards 1. Wash or sanitize your hands to ensure infection control. 2. Identify the type of pack to be used. Gather the instruments and other equipment. 3. Lay the towels at in a diamond conguration and place the instruments in the center. 4. Open all hinged instruments. If the hinged instruments can touch, separate them with a 2 2 gauze pad to maximize surface exposure of the instruments. 5. Place the sterile indicator strip at the top of the contents to allow the user to verify the sterility of the package contents. 6. Bring the bottom of the diamond up to cover the contents and fold the tip of the corner. 9. Fold the bottom of the wrap over, including the instruments, to align with the top edges of the side folds.

10. For packages that must be double-wrapped, place the package in the center of a second sheet of wrapping material and repeat steps 6 to 9 to facilitate sterile technique when the package is opened. 11. Bring the top of the wrap down and seal the top ap with sterile indicator tape. 12. Label the tape with the contents, the date, and your initials to allow the user to verify the contents and date of sterilization.

7. Bring one side of the wrap over to cover the contents and fold up the tip of the corner. 8. Bring the other side of the wrap over to cover the contents and fold up the tip of the corner.

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Arrange containers on their sides and leave the lids ajar. Leave instruments unwrapped that do not need to be sterile for use (such as vaginal speculums).

Operating the Autoclave

After wrapping instruments and loading the autoclave, the medical assistant should follow these guidelines for operating the autoclave:

that describes the problem she encountered and the steps she took to correct it. Additional documentation should reect satisfactory autoclave performance. (See Procedure 19-6: Using an autoclave for sterilization, page 304.)

Chemical Sterilization
Some instruments cannot withstand the high temperatures of the autoclave, such as ber-optic endoscopes. Therefore, they need sterilization using chemicals. The medical assistant should mix the sterilization solution carefully according to the instructions on the container and mark the solution container with the date of preparation and expiration. She should be sure to use gloves and other PPE for protection if the solution is caustic. Then she should immerse the items in the solution for a specied period of time, commonly 8 or more hours. Upon completion, she must remove the items from the solution with sterile transfer forceps, rinse them with sterile water, dry them with sterile towels, and place them on the sterile eld so that they are ready for use.

Use only distilled water to prevent mineral deposits. Set the autoclave to at least 250F (121C), depending on the item to be sterilized, and 15 lb per square inch (psi) of pressure. Begin the processing time after the autoclave reaches the desired operating conditions of temperature and pressure. Process unwrapped items for 20 minutes. Process small wrapped items for 30 minutes. Process large or tightly wrapped items for 40 minutes.

Unloading the Autoclave

When the autoclave sterilization process is complete, the medical assistant should unload the autoclave following these guidelines:

Types of Asepsis
Within the health care professions, there are two types of asepsis: medical asepsis and surgical asepsis.

After completion, open the door slightly and carefully, using heat-resistant gloves, to let steam escape. Do not remove wrapped items until they have completely cooled and dried.

Medical Asepsis
Medical asepsis refers to the destruction of pathogenic organisms after they leave the body. More specically, medically aseptic technique is a method of performing procedures and providing patient care so that pathogenic organisms are not transmitted from the ill patient to other patients or anyone else. The simplest way to apply medical asepsis is to follow standard precautions consistently. The medical assistant should always consider collected specimens to be contaminated, whether labeled or not. Body uids that are not considered contaminated are tears, sweat, and saliva. However, medical assistants should always be cautious and wear examination gloves when there is any possibility of contamination.

Storing Sterilized Items

After sterilization with the autoclave, the medical assistant should store the packs in a dry place. Items sterilized in towels or cloth are considered sterile for 28 to 30 days. Items sterilized in polypropylene autoclave bags are considered sterile for as long as 6 months.

Autoclave Maintenance
The autoclave itself is an important piece of medical equipment and requires careful care and attention to keep it in top operating condition. General guidelines include daily washing of the inner chamber as well as regular draining of the water so that the medical assistant can clean the autoclave with an approved solution. To clean the autoclave, the medical assistant must use distilled water and run two consecutive sterilization cycles. She must also wipe down the inner chamber of the autoclave and remove and scrub the inner shelves. For specic instructions on how to clean the autoclave, the medical assistant should refer to the manufacturers instructions for the autoclave in her ofce.

Surgical Asepsis
Surgical asepsis is the practice of destroying all pathogenic organisms before they enter the body. More specically, surgical aseptic technique is a method of performing invasive procedures so that patients are protected from pathogenic microorganisms. When performing invasive procedures, the medical assistant must use this technique. Invasive procedures are those in which the patients normal protective barriers are punctured or disrupted in some manner. Examples of some procedures that require surgical asepsis include injections, urinary catheterization, wound care, and such surgical procedures as tissue biopsy or repair and suturing of lacerations. (See Medical versus surgical asepsis, page 305.)

Quality Control
The medical assistant should conduct and document quality-control testing on the autoclave on a regular schedule. Documentation should include a description of the test, the date, and the results. In the event of incomplete or inadequate sterilization, the medical assistant should le a report

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PROCEDURE 19-6

Using an autoclave for sterilization

Task Perform sterilization. Conditions Packages ready to be sterilized Autoclave procedure manual Autoclave Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform sterilization using an autoclave. Performance Standards 1. Wash or sanitize your hands to ensure infection control. 2. Load wrapped, labeled packages into the autoclave. 3. Position packages so they are not touching. If sterilizing containers, place containers on their sides so that the steam can circulate around all packages, allowing adequate sterilization to occur. 4. Close the autoclave door and secure it. 5. Following manufacturers instructions, plug the autoclaves electrical cord into a power outlet and turn on the power. 6. Set the indicator to the contents loaded into the autoclave, such as glass, cloth, or instruments. 7. Set the temperature and pounds of pressure. 8. Set the exposure time. 9. Press the start button. 10. Make sure that the autoclave starts and the door remains secured until the sterilization and drying time are complete. 11. Prior to removing the contents, wash your hands and dry them thoroughly to keep the outside of the packages as clean as possible. 12. Place the sterile packages in a dry storage area.

Autoclave loaded with instruments wrapped in a polypropylene autoclave bag

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Medical versus surgical asepsis

In general, medical aseptic technique is used to protect health care providers and others from the patients pathogenic microorganisms. Surgical aseptic technique is used to protect the patient from any pathogenic organisms external to his body. Here are some examples of procedures that require medical and surgical asepsis.

Medical asepsis
Taking a patients temperature Removing an old dressing from a patients wound Scrubbing and disinfecting used surgical instruments Emptying an emesis basin

Surgical asepsis
Inserting a urinary catheter Administering an intramuscular injection Applying a new dressing to a patients wound Opening a sterile package Setting up a tray for the physician to perform suturing

Chapter Summary

Because the health care environment brings individuals together, many of whom have infectious diseases or weakened immune systems, it sets the stage for the very real possibility of disease transmission between patients and even health care staff. To prevent such transmission from happening, medical assistants must have an understanding of how disease is transmitted and how to take every reasonable precaution to reduce disease transmission in the medical ofce. Potentially harmful organisms, such as bacteria, fungi, and protozoa, are found on and in the body. Normally, a healthy balance of these microorganisms exists; however, when this balance is disturbed, the individual becomes more vulnerable to illness and disease. Pathogens are microorganisms capable of producing disease. To grow and thrive, most pathogens require nutrients, moisture, warmth, and a suitable pH environment. Therefore, some parts of the human body tend to provide a hospitable environment for pathogenic growth. The ve main types of pathogens are bacteria, Rickettsia, virus, fungus, and protozoa. Learning about the chain of infection helps medical assistants understand how microorganisms are transmitted and how people become infected. The elements of the

chain consist of the pathogen, reservoir host, means of exit, mode of transmission, and susceptible host. Infections can be categorized according to their general duration and whether they occur only once or repeatedly. Types of infection are acute, chronic, and latent. There are several stages in the disease process, including incubation, prodromal, acute, declining, and convalescent stages. The bodys natural protective mechanisms normally protect human beings from pathogens. These mechanisms take on mechanical, chemical, and cellular forms. Mechanical defense mechanisms include the skin, mucous membranes, protective reexes such as coughing and sneezing, and the ushing action of body uids such as tears and urine. Chemical defense mechanisms include secretions of the sebaceous glands, acidic uids in the stomach, uids of tears and the urinary tract, and the activity of interferons and certain enzymes. When the bodys natural defenses are unsuccessful in eliminating invading organisms, infection may occur. Symptoms of localized infection include redness, swelling, heat, pain, fever, and general malaise. Immunity is a powerful defense system within the body that responds to the invasion of foreign substances, such as bacteria, viruses, fungi, and parasites. When these substances enter the body, the bodys immune system recognizes them as foreign and attacks them. There are several types of acquired immunity, including natural active immunity, articial active immunity, natural passive immunity, and articial passive immunity. The Occupational Safety and Health Administration (OSHA) ensures safe, healthy working conditions for Americans. OSHA guidelines for bloodborne pathogens were developed to decrease the transmission of diseases in the health care setting. In the medical ofce, common personal protective equipment includes such items as gloves, masks, eye protection, shoe covers, and gowns to wear during minor ofce surgeries and procedures when there is a risk of contact with blood or body uids. Medical assistants must dispose of biohazardous wastes appropriately. Containers that have blood or body uids are required to have the biohazard label. Red leakproof bags are used for contaminated supplies, such as gloves, gauze, bandages, gowns, and linens. In most cases, medical assistants must provide documentation of all necessary vaccinations prior to employment. Examples include the hepatitis B vaccination and testing for tuberculosis exposure. If the medical assistant has not completed certain vaccinations, the employer will provide them at no cost to the employee within 10 days of becoming employed.

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In the event of an exposure, the medical assistant must wash or ush the exposed area and then report the incident to the employer right away. OSHA guidelines require employers to develop exposure control plans and make this plan known to employees. Medical assistants must be familiar with ofce protocol for responding to a biohazard spill. Asepsis is a condition free from pathogens. Within the health care professions, there are two types of asepsis: medical asepsis and surgical asepsis. Medical asepsis refers to the destruction of pathogenic organisms after they leave the body. More specically, medically aseptic technique is a method of performing procedures and providing patient care so that pathogenic organisms are not transmitted from the ill patient to other patients or anyone else. The simplest way to apply medical asepsis is to consistently follow standard precautions, that is, guidelines developed by the Centers for Disease Control (CDC) for the protection of all people who come into contact with blood and any other potentially infectious substances that come from the body. The most effective standard precaution practice that breaks the chain of infection and protects everyone is consistent, proper hand hygiene. Medical assistants must sanitize their hands regularly with soap and warm water or alcohol-based hand sanitizer. Sanitization must occur before sterilization can take place and involves the removal of microorganisms from reusable equipment and surfaces by use of chemicals, heat, or ionizing radiation. Disinfection is dened as the application of a disinfecting agent to equipment, surfaces, or other items to kill pathogenic microorganisms. However, this process does not always kill all microorganisms and does not kill spores (bacterial or fungal cells resistant to temperature extremes). Surgical asepsis is the destruction of all pathogenic organisms before they enter the body. More specically, surgically aseptic technique is a method of performing invasive procedures so that patients are protected from pathogenic microorganisms. When using surgical asepsis, all instruments and supplies must be sterile. Therefore, they must have been previously treated or prepared in a manner that eliminated all microorganisms. An autoclave is a device that sterilizes items by steam pressure at temperatures of 250 to 270F (120 to 130C) with 15 lb of pressure for a specic amount of time, depending on the contents to be sterilized.

Team Work Exercises

1. Divide into teams of four or ve students. Create a plan in writing that designates disinfection duties that each member of the team might perform at the end of each day to be sure that the ofce is clean and safe for patients the following day. Consider the accidental exposures listed in Protecting each other on page 297. Put into writing the strategies that could have been employed by members of the team to prevent these accidents. Share your teams plan with the rest of the class. 2. Divide into teams of three to ve students. Select several items that are commonly sterilized by autoclave. Take turns demonstrating for the rest of the class different ways in which items might be properly wrapped and prepared for autoclaving. Use as many variations in packaging and wrapping technique as you can think of, including sterilization wrap, sterilization pouches, and sterile towels.

Cases Studies
1. Your coworker, Elizabeth, is assisting with a minor ofce surgery when she accidentally punctures her finger (through her glove) with the needle used to inject medication into the patient. She is embarrassed and ashamed that she was careless enough to let this happen. Elizabeth tells you about the incident and asks you not to tell anyone. What should you do? 2. The facility you work for asks you to develop a pamphlet for patients. The pamphlet will be used to inform patients about commonsense, everyday measures they can use to prevent disease transmission and keep healthy during cold and u season. What data will you include?

Resources

Centers for Disease Control and Prevention website: www.cdc.gov Free infection-prevention online course: www.engenderhealth .org/IP/index.html OSHA website: www.osha.gov World Health Organization website: www.who.int/en

CHAPTER

The Patient Interview

Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell the key terms in the glossary describe the purpose and the key components of the patient interview list nine interviewing techniques and the purpose of each identify effective strategies for interviewing the talkative patient and the quiet patient differentiate among closed questions, open-ended questions, and directive statements and give an example of each list ve obstacles to effective interviewing and discuss an effective alternative strategy for each describe techniques that may be used to help patients feel more comfortable discussing sensitive information list at least three examples of ageappropriate interviewing techniques list the main components of the medical history conduct a patient interview to obtain a medical history accurately document the patients medical information on a history form describe three methods of documentation.

20
Procedures
Interviewing a patient to obtain a medical history

CAAHEP Competencies
Clinical Competencies Patient Care
Obtain and record patient history

General Competencies Professional Communications

Recognize and respond to verbal communications

Chapter Outline
First Impressions Interviewing Techniques
Talkative Patient Quiet Patient

Legal Concepts
Establish and maintain the medical record Document appropriately

Obstacles to Effective Interviewing

Offering Opinions and Advice Offering False Reassurance Using Technical Language Talking Too Much Asking Judgmental Questions Discussing Sensitive Topics Age-Appropriate Communication

ABHES Competencies
Professionalism
Be courteous and diplomatic

Communication
Be attentive, listen, and learn Adapt what is said to the recipients level of comprehension Interview effectively Receive, organize, prioritize, and transmit information expediently Recognize and respond to verbal and nonverbal communication Principles of verbal and nonverbal communication Adaptation for individualized needs

Medical History Documentation

Documentation Types Source-oriented Problem-oriented

Chapter Summary Team Work Exercises Case Studies Resources

Administrative Duties
Prepare and maintain medical records

Clinical Duties
Interview and record patient history

Legal Concepts
Document accurately

307

Key Terms
acronym

First Impressions
Most patients enter the health care setting because they wish to meet with their health care provider. However, the physician is rarely the rst person the patient encounters. After checking in with the receptionist, the patient is usually greeted by a medical assistant. The medical assistant plays an important role in connecting the patient and physician. In addition to weighing the patient, showing him to an examination room, and obtaining vital signs, the medical assistant asks questions about the patients medical history. This chapter focuses on the role of the medical assistant in the history-taking process and effective interviewing strategies. The interviewing process generally occurs in three parts:

Word created from the rst letters of a series of words

active listening

Nonverbal communication that indicates the listener has heard the message and concerns of the patient
closed question

Question that can be answered with one word

directive statement

Statement that guides the listener in discussing topics as directed

layperson

Nonmedical person
medical jargon

Terminology and abbreviations used in medicine that are not readily understood by laypersons
open-ended question

Question that requires more than a one-word answer

problem-oriented medical record

System of documentation that includes the database, problem list, plan, and progress notes
rapport

Empathetic relationship
redirecting

Guiding the patient back to relevant subject matter

reecting

Validating the patients feelings and concerns

restating

Rewording a statement to check for accuracy

silence

Communication strategy that allows the patient time to process information and formulate a response
source-oriented medical record

System of documentation that includes a note for each patient visit, arranged in reverse chronological order
summarizing

InitiationDuring initiation, the medical assistant introduces herself to the patient and any family members that may be accompanying him. She also seeks clarification regarding the purpose of the visit. Because this part of the conversation may include the patients personal health care information, it should take place in the private examination room. By using effective communication techniques and body language, the medical assistant conveys respect for the patient. BodyDuring the main part, or body, of the interview, the medical assistant uses therapeutic communication techniques to establish trust and rapport. She gathers more detailed information about the nature of the patients problem as well as his goals and expectations for care. The amount of detailed information the medical assistant obtains depends on the nature of the visit and the ofce policy. SummaryThe medical assistant closes the interview with a brief summary of the main points of the conversation. This summary allows the patient to make additions, corrections, or clarications to the information.

Clarifying the patients key issues

Interviewing Techniques
The medical assistant should use several interviewing techniques to ensure that she obtains the most complete, relevant information possible about the patient and his problem in a timely manner. Such techniques can be modified as needed in any situation. For example, a patient may feel reluctant to discuss personal topics or answer questions about his personal habits. On the other hand, a talkative patient might give lengthy answers and get sidetracked with detailed stories that do not provide essential health information. In such situations, the busy medical assistant must use proven interviewing techniques in order to obtain accurate information and complete the interview in a timely

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fashion. Here are some of the most common interviewing techniques used to respond to these different communication styles:

A closed (direct) question seeks specic information and invites a reply in the form of a one-word answer, such as yes or no, or a number, such as 43. An example of a closed question is How old are you? An open-ended question encourages the patient to answer the question in whatever manner he or she prefers and allows elaboration, such as What brings you here today? A directive statement guides the patient in discussing whatever topic is indicated by the interviewerfor example, Tell me how you injured your ankle. Restating checks the listeners understanding and interpretation of the patients message and invites conrmation or correction. Reecting validates the patients feelings and concerns for example, It sounds like you feel upset that the treatment didnt work and you are worried that your condition is worsening. Redirecting guides the patient back to relevant subject matter, such as You mentioned earlier that your headaches are getting worse. Please tell me more about that. Summarizing claries key issues for the medical assistant and the patientfor example, Based on what youve told me your main issues of concern today are Active listening is nonverbal communication that indicates the medical assistant is hearing and attending to the message and the concerns of the patient. She focuses all of her energy on being fully present with the patient and uses body language, such as leaning forward, eye contact, head nodding, and facial expression to convey her attention and concern. Silence allows the patient ample opportunity to process what has been said and think about what he wants to say next. In allowing him this gift of time, the medical assistant communicates acceptance and caring.

1. Set clear expectations of the interview. For example, the medical assistant might tell a patient, Mrs. Singh, Id like to ask you a few questions about your menstrual history. 2. Ask closed questions to gather very specic data, as necessary, by asking questions that typically require a oneword answer. For example, the medical assistant might ask the patient, How old were you when you rst began having menstrual periods? 3. Restate the message in order to verify accurate understanding of key information and allow the patient to conrm or correct it. For example, the medical assistant may say to the patient, You were 13 years old when you began menstruating. 4. Redirect the patient in a kind, yet assertive manner if she wanders too far off the subject. This technique is most effective if followed up by a closed question or a directive statement. For example, the medical assistant might say, Id like to hear more about your menstrual pattern. How many days does each menstrual period usually last? or, Id like to hear more about your menstrual discomfort. Please describe the pain you said you typically have.

Quiet Patient
The quiet patient is one who may be withdrawn or shy. Such a patient typically talks very little, providing one- or two-word answers that reveal little detail. When interviewing such a patient, the medical assistant should use these techniques:

Use open-ended questions, which require (or encourage) more elaborate answers. Practice wording questions ahead of time. Most people nd open-ended questions difcult to phrase. Therefore, medical assistants should practice wording open-ended questions ahead of time. Use directive statements, rather than questions. Such statements allow the medical assistant to direct the conversation to relevant subjects and prompt the patient to disclose information.

Talkative Patient
A talkative patient can make the medical assistants job interesting and enjoyable. However, she can also present a challenge. The medical assistant is generally busy and does not have extra time to listen to many of a talkative patients stories. Therefore, the medical assistant may often find herself in the difficult situation of needing to interrupt the patient to ask questions, give instructions, or even exit the room. Finding ways to do this without appearing rude or insensitive can be challenging. The medical assistant will find it helpful to follow these steps in interviewing such a patient:

All three techniques described may be effective or ineffective, depending on how they are used. Therefore, the medical assistant should become familiar with the advantages and potential disadvantages of each in order to use them most effectively. (See Using interviewing techniques effectively, page 310.) In addition, a patient who is quiet or shy may be much more willing to share questions and concerns in writing. Providing the patient with a self-assessment tool before the patient interview allows him to approach these subjects in a less embarrassing way. The medical assistant or physician can then follow up on the subjects in the interview, as appropriate. (See Self-assessment questionnaire, page 310, and Selfassessment of needs, page 310.)

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Using interviewing techniques effectively

This table lists three common interviewing techniques with advantages and disadvantages of each.

Technique
Closed question

Example
Would you mind telling me about your health history? Do you have pain? How are you today?

Advantage
Helps get specic information from overly talkative patients. Saves time when the medical assistant is extremely busy.

Disadvantage
May be answered with no, which becomes a barrier to further communication. May be answered simply with yes or another one-word answer, such as ne or terrible, which requires further questioning.

Open-ended question

What brings you here today? Why dont you describe your pain? Why are you here today?

Discourages patient from providing one-word answers when elaboration is desired. Allows patient to discuss issues of personal concern.

May entice the overly talkative patient to tell lengthy stories or get sidetracked. May not elicit the specic information desired. Can seem like a command unless worded carefully and spoken tactfully.

Directive statement

Tell me about your current problem. Describe the pain you are having. Tell me how youve been feeling.

Easier to phrase than openended questions. Allows the interviewer to focus on specic areas of concern. Discourages one-word answers.

Front ofceBack ofce connection

Self-Assessment Questionnaire
In some medical ofces, the administrative medical assistant will ask a patient to complete a questionnaire while he is waiting in the reception area. Doing so can save the clinical medical assistant some time during the interview process. It may also provide a more comfortable way for patients to discuss personal topics such as sexual function. Questions asked on such questionnaires vary with the medical specialty area; however, here are some common examples: What is the main problem that brings you to the clinic? What do you think might be causing your current physical problem? Where have you traveled in the past 2 years and when? Are stress or conict common in your household? Do you fear being harmed in your own home? Are you experiencing sexual problems or a change in sex drive? Do you enjoy your work? Do you frequently feel depressed or anxious? Have you seriously thought about suicide?

Patient Education

Self-Assessment of Needs
The medical assistant or ofce manager should consider adding questions to the self-assessment questionnaire that can help the patient identify his goals for the visit and his own learning needs. Doing so can help the medical assistant and physician understand the patients expectations and learning needs and how to direct patient education efforts. Having patients answer such questions in writing also gives the medical assistant clues about the patients reading and writing ability. Such questions might include: What do you hope to accomplish on this visit? What do you most want the physician to know? What do you most wish to know and understand about your condition, disease, or disorder? What is your greatest fear regarding your condition, disease, or disorder?

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Obstacles to Effective Interviewing

When communicating with patients, the medical assistant must be thoughtful and deliberate in word choice and body language. Doing so requires a degree of focus and concentration not normally used in everyday conversation with family and friends. If she is not careful, the medical assistant may unintentionally lapse into ineffective communication patterns. If she is not always mindful in her communications with patients, the medical assistant could convey the wrong message to the patient and, perhaps worse, break the law. In order to avoid obstacles to good communication with patients, the medical assistant should become familiar with such obstacles and develop skills to avoid them. Common obstacles include:

everything in our power to provide you with the best care possible.

Using Technical Language

Using medical jargon, which is technical or specialized language used mainly by medical professionals, tends to add to the patients confusion and anxiety, especially if he has a perceptual decit or is not a native English speaker. In such a case, the patient may not understand what has been said but may feel too embarrassed to admit it. When speaking with patients, the medical assistant should keep language and vocabulary professional and appropriate. However, she should also choose terms easily understood by the average layperson (nonmedical person). (See Good interviewing is a team effort, page 312.)

offering opinions and advice offering false reassurance using technical language talking too much asking judgmental questions.

Talking Too Much

The overly talkative medical assistant risks offending patients and robs them of the opportunity to discuss their concerns. The medical assistant should remember that effective communication happens when she talks little and listens much. In addition, allowing silent pauses encourages the reluctant patient to share concerns.

Offering Opinions and Advice

The medical assistant should always refrain from offering opinions or medical advice. The medical assistant who offers opinions and advice to patients risks acting outside of her scope of practice, putting herself in legal jeopardy. Furthermore, doing so takes the responsibility for decision making away from the patient. Instead, she should try to answer the question with a question, such as asking the patient what he thinks is a reasonable course of action, based on the information provided by the physician. Additionally, she might inquire whether the patient needs more information before making a decision. The medical assistant may also need to refer the patient back to the physician for answers to some questions.

Asking Judgmental Questions

Questions should be worded as neutrally as possible. Poorly worded questions may imply a negative judgment and discourage the patient from providing a truthful, accurate response. The medical assistant should practice ways to word delicate questions so she can feel more comfortable asking them and convey a message of acceptance. Doing so will encourage patients to be more forthcoming about such information. For example, a judgmental question might be, You dont drink alcohol do you? or, Do you drink alcohol? A more neutral alternative is, How much alcohol do you drink during an average week? Of course, some people do not drink alcohol at all; however, if so, they will simply say so. If the patient does drink alcohol, he will feel more inclined to give an honest, accurate answer if asked in a nonjudgmental way.

Offering False Reassurance

The desire to provide reassurance is natural, but doing so could convey an inaccurate message that the patient may later resent. As much as patients wish for reassurance, they also need and deserve honesty. Responding in any other manner invalidates and trivializes the patients concerns. The medical assistant must also remember that only the physician may reveal certain information to patients, such as a diagnosis or prognosis. Instead of offering false reassurance, the medical assistant should use reection to acknowledge and validate the patients concerns and feelings. When she feels compelled to provide some reassurance, she should make statements that are honest, yet vague. For example, instead of saying, Im sure everything will turn out just ne, the medical assistant might say, We will do

Discussing Sensitive Topics

When interviewing a patient to obtain the medical history, the medical assistant must commonly ask questions about personal subjects, such as sexual activity, use of birth control, number of sexual partners, bowel and bladder function, and menstrual pattern. While some patients are not shy about discussing such subjects, many nd such conversations uncomfortable or embarrassing. There are several strategies the medical assistant can employ to help ease the patients discomfort and promote more effective communication:

Consider the environment. Before beginning the interview, the medical assistant must give due consideration to such

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Front ofceback ofce connection

Good Interviewing Is a Team Effort

Administrative and clinical medical assistants must work stogether to accomplish the patient interview in an effective manner. Here are some examples of the contribution each person can make. need to be separated for part of the interview and work out a cooperative plan to accomplish doing so.

Clinical medical assistant

Quickly glance at the updated demographic data gathered by the administrative medical assistant to identify clues to signicant changes in the patients home situation (such as a change of occupation or loss of insurance). Tactfully follow up on these changes during the interview as appropriate. Communicate special requests (such as asking the administrative medical assistant to keep parents occupied while you interview their teenage daughter) in a timely, respectful manner. Convey appreciation to the administrative medical assistant for any cues or help offered to foster mutual respect and team spirit.

Administrative medical assistant

Verify demographic information when the patient checks in, including current address, phone number, employer, and insurance. Notice whether the patient has language, perceptual, or sensory decits or other issues that might hinder the interviewing process. Let the clinical medical assistant know immediately and discreetly to allow her time to plan success strategies. Give the patient a self-assessment questionnaire to complete prior to the interview and note whether the patient has difculty completing it or if anyone else helps with it. Check in with the clinical medical assistant discreetly to see if a patient and an accompanying individual might

environmental issues as privacy and patient comfort. Also, reminding the patient that all information will be kept in strict condence will reassure the patient. Establish guidelines. After introducing herself, the medical assistant should establish the guidelines of the interview so that the patient understands the nature and purpose of the questions the medical assistant will ask. If the patient seems hesitant to answer questions, the medical assistant should explain why such information is important in providing a complete health picture. Begin with general questions. The medical assistant should begin with general questions and save more personal questions for later in the interview when some degree of trust and rapport (the development of an empathetic relationship) has been established. If a patient refuses to answer a question, the medical assistant should not press the matter but leave it for the physician to pursue. (See Looking for clues.)

Patient Education

Looking for Clues

A professional medical assistant acts as a sort of health care detective. Throughout the patient interview, she gathers data about the patients current health practices and concerns. She must get into the habit of noticing clues the patient offers that may signal a potential learning need. The medical assistant can address simple topics right away. For example, if a patient asks what the normal range is for blood pressure measurement, the medical assistant can share that data. However, she may need to refer more complex topics to the physician (or even another provider). The medical assistant should make a special note about the patients significant learning needs and be sure to bring them to the physicians attention.

Age-Appropriate Communication
In order to interview a patient effectively, the medical assistant must adapt her vocabulary and interviewing strategies to the age of the patient. Techniques for interviewing a toddler will differ from those for interviewing a teenager. Both will differ from techniques for interviewing an elderly person. Age-appropriate interviewing techniques include:

Children Drop to the childs level or sit at eye level in order to make eye contact without looking down on the child. Speak at a normal volume. Use a kind, yet rm tone.

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Provide a simple explanation of procedures before doing them. Use simple, age-appropriate language. Let the child remain on the parents lap, if desired. Offer limited choices when possible but do not ask the child if he or she wants to do something that is not optional (such as get an injection). Offer praise and positive reinforcement whenever possible. Include the child in the conversation and direct some simple questions to the child so that she feels included. Allow the child to touch some of the equipment, such as a stethoscope, to help to alleviate anxiety about it. Save uncomfortable procedures for last. Be truthful about uncomfortable procedures (such as injections) but err on the side of understating rather than exaggerating the truth. (Children are unlikely to forgive or forget being lied to.) Older children and adolescents Use age-appropriate language and vocabulary. Offer choices whenever possible. Take extra care to provide for privacy, because patients in this age group are acutely self-conscious about their bodies. Explain procedures prior to doing them. Explain ndings. Assure the patient of his normalcy. Allow the patient to ask questions and answer them as completely and honestly as possible. Take advantage of opportunities to teach the patient about relevant health and wellness issues as well as disease prevention or management. Elderly patients Be aware of and adapt communication techniques for any sensory or perceptual decits, such as diminished hearing or vision. Allow elderly patients time to process information and formulate responses. Do not assume that all elderly patients are hard of hearing, forgetful, or senile. Convey respect and address the patient by his last name (such as Mr. Pederson) unless specically requested by the patient to do otherwise. (See Figure 20-1.)

FIG 20-1 Age-appropriate interviewing techniques. (A) Interviewing a child. (B) Interviewing an elderly person.

Medical History
The initial patient interview is usually conducted to obtain a detailed medical history. In some cases, the physician will conduct this entire interview. In other cases, the medical assistant may be responsible for conducting part of it. The standard medical history includes:

Additional strategies for effectively providing care for pediatric and geriatric patients is addressed in depth in Chapter 33, Pediatrics, on page 641, and Chapter 35, Geriatrics, on page 707.

databaselogistical data, such as the patients name, address, date of birth (DOB), and insurance coverage; initial physical examination ndings; and initial laboratory test results past medical history (PMH)immunizations, allergies, prior surgeries (sometimes listed separately as prior surgical history [PSH]), past or current disorders and diseases, and traumatic injuries family history (FH)health information about parents, siblings, and children, which may provide clues about the patients risk factors and emotional support system. (If parents are deceased, the medical assistant should record their ages at time of death and cause of death.) social history (SH)patients occupation, hobbies, lifestyle, education, activity level, sleep habits, sexual activities, dietary practices, and use of tobacco, alcohol, and illicit drugs

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review of systems (ROS)systematic method of collecting data about major body systems, including cardiovascular, gastrointestinal, neurological, musculoskeletal, urinary, reproductive, sensory, integumentary, respiratory, and endocrine systems, that ensures a comprehensive review of the patients overall health. (See Procedure 20-1: Obtaining a medical history.)

physician specialists, nurses, therapists, and medical assistants, will all read and contribute to parts of it. The patients chart also serves as a legal document because it is the ofcial record of all care provided as well as the patients response to such care. Because the patients chart serves these important purposes, all entries in the chart must be thorough, legible, and professional. (See Charting dos and donts.)

Documentation
The patients chart serves as a record of the patients medical history as well as a place for recording ongoing care. The chart is also a communication tool because a variety of providers, including the primary care physician, consulting
PROCEDURE 20-1

Documentation Types
There are several methods of documentation commonly used by health care providers. Traditionally, physicians dictate entries that are subsequently typed by a transcriptionist and then entered into the chart. Many health care providers still use this method. However, with the increasing popularity of electronic health records (EHR), more health care

Obtaining a medical history

Task Interview a patient to obtain a medical history. Conditions Patient history form Black and red ink pens Clipboard Private area to conduct the interview Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully conduct a patient interview to obtain the patients health history. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify the patient by his last name to convey respect. Use a pleasant, professional manner and introduce yourself to put the patient at ease. 3. Guide the patient to a private, quiet, comfortable area to ensure privacy. Explain the purpose and nature of the interview to help patient understand why certain information is requested. 4. Gather medical information to complete the history form using therapeutic communication techniques to put patient at ease, develop trust and rapport, and facilitate information gathering. 5. Review the self-history section if one was completed to clarify patient responses. 6. Throughout the interview, explain or translate any medical terms the patient does not understand to enhance patient understanding and accuracy of responses. 7. Allow the patient adequate time to answer each question. Some patients need extra time to process questions and formulate responses. 8. Record the patients allergies in red ink so that this critical safety information is easily visible. 9. Speak in a pleasant, unhurried manner using adequate volume and enunciation to enhance the patients understanding. 10. Use culturally appropriate body language to convey respect and facilitate communication. 11. Repeat the patients answers as needed for clarication or conrmation to ensure the accuracy of the communication. 12. Write legibly in black ink, which is less likely to fade and will photocopy better when records must be copied. 13. Document all data accurately and objectively in measurable terms to ensure accuracy and legal defensibility. 14. If more explanation is needed than the space on the form allows, mark it with an asterisk (*) and write an explanation in the comments section to allow inclusion of signicant details. 15. Thank the patient to convey respect and explain the next step in the examination to help the patient feel less anxious. 16. Invite the patient to use the restroom (and collect a specimen if appropriate) before the examination to promote patient comfort during the examination.

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Charting dos and donts

All members of the health care team should be aware of these common charting dos and donts. Correct errors by drawing one line through the erroneous entry, writing the date and time and a brief explanation, signing the correction, and then writing in the correct entry.
Date 01/30/09; 9:15 a.m. Pt c/o pain 7/10, in low back described as sharp & intense. Administered 2 Vicoden per MD order ------------------------------------------------------------------------------------- S. Gonzalez, CMA Wrong chart, ----------------- S. Gonzalez, CMA, 0915, 01/30/09

Do
Identify all documents with patient name and account number. Record data on the correct forms. Write legibly and spell correctly. Use black ink. Sign and date all entries. Include appropriate credentials after the signature (such as CMA, LPN, RN, and so forth). Use only abbreviations and symbols approved by the facility. Keep a current list of medications used by the patient (including prescription medications, over-the-counter preparations, and nutritional supplements) in the front of the chart. Indicate the patients own words or statements by using quotation marks. Record data in a factual, accurate, nonjudgmental manner. Strategies for doing so include quoting the patients description of symptoms and quantifying measurable factors by using a pain scale and descriptive adjectives, such as red, pale, warm, cool, and so forth. Use correct medical terminology, rather than laymans terms (such as sutures, rather than stitches).

Identify any information added at a later time as a Late Entry with the current date and time indicated.

Dont
Do not chart in pencil. Do not obliterate errors in any manner (such as erasing or using correction uid). The erroneous entry must remain legible. Do not go back at a later time and add information in a manner that attempts to conceal the fact of the time discrepancy. Do not make up new abbreviations or symbols or use any that are not approved by the facility. Do not chart subjective assumptions or opinionsfor example, The patient was angry and irrational. Instead, chart the objective data that led to that assumptionfor example, Patient shouted and swore at his wife and left the room before the examination was completed.

providers are using computers to enter their own notes directly into the patients medical record. Regardless of whether a health care provider performs documentation using transcription, handwritten notes, or a computer, a medical practice will usually follow a common documentation system. Two of the most common documentation systems used are:

extensive amount of time required to search through the chart and locate specic data.

Problem-oriented
The problem-oriented medical record (POMR) is a more efcient system of documentation that organizes data in a logical manner intended to identify, clarify, and resolve problems. The four key parts of the POMR system include:

source-oriented problem-oriented.

Source-oriented
The source-oriented medical record (SOMR) is a traditional method of documentation that includes a note for each patient visit. The notes are arranged in reverse chronological order, with the most recent visit rst. The advantage of this system is that it tells the patients story in the order in which it occurred. The disadvantage of this system is the

databasethe patients medical history, laboratory and diagnostic test results, and physical examination ndings problem listthe patients problems listed individually with an assigned number plancurrent ndings with a description of the current treatment plan progress notesnotes about each identied problem with a summary of the patients complaints, current condition, and responses to treatment provided

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SOAP or SOAPE
In the problem-oriented medical record, progress notes are written using the SOAP or SOAPE method. This acronym stands for:

symptom of chest pain, the physician will rst attempt to rule out a myocardial infarction (MI) by documenting chest pain, R/O MI. Plan of care The plan of care section of SOAP is where the physician describes how the patients health problem will be further evaluated and treated. The plan may include further diagnostic studies, laboratory tests, medications, and treatments as well as surgery or other therapies and patient education. Evaluation The added element of evaluation creates the SOAPE method. Evaluation describes the patients understanding of the overall plan as well as his compliance with it. Not all medical practices add the evaluation part.

subjective objective assessment plan of care evaluation (added for the SOAPE method).

Subjective The subjective part of the SOAP method is information that is known only by the patient and that the patient must share with the health care team for them to be aware of it. Examples of subjective data include description of pain, nausea, and emotional distress. In order to make the subjectivity of such data clear in the written record, the medical assistant should include the patients own words enclosed within quotation marks or include such words as the patient reports or the patient stated. Objective The objective part of the SOAP method is data obtained through the observations of the health care provider. The medical assistant recording such data should record it as accurately as possible using quantitative terms. Examples of objective data include physical examination ndings, weight, vital signs, and test results. (See Subjective versus objective data) Assessment The assessment part of SOAP is the physicians conclusion about the patients condition, or the diagnosis. In some cases, the diagnosis is not yet certain. In such cases, the physician may indicate this by listing the most likely diagnoses. For example, if the physician suspects either angina or gastroesophageal reux disease (GERD) as the patients diagnosis, she must document it as angina vs. GERD. When a diagnosis remains unconrmed, the physician may list the patients primary symptom with the goal to rule out (R/O) the most life-threatening diagnosis related to that symptom. If that diagnosis is ruled out, then the physician will investigate other possible causes next. To document such an instance, the physician must indicate the symptom and the diagnosis to rule outfor example, for a

Chapter Summary

Subjective vs. objective data

Here is a handy tip to help you remember the difference between subjective and objective data: Subjective data is what the patient says. Objective data is what you observe.

The medical assistant plays an important role in connecting the patient and physician. In this regard, the medical assistant may help with the patient interview. Interview techniques should be modied as needed for the individual situation in order to obtain complete, relevant information in a timely manner. Communication techniques include closed questions, restating, redirecting, open-ended questions, and directive statements. Establishing guidelines sets clear expectations of the interview. Medical assistants must be aware of potential obstacles to effective interviewing, including offering advice, providing false reassurance, using medical jargon, being too talkative, and implying judgment. The medical assistant can employ certain strategies to ease a patients discomfort when discussing sensitive topics, including providing privacy and comfort, explaining the purpose and nature of the interview, and assuring the patient that all information will be kept confidential. The medical assistant must adapt vocabulary and interviewing strategies to the age of the patient. The patients medical history typically includes the database, past medical history, family history, social history, and a review of systems. The patients chart serves as a record of the patients medical history, a communication tool, and a legal document. With the increasing popularity of electronic health records (EHR), more health care providers are using computers to enter their own notes directly into the patients medical record.

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Types of documentation commonly used by health care providers include source-oriented medical records and problem-oriented medical records. Progress notes are written using the SOAP or SOAPE method, which includes subjective data, objective data, assessment, plan of care and, sometimes, evaluation.

Team Work Exercises

1. Working in groups of four or ve, students should create posters that illustrate the various parts of the medical record and the purpose and nature of each, including the database, past medical history, family history, social history, and review of systems. 2. Working in groups of four or ve, students should create posters that illustrate the various parts of SOAPE documentation, listing examples of the type of data contained in each, including subjective data, objective data, assessment, plan of care, and evaluation.

dysuria. The medical assistant must obtain a complete health history, including information about sexual activity, birth control, menstrual pattern, and current symptoms. List and describe strategies the medical assistant might employ to put this patient at ease and obtain the necessary data. 2. Gloria Sherman is a 69-year-old patient visiting the clinic for her annual checkup. She is a friendly, talkative woman who loves to tell stories and gets easily sidetracked. She has multiple medical complaints and is eager to discuss them all at great length. The medical assistant must obtain a complete health history, including information about Mrs. Shermans current complaints in a timeeffective manner. List and describe strategies the medical assistant might employ to keep this patient on track.

Resources

Case Studies
1. Melinda Cross is a 22-year-old patient who has come to the clinic for the rst time to establish care. She is quiet and shy and reluctant to disclose personal information. Her current chief complaint is pelvic discomfort and

Miller, W.R., and Rollnick, S.: Motivational Interviewing: Preparing People for Change, 2nd ed. New York: Guilford Press, 2002. Simulated patient encounters: medicus.marshall.edu Tips for interviewing children: www.casanet.org/library/ advocacy/interviewing.htm and www.kidscounsel.org/ interviewing child client.pdf

CHAPTER

Vital Signs
Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell the key terms in the glossary list normal values for temperature, pulse, respiration, blood pressure, and pulse oximetry describe variables that might affect temperature, pulse, respiration, blood pressure, and pulse oximeter readings discuss potential causes of fever and list common symptoms describe the three common fever patterns cite four types of thermometers and demonstrate how to measure a patients temperature with each list common factors that can affect pulse rate, rhythm, and strength locate and identify the major pulse sites on the human body differentiate between internal and external respiration discuss the three key characteristics of respiration differentiate between systolic and diastolic blood pressure list and describe factors that commonly impact blood pressure cite risk factors for hypertension and identify which are modiable describe the ve types of sounds commonly heard when obtaining a blood pressure measurement and discuss the signicance of each explain how a pulse oximeter measures blood oxygen levels list several factors that might interfere with an accurate pulse oximeter reading demonstrate several trouble-shooting techniques when obtaining the arterial oxygen saturation (SpO2) measurement. Pulse

21
Tympanic thermometer Chemical thermometers Temporal thermometer Disinfecting Thermometers Celsius versus Fahrenheit Pulse Sites Temporal Carotid Brachial Radial Apical Femoral Popliteal Dorsalis pedis Posterior tibialis

CAAHEP Competencies
Clinical Competencies Patient Care
Obtain vital signs

ABHES Competencies
Clinical Duties
Take vital signs

Respiration
Characteristics of Respiration Rate Rhythm Depth

Procedures
Measuring oral temperature using a digital thermometer Measuring axillary temperature using a digital thermometer Measuring rectal temperature using a digital thermometer Measuring temperature using a tympanic thermometer Measuring temperature using a temporal thermometer Measuring radial pulse and respirations Measuring apical heart rate Measuring blood pressure Measuring oxygen saturation using a pulse oximeter

Blood Pressure
Evaluating Blood Pressure Korotkoff sounds Postural vital signs

Oxygen Saturation Chapter Summary Team Work Exercises Case Studies Resources

Chapter Outline
Vital Signs Prociency Temperature
Fever Thermometer Types and Uses Glass thermometer Digital thermometer

319

Key Terms
apnea

Vital Signs Prociency

Measurement of vital signs (VS) is among the most common procedures medical assistants perform on a daily basis. Such routine, yet very important measurements provide valuable information about a patients health status. Thus, a medical assistant must become procient in vital signs measurement. Furthermore, a medical assistant should maintain prociency, regardless of her chosen specialty, so she can help out whenever needed by obtaining an accurate set of vital signs (See Stat vital signs.) Vital signs include temperature, pulse, respiration, blood pressure, and oxygen saturation.

Temporary absence of breathing

auscultatory gap

Disappearance of tapping sounds during phase II of a blood pressure measurement

bradypnea

Abnormally slow breathing

core temperature

Temperature within the bodys deep internal structures

diastolic pressure

Blood pressure between heart contractions

diurnal rhythm

Normal daily cyclic uctuation in body temperature

dyspnea

Labored or difcult breathing

expiration

Temperature
Body temperature (T) is an indicator of health and disease. It is regulated by the hypothalamus in the brain and is an important part of homeostasis, or the state of dynamic equilibrium in the body. However, a number of physiologic factors can impact temperature. As much as 85% of body heat is lost through the skin. The rest is lost through the lungs and excretions of the bowel and bladder. The body creates heat energy as a by-product of metabolism and exercise. Body temperature also increases temporarily in response to infection, dehydration, hormonal uctuations, and exposure to a warm environment. Conversely, body temperature decreases slightly with exposure to a cold environment and in elderly patients. It may also be decreased in patients with hypothyroidism or those who have suffered traumatic injury. Normal body temperature varies with the time of day and the site of measurement. Core temperature is the temperature

The act of exhaling

external respiration

Movement of air into and out of the lungs

homeostasis

State of equilibrium in the body

hyperventilation

Increased ventilation resulting in a higher blood pH

inspiration

The act of inhaling

Korotkoff sounds

Sounds heard when auscultating blood pressure

point of maximal impulse

Point on the chest wall at which cardiac contractions are best seen or felt
postural vital signs

Vital signs performed to test for orthostatic hypotension

pulse decit

Difference between the apical pulse and radial pulse

pulse pressure

Front ofceBack ofce connection

Difference between systolic and diastolic pressures

sleep apnea

Stat Vital Signs

Measuring vital signs is one of the most basic yet most important jobs of the medical assistant. Therefore, regardless of whether a medical assistant ends up working in the clinical or administrative setting, she must make the commitment to maintain prociency in this skill. Doing so will be appreciated by others during times of short stafng or an emergency. During an emergency or urgent situation, the administrative medical assistant will be able to help out by getting a quick set of vital signs, including an oximeter reading. By doing so, she will help to establish critical patient baseline information quickly and free up the clinical medical assistant for more complex clinical tasks, such as performing a stat ECG or administering medications.

Temporary cessation of breathing during sleep

sphygmomanometer

Blood pressure cuff

systolic pressure

Tension exerted against arterial walls during ventricular contraction and represented by the top number in a blood pressure reading
tachycardia

Abnormally rapid heart rate

tachypnea

Abnormally rapid breathing

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within the bodys deep internal structures, such as the bladder and heart. Core temperature is slightly higher than peripheral body temperature taken in the mouth or axilla. In general, normal body temperature of a healthy individual uctuates 1 or 2F between 97.5 and 99.5F (36.4 to 37.3C) and averages 98.6F (37C). However, some persons, especially elderly persons, may have an average temperature as low as 96.8F. Body temperature also follows a cyclic uctuation called the diurnal rhythm, which causes body temperature to be lower in the morning and higher in the late afternoon. (See Factors that affect body temperature.)

Thermometer Types and Uses

Body temperature is measured with a thermometer. There are several different types of thermometers available. (See Figure 21-1.) Each has advantages and disadvantages. Most are available in the medical ofce and are also available for purchase in most drugstores and some grocery stores. Some electronic versions allow medical assistants the option of measuring in Fahrenheit or Celsius. The best choice of thermometer depends on a number of variables, including the patients age, condition, level of consciousness, and ability to cooperate, as well as on facility policy. Regardless of the type of thermometer used, the medical assistant must be familiar with the function and care of each type.

Fever
Fever, sometimes called pyrexia, is not an illness itself but is a common symptom of illness caused by bacterial or viral infection. Other causes of fever include tumors, the breakdown of necrotic (decaying) tissue, central nervous system (CNS) damage, and certain diseases. Depending on the cause and severity of a fever, the physician may elect to refrain from treating it because an increase in body temperature is thought to be a natural response designed to inhibit the growth of some bacteria and viruses. Even so, febrile (fever) illness in infants under 3 months of age is evaluated carefully because it may indicate a serious condition. Onset of fever may be rapid or slow. The patient may exhibit chills and an increased pulse and respiratory rate that continues. The patient feels warm to the touch and may complain of thirst, anorexia (loss of appetite), headache, and malaise (feelings of discomfort, weakness, and fatigue). The fever may subside slowly or suddenly and the patient may experience diaphoresis (profuse sweating). This change is known as the crisis, but is commonly described by the layperson as the fever breaking. During the course of the fever, body temperature uctuates according to one of three pattern types:

Glass Thermometer
Glass thermometers are no longer used in the medical ofce. However, many patients still keep and use them at home. Because the older mercury thermometers have been deemed unsafe, medical assistants should advise patients to properly dispose of them. (See Mercury thermometer disposal, page 323.) There are mercury-free glass thermometers available that function in a similar way to the older types. These thermometers contain a nontoxic silver or red-colored uid. They do not require a battery and come in oral and rectal versions. Some are available with magnifying optical cases, which make them easier to read. Many also have dual scales, allowing the patient to read the temperature in Fahrenheit or Celsius. Medical assistants should be familiar with the proper use of glass thermometers because some patients may own them and may need instruction in their use.

Digital Thermometer
Digital thermometers are battery operated and portable and can obtain a temperature reading in a minute or less. The temperature is displayed on a light-emitting diode (LED)

continuous intermittent remittent. (See Fever patterns, page 322.) D

Factors that affect body temperature

A number of factors impact body temperature, including: external environment, such as heat, humidity, cold, and wind age, as in elderly persons, who commonly have body temperatures that are 1 to 2F lower than the average 96.8F for most persons (due in part to a slower metabolism in elderly persons) infection or illness (elevated temperature, or fever).

FIG 21-1 Types of thermometers. (A) Oral (or rectal) digital. (B) Tympanic. (C) Temporal. (D) Rectal. (E) Disposable.

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Fever patterns
This table lists fever patterns along with a description of each.

Pattern
Continuous

Description
Fever that uctuates slightly yet remains consistently above normal

F. 102 101 100 99 98 97 96 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 June

Intermittent Fever that uctuates widely between relatively high levels to normal or even subnormal levels

C. 39 38 37 36

F. 102 101 100 99 98 97 96 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 June

Remittent Fever that uctuates widely, yet remains above normal until it nally resolves

C. 39 38 37 36

F. 102 101 100 99 98 97 96 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 June

C. 39 38 37 36

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Patient Education

Mercury Thermometer Disposal

Because of the health hazards associated with mercury, thermometers that contain this heavy metal are no longer recommended for use in body temperature measurement. The medical assistant should check with patients regarding the type of thermometer they use at home. If a patient uses a mercury thermometer, the medical assistant should instruct the patient on the proper methods for disposing of this toxic substance, including these guidelines: Never throw a mercury thermometer in the garbage because the mercury will eventually make its way into the environment and impact animals and humans. Instead, call a household hazardous waste collection facility. Most municipalities conduct periodic collections of household hazardous waste. Contact the local municipal waste disposal organization for more information. Mercury poisoning can occur by ingestion, inhalation, or even through skin exposure. It affects the central nervous system, kidneys, and liver and causes alterations in sensation, taste, and movement. It also causes vision disturbances, stupor, and even coma. In pregnant women, mercury crosses the placenta and affects fetal development. Children subjected to mercury poisoning show lowered intelligence, poor muscle coordination, and impaired hearing. Persons concerned about possible mercury poisoning should contact the regional poison control center; state, county, or local health department; the Agency for Toxic Substances and Disease Registry (ATSDR); or their physician for advice.

screen. Some types come with oral and rectal probes. (See Procedure 21-1: Measuring oral temperature using a digital thermometer, page 324.) A disposable cover, or sheath, ts over the probe for sanitary use and makes cleaning between patients unnecessary. A digital thermometer may also be used to measure oral, axillary, or rectal temperature. (See Procedure 21-2: Measuring axillary temperature using a digital thermometer, page 325.) The medical assistant should avoid taking the patients temperature rectally if other reliable means are available. There is potential for rectal trauma if the procedure is not performed carefully, as well as potential embarrassment to the patient. However, rectal temperature readings are considered among the most accurate because the rectum is a highly vascular, closed cavity. The medical assistant may use this route for infants, small children, patients who are unconscious, or those for whom other temperature routes are deemed unreliable. When measuring the patients temperature rectally, the medical assistant must take measures to ensure privacy and careful positioning. In addition, she must be sure to document that she took the temperature rectally, because rectal temperature readings are generally 1F higher than those taken by other routes. (See Procedure 21-3: Measuring rectal temperature using a digital thermometer, page 326.)

patients unnecessary. The tympanic thermometer provides a reading in under 2 seconds. The tympanic thermometer records the temperature of the tympanic membrane, which is protected inside the ear canal. This type of thermometer is used when taking an oral temperature is not possible or practical, such as with a small child or after a patient has just had something hot or cold to drink. However, the medical assistant must take care to use proper technique in order to obtain accurate results, including making sure that the thermometer ts snugly into the ear canal and is pointed slightly forward toward the tympanic membrane. (See Procedure 21-4: Measuring temperature using a tympanic thermometer, page 327.)

Chemical Thermometers
Chemical thermometers come in disposable and reusable versions. They contain a heat-sensitive substance that changes color when exposed to body heat. Although not as accurate as other types of thermometers, they are convenient for home use. Disposable, single-use thermometers are placed under the tongue for the designated time (usually 60 seconds) and then read according to the number of small dots that have changed color. Temperature strips may be pressed onto the forehead and read when the colors stop changing (usually 15 seconds). They are especially convenient for the worried parent who wishes to check the fever of a sleeping child.

Tympanic Thermometer
A tympanic thermometer, also called an aural thermometer, is a small, handheld device with a tympanic probe that ts into the outer part of the ear canal. It is covered with a disposable sheath for sanitary use, which makes cleaning between

Temporal Thermometer
The temporal thermometer is a newer type of thermometer. It allows a fast, noninvasive method of taking a temperature
(Text continues on page 328)

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PROCEDURE 21-1

Measuring oral temperature using a digital thermometer

Task Measure oral body temperature using a digital thermometer. Conditions Digital thermometer Oral probe Probe cover Waste container Pen Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure and record a patients oral temperature using a digital thermometer. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Prepare the oral probe for use according to the manufacturers directions to prevent errors and ensure accuracy. 3. Greet and identify your patient and introduce yourself. Explain the procedure and ask if the patient has smoked, exercised, or had anything to eat or drink within the past 30 minutes. These activities can affect the accuracy of the temperature measurement. 4. Apply the disposable probe cover, making sure it locks into place to ensure infection control and activate the thermometer. 5. Place the probe under patients tongue in the pocket on either side of the frenulum linguae to access the warmest part of the mouth. 6. Instruct the patient to close her mouth. Continue holding the end of the probe to keep it in the proper position. 7. Remove the probe after the thermometer beeps and read the number on the digital display screen. Eject the probe cover into the waste container by pressing the ejection button and without touching the probe cover to prevent transfer of microorganisms. 8. Return the probe to its storage position in the thermometer unit to turn off and reset the thermometer and return the thermometer to its base to ensure easy access for future use. 9. Wash or sanitize your hands and disinfect equipment if indicated to ensure infection control.

Base of tongue

Heat pockets

Correct placement of an oral thermometer

10. Record the patients temperature in the medical record, including the date and time, to ensure accurate documentation and make the information available to the physician.
Date 05/26/09; 9:45 a.m. T: 98.4 F. ------------------------------------------------- S. Lind, CMA

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PROCEDURE 21-2

Measuring axillary temperature using a digital thermometer

Task Measure axillary body temperature using a digital thermometer. Conditions Digital thermometer Oral probe Probe cover Waste container Pen Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure and record an individuals axillary temperature using a digital thermometer. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify your patient, introduce yourself, and explain the procedure to ease the patients anxiety. 3. Prepare the oral probe for use according to the manufacturers directions to ensure accuracy. 4. Assist the patient in removing or loosening clothing around the shoulder and arm as needed to provide access to the axilla. 5. Pat the axilla dry if needed to ensure accuracy. 6. Apply a disposable probe cover, making sure it locks into place, to activate the thermometer and ensure infection control. 7. Insert the probe into the center of the axilla pointing toward the upper chest. Tell the patient to hold his upper arm snugly against the side of his rib cage and assist him as necessary to ensure accuracy by preventing exposure of the probe to air. Hold the probe in place until you hear the beep sound that indicates the reading is complete. 8. Remove the probe and read the number on the digital display screen. Eject the probe cover into the waste container by pressing the ejection button without touching the probe cover to ensure infection control. 9. Return the probe to its storage position in the thermometer unit to turn off and reset the thermometer and return the thermometer to its base to ensure easy access for future use.

Insert the probe into the center of the axilla pointing toward the upper chest.

10. Wash or sanitize your hands and disinfect equipment if indicated to ensure infection control. 11. Record the patients temperature in the medical record, including the method of measurement (in this case, axillary), the date, and the time, to ensure accurate documentation and make the information available to the physician.

Date 06/27/09; 9:56 a.m. T: 101.2 F (axillary). ----------------------------------S. Lind, CMA

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PROCEDURE 21-3

Measuring rectal temperature using a digital thermometer

Task Measure rectal body temperature. Conditions Digital rectal thermometer Rectal probe Probe cover Lubricant Tissues Nonsterile examination gloves Waste container Pen Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure and record the patients rectal temperature. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify the patient and introduce yourself to ease patient anxiety. 3. Prepare the rectal probe for use, according to the manufacturers instructions. Apply a disposable probe cover to ensure infection control, making sure it locks into place to turn the thermometer on. 4. Apply nonsterile examination gloves to ensure infection control. 5. Assist the patient in removing clothing below the waist. Assist the adult or child patient into a Sims or sidelying position. Drape the patient as completely as possible, exposing only the anal area to ensure privacy, warmth, and comfort while providing access to the anal opening. Position the infant patient on his abdomen. 6. Apply lubricant to the tip of the thermometer to ensure easier insertion and minimize patient discomfort. Insert the thermometer into the rectum past the external sphincter. For an infant or small child, take care to insert it no more than 1/2 and no more than 1 for an older child or adult to avoid causing injury. Continue holding the probe end to prevent it from slipping out or further in. 7. Remove the probe after the beeping sound. To prevent transfer of microorganisms, eject the probe cover into the waste container without touching the probe cover and dispose of examination gloves. 8. Read the number on the digital display screen. 9. Offer tissues to the adult or child patient so she can wipe off excess lubricant herself. Wipe excess lubricant from the infant. 10. Return the probe to its storage position in the thermometer unit to turn off and reset the thermometer and return the thermometer to its base to ensure easy access for future use. 11. Wash or sanitize your hands and disinfect equipment if indicated to ensure infection control. 12. Assist the patient with positioning and dressing as needed to put patient at ease. 13. Record the patients temperature in the medical record, including the method of measurement (in this case, rectal), the date, and the time, to ensure accurate documentation and make the information available to the physician.
Date 12/10/09; 9:30 a.m. T: 99.8 F. (rectal) --------------------------------W. Jones, CMA

Taking an infants rectal temperature

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PROCEDURE 21-4

Measuring temperature using a tympanic thermometer

Task Measure body temperature using a tympanic thermometer. Conditions Tympanic thermometer Probe cover Waste container Pen Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure and record a patients body temperature using a tympanic thermometer. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify your patient, introduce yourself, and explain the procedure to ease the patients anxiety. 3. Prepare the tympanic thermometer for use according to the manufacturers directions, making sure that probe lens is clean and the display screen is adjusted for the patients age to prevent errors and ensure accuracy. 4. Apply the disposable probe cover, making sure that it snaps into place to activate the thermometer and ensure infection control. 5. When the thermometer display reads READY, straighten the patients ear canal with your other hand by gently pulling the auricle up and backward for patients over age 3 or by gently pulling the pinna down and backward for younger patients to straighten the ear canal. 6. Insert the probe into the patients ear canal just far enough to seal the opening but without applying pressure to minimize patient discomfort while ensuring accuracy. 7. Press the button and hold it down briey, as indicated in the manufacturers instructions. Check the temperature reading that appears on the display screen. 8. Remove the probe and eject the probe cover into a waste receptacle without touching it to ensure infection control. 9. Record the patients temperature in the medical record, including the method of measurement (in this case, tympanic), along with the ear in which it was measured, the date, and the time, to ensure accurate documentation and make the information available to the physician.
Date 11/20/09; 1:30 p.m. T: 99.8 F (tympanic, left ear). --------------------S. Lind, CMA

Insert the probe into the patients ear canal without applying pressure.

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by scanning the thermometer across the forehead over the temporal artery where it detects infrared readings of blood ow in the temporal artery. Disposable covers may be placed over the probe or it can be cleaned between patients with a disinfectant wipe. Evidence indicates that this method of temperature measurement is as accurate as obtaining a rectal temperature and may be more accurate than the tympanic method. Because it is fast and noninvasive, this method is quickly gaining popularity among patients and health care providers. (See Procedure 21-5: Measuring temperature using a temporal thermometer.)

Disinfecting Thermometers
The medical assistant should disinfect reusable thermometers between uses. The World Health Organization (WHO) recommends two methods for disinfecting reusable thermometers: with 70% isopropyl alcohol or a 1:100 bleach solution. To disinfect with 70% isopropyl alcohol, the medical assistant should moisten a clean cloth or gauze pad with alcohol, carefully wipe the thermometer, hold the cloth around it for 30 seconds, and then discard the cloth and let the thermometer air dry. To disinfect with a 1:100 bleach solution, the medical assistant should use a clean cloth or

PROCEDURE 21-5

Measuring temperature using a temporal thermometer

Task Measure body temperature using a temporal thermometer. Conditions Temporal thermometer Probe cover or disinfectant wipe Waste container Pen Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will accurately measure and record a patients temporal temperature. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify the patient, introduce yourself, and explain the procedure to ease the patients anxiety. 3. Apply a disposable probe cover, as necessary, to ensure infection control. 4. Scan the probe across the patients forehead over the temporal artery as indicated in the manufacturers instructions.

Scan the probe over the temporal artery.

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PROCEDURE 21-5contd

5. Read the temperature on the digital display screen. 6. Eject the probe cover into the waste container without touching the probe cover or clean the probe with a disinfectant wipe to ensure infection control. 7. Wash or sanitize your hands to ensure infection control. 8. Record the patients temperature in the medical record, including the method of measurement (in this case, temporal), the date, and the time, to ensure accurate documentation and make the information available to the physician.

Date 11/20/09; 9:30 a.m. T: 99.8 F (temporal). -----------------------------C. Chapin, CMA

gauze pad dipped in the bleach solution to wipe the thermometer. Alternatively, she may soak the thermometer for 10 minutes and then allow it to air dry. Reusable thermometers should be disinfected in this manner or according to office policy any time they have come into contact with body fluids. Tympanic thermometers can be disinfected in a manner similar to other thermometers except that the tip of the probe surface should not get wet, because disinfectant may ruin it. Thus, the medical assistant should be sure to use a probe cover whenever she uses a tympanic thermometer.

Pulse
Each time the heart beats, the chambers of the heart contract. This contraction propels blood forward through the circulatory system. As the left ventricle contracts, it forces blood into the aorta, the largest artery in the body. From the aorta, it moves through smaller and smaller arteries throughout the rest of the body. Because the arteries are essentially already full of blood, when the new supply of blood is forced into them by the beating heart, a wavelike pulsation is created as the elastic arteries expand. This pulsation can be felt (palpated) when the medical assistant places the pads of her ngers over a supercial artery. Veins do not pulsate because blood moves through them under much lower pressure. (See Factors that affect pulse.)

Celsius Versus Fahrenheit

Historically, the Fahrenheit scale has been used for temperature measurement in the United States. While many measurements in the United States are still typically nonmetric, metric is the standard scale for measurement within the health care setting. Even so, medical ofces may record temperatures using the Fahrenheit or Celsius scale, so the medical assistant should be familiar with both and follow facility policy. In some situations, the medical assistant may need to convert temperature readings from one system to another. (See Temperature conversions.)

Factors that affect pulse

There are a number of factors that can affect pulse rate, rhythm, and strength. The medical assistant must consider all of these factors when assessing the patients pulse, including: AgePulse rate decreases with age. A newborn infants pulse may be as high as 160 beats/minute and an adults pulse may be as slow as 60 beats/minute. SexWomen tend to have slightly faster resting pulse rates than men. Exercise habitsPeople who are very athletic may have a normal resting pulse as slow as 40 beats/ minute. Emotional statePulse rate normally increases with exercise and emotional states such as fear, anxiety, anger, and excitement.
Continued

Temperature conversions
Medical assistants must know how to convert temperatures between Fahrenheit and Celsius. The formulas for conversion are: C (F 32) 5/9 F (9/5 C) 32 OR C (F 32) 1.8 F (C 1.8) 32

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Factors that affect pulsecontd

Pregnancy and other metabolic conditions Conditions that increase the metabolism, such as pregnancy and hyperthyroidism, will increase the pulse. MedicationSome medications may increase or decrease a patients pulse rate. For example, lanoxin is a cardiac medication that slows the heart rate, and albuterol is a pulmonary medication that opens the air passages but causes tachycardia (rapid heart beat) as an adverse effect. FeverFever increases a patients pulse rate. ArrhythmiaCardiac arrhythmias (abnormal rhythms) may cause an irregular pulse and may cause some pulsations to be stronger than others. HypertensionA person with hypertension may have a bounding pulse which is very strong and easily palpated. DehydrationA person who is dehydrated may have a weak pulse that is difcult to palpate.

Front ofceBack ofce connection

Using Pulse Points to Control Bleeding

In the event of a bleeding emergency, the administrative medical assistant may be asked to apply pressure to a pulse point while the clinical medical assistant applies direct pressure to the wound with an absorbent dressing. Thus, it is important for an administrative medical assistant to remember where the pulse points are located.

Superficial temporal External maxillary Carotid

Pulse Sites
There are many pulse points in the body. A pulse point is any area where the pulse can be felt by pressing a supercial artery against a bone. Such areas may be palpated to evaluate circulation in that area or to count heart rate. In cases of hemorrhage, the pulse point can also be compressed to control bleeding. (See Using pulse points to control bleeding.) Common pulse points include:

Brachial

Ulnar Radial
ED: please supply new art.

temporal carotid brachial radial apical femoral popliteal dorsalis pedis posterior tibialis. (See Figure 21-2.)

Femoral

Popliteal

Temporal
The temporal pulse is located over the temporal bone, lateral to the eyes. It is rarely used to measure pulse but pressure may be exerted there to control the bleeding of a head wound.

Carotid
The medical assistant can locate the carotid pulse by pressing her ngertips into the groove between the larynx and the sternocleidomastoid muscle on either side of the neck.

Dorsalis pedis FIG 21-2 Common pulse points.

Posterior tibial

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Because it is one of the strongest pulses in the body and easily accessible, it is used to assess a patients circulation during cardiopulmonary resuscitation (CPR). A person may also assess his own carotid pulse during exercise. Because it provides the major blood supply to the brain, the medical assistant should use just enough pressure to feel the pulse without occluding blood ow and should only palpate it on one side at a time.

Brachial
The medical assistant can palpate the brachial pulse at the antecubital space in the bend of the arm, anterior to the elbow. This is the site the medical assistant will auscultate when measuring blood pressure. It is also the site for assessing pulse during infant CPR.

Radial
The radial pulse is the most common pulse used for checking the pulse rate. It is located in the distal part of the forearm on the inner aspect of the wrist, just below the base of the thumb. Because the artery lies over the radius (giving this pulse point its name), the medical assistant should be able to feel it easily when pressing the point with the pads of her fingers. (See Counting radial pulse.) The most accurate and easiest measurement of pulse and respiration occurs when these measurements are taken together. (See Procedure 21-6: Measuring radial pulse and respirations, page 332.)

Apical
The apical pulse is more accurately referred to as the apical heart rate because it is usually auscultated with a stethoscope.

It lies over the apex of the heart at the fth intercostal space at the midclavicular line. It is just below the nipple in men. In a patient who is young and thin, the medical assistant may be able to palpate this pulse easily as the point of maximal impulse (PMI), which is where the apex of the heart touches the inner chest wall and pulsations can sometimes be observed and felt. The PMI is typically located in the fourth or fth intercostal space along the midclavicular line. However, the medical assistant may nd it difcult to palpate it in others. Regardless, she can easily auscultate the apical heart rate in nearly everyone. An apical heart rate measurement is helpful if a patient has an irregular heart rhythm or a radial pulse that is difcult to palpate. When listening to the patients heart, the medical assistant must be sure to note that each heartbeat includes two sounds in quick succession. These sounds are commonly described as a lubb-dupp sound. Each lubb-dupp is counted as one heartbeat. Additionally, the medical assistant may check the patient for a pulse decit by counting the apical heart rate and the radial pulse and noting the difference, if any. In some cases, such as in patients with a common abnormal heart rhythm known as atrial brillation, the apical heart rate may be higher than the radial pulse. Such a result may happen if some of the heart contractions are weaker than others and do not generate a high enough stroke volume to create a palpable radial pulse. In such a case, the apical heart rate is more accurate, and the medical assistant should record it in the medical record. (See Procedure 21-7: Measuring apical heart rate, page 333.) A medical assistant will commonly use a stethoscope to check a patients vital signs. Therefore, she should become

Patient Education

Counting Radial Pulse

To teach a patient how to take his pulse, the medical assistant should follow these simple steps: Tell the patient to position a clock or wristwatch with a second hand within easy view. Show the patient how to locate his radial pulse in both wrists. Let the patient continue palpating his radial pulse in whichever wrist is easiest for him. Palpate his pulse in his other wrist so you are both palpating it at the same time. Count for a full minute and then compare numbers. (The numbers may not match exactly but should only vary by one or two beats.) Some patients may wish to complete the process more quickly by counting for 30 seconds and then multiplying by 2. Although this practice may be acceptable if the pulse is regular, counting for a full minute ensures greater accuracy. Medical assistants typically count for just 30 seconds and multiply by 2 once they become very procient in obtaining vital signs. However, whenever a patient has an irregular pulse, even the medical assistant should count for 1 full minute. The medical assistant should make sure that this practice is acceptable to the physician before allowing the patient to estimate pulse rate in this way.

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PROCEDURE 21-6

Measuring radial pulse and respirations

Task Measure and record radial pulse and respirations. Conditions Clock or watch Pen Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will accurately measure and record radial pulse and respirations. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify the patient, introduce yourself, and explain the procedure to ease patient anxiety. 3. Assist the patient into a comfortable sitting position with his arm relaxed and slightly exed to make the pulse easier to palpate and ensure an accurate resting pulse measurement. 4. Grasp the patients wrist with the pads of your middle three ngers placed over the radial site and apply just enough pressure to distinctly palpate the pulse. Pressing too hard may occlude the pulse. Do not palpate with the thumb, to avoid feeling your own pulse instead of the patients. 5. Count the pulse for 30 seconds as measured with your watch and multiply by 2 to save time while preserving accuracy. 6. To count respirations, continue holding the patients wrist while looking at your watch so the patient will not be aware that you are counting respirations and, thus, will continue to breathe normally. Count the patients respirations for 30 seconds, then multiply by 2. Be sure to note the character of the respirations, including depth and rhythm, to provide information about respiratory function. 7. Record the patients pulse and respirations in the medical record, including date and time, to ensure accurate documentation and make the information available to the physician. 8. Wash or sanitize your hands to ensure infection control.
Date 07/16/09; 11:50 a.m. P: 66, reg, strong. R: 16, reg, nonlabored -----S. Lind, CMA

Place the pads of your ngers over the radial site.

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PROCEDURE 21-7

Measuring apical heart rate

Task Measure and record a patients apical heart rate. Conditions Watch with a second hand Stethoscope Patient examination gown Antiseptic wipe Pen Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will accurately measure and record the apical heart rate. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify the patient, introduce yourself, and explain the procedure to ease patient anxiety. 3. Clean the earpieces and chest piece of the stethoscope with an antiseptic wipe to ensure infection control. 4. Assist the patient in undressing from the waist up and putting on an examination gown, if preferred, with the opening in the front. (Some male patients prefer not to wear a gown. However, the medical assistant should be sure to offer one.) Place the patient in a sitting or reclining position to ensure patient comfort while allowing apical access. 5. Because apical heart sounds are heard best with the bell, place the bell of the stethoscope over the apical area (fth intercostal space at the midclavicular line), applying just enough pressure to ensure full contact with the skin. Pressing too hard may diminish the sound.

Place the bell of the stethoscope over the apical area.

6. Count the heart beat for a full minute as measured with your watch to ensure accuracy, especially in patients with irregular heart rhythms. 7. Wash or sanitize your hands and sanitize the earpieces and chest piece of the stethoscope to ensure infection control. 8. Record the patients apical heart rate and rhythm in the medical record, including the date and time, to ensure accurate documentation and make the information available to the physician.
Date 07/21/09; 3:50 p.m. AP: 72, reg. -------------------------------------- J. Morgan. CMA

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familiar with this important piece of medical equipment. The parts of a stethoscope include the earpieces, called binaurals, tubing, and chest piece. (See Figure 21-3.) The chest piece includes a diaphragm, which is a large, round disc, and may also include a bell on the opposite side, which is smaller in diameter and concave in shape. The diaphragm is helpful when listening to high-pitched sounds and the bell is more useful for listening to low-pitched sounds. When using the stethoscope, the medical assistant must make sure the chestpiece is turned in the correct direction or no sound will be heard.

used, but may be very useful with patients who are in cardiac arrest or have very weak radial and carotid pulses.

Popliteal
The popliteal pulse is usually difcult to locate and palpate. It is located behind the knee and must be palpated with the leg in a slightly exed position. This site is sometimes used to assess circulation in the lower leg.

Dorsalis Pedis
The dorsalis pedis pulse is located on the top of the foot near the extensor tendon of the great toe. It is easily palpated in some patients but difcult in others and possibly congenitally absent. It is palpated to assess circulation in the foot.

Femoral
The femoral pulse is located where the upper leg bends, in the inguinal area very near the groin. It is most easily palpated by pressing the pads of the ngers rmly downward when the patient is lying supine. This pulse is not commonly

Posterior Tibialis
The posterior tibialis pulse lies slightly inferior and posterior to the inside ankle bone. It is easy to palpate in some individuals and difcult in others. It is used to assess circulation in the foot.

Binaurals

Respiration
Chest piece

Bell

Diaphragm

Tubing

FIG 21-3 Parts of the stethoscope.

Respiration involves the movement of air into and out of the lungs so that gas exchange can occur in the alveoli, which are the tiny air sacs in the lungs. Even though oxygen is necessary to sustain life, oxygen levels are not the main stimulus for breathing in most people. The real stimulus is the lowered pH level of the blood caused by carbon dioxide (CO2) buildup. As the pH level drops, a message is sent to the medulla oblongata in the brain, which then sends out a message to the body to increase the rate and depth of respiration. As a result, more CO2 is blown off and eliminated from the body. Blood pH rises back to a more normal level and homeostasis is maintained. Conversely, when the pH level rises too high, messages to and from the medulla oblongata stimulate a decrease in the rate and depth of respiration, which allows the body to retain more CO2, thus lowering the pH level to normal. External respiration involves the movement of air in and out of the lungs. Inspiration, or the act of breathing in, occurs when the diaphragm and other muscles contract, pulling the thorax (rib cage) upward and outward. At the same time, the lungs expand, causing air to be pulled in through the mouth and nose. Inspiration is the active phase of breathing and requires the muscles to work. However, expiration, or the act of breathing out, is usually passive. The diaphragm and other muscles simply relax, allowing the rib cage to return inward and downward as air is expelled from the lungs. The medical assistant should be aware of factors that might impact respiration. Some are normal variations in

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response to physical and emotional stress. Others may be indicators of illness or disease. (See Factors that affect respiration.)

Characteristics of Respiration
While a person may exert some voluntary control over respiration, it is generally an automatic or involuntary function controlled by the nervous system. Respirations are most easily and accurately measured when performed simultaneously with pulse measurement. The medical assistant should continue to hold the patients wrist in a manner that allows for easy observation of her watch as well as the patients chest. Doing so prevents the patient from being aware that the medical assistant is measuring his respirations, which might cause him to self-consciously alter his breathing pattern. There are three major characteristics of respiration:

term for abnormally slow breathing. While bradypnea is uncommon, it can occur in certain disease states. Apnea refers to the absence of breathing. Sleep apnea is a condition in which the individual stops breathing for short periods of time while sleeping due to temporary obstruction of the upper airway. This condition is usually associated with severe snoring and can have a profound impact on a persons quality of life. Tachypnea is a state of abnormally rapid breathing. It may be caused by many factors, including such respiratory disorders as asthma and emphysema. Tachypnea commonly occurs when an individual is exercising or physically working. Another common cause of tachypnea is hyperventilation, which may occur when an individual is feeling anxious or upset. This problem corrects itself as the individual calms down.

rate rhythm depth.

Rhythm
The normal respiratory pattern is described as even and regular. However, normal interruptions in the respiratory pattern may occur when an individual sighs or yawns. Rhythm also varies with speech patterns. Abnormal variations in rhythm may occur with injury or disease. For example, if a person has sustained an injury to the ribs, the breathing pattern may be more rapid and shallow due to pain experienced when the patient takes a deeper breath. Patients with lung disease such as asthma or chronic obstructive pulmonary disease (COPD) may easily develop dyspnea. In a patient with dyspnea, respirations may be more rapid and the expiratory phase becomes prolonged because the patient must work harder to breathe out.

Rate
The medical assistant should count the respiratory rate in breaths per minute. One breath includes inspiration and expiration. The normal respiratory rate for adults is 12 to 20 breaths per minute, but the rate varies with age and other factors. (See Normal respiratory rate by age.) Bradypnea is the

Factors that affect respiration

The rate and depth of respirations may increase or decrease in relation to many factors. Some of the most common are listed here.

Depth
Depth of respiration varies with physical activity and may be described as normal, deep, or shallow. Respirations become deeper with physical exertion and become more shallow at rest. Depth is also impacted by injury or disease. For example, a patient with a rib injury or one who has undergone recent chest or abdominal surgery may experience increased pain when taking deep breaths. Even so, such patients must

Increased rate
severe pain (Depth may be increased or decreased depending on the location and type of pain.) fever

Increased rate and depth

emotions, such as fear, anger, anxiety, or excitement physical exertion or exercise illness condition that causes acidosis, such as severe diabetic coma, exacerbation of chronic obstructive pulmonary disease, asthma, or breathing impairment due to a brain or chest injury

Normal respiratory rate by age

Normal respiratory rate varies with age. Here are normal ranges for respiratory rates by age group: newborn30 to 60 breaths/minute infant (less than 6 months)30 to 50 breaths/minute toddler (less than 2 years)25 to 32 breaths/minute child20 to 30 breaths/minute adolescent16 to 19 breaths/minute adult12 to 20 breaths/minute.

Decreased rate and depth

illness condition that causes alkalosis, such as excessive intake of antacids or severe or prolonged vomiting

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be instructed and encouraged to take frequent, deep breaths and even cough in order to keep the alveoli open and fully functioning. Occasionally, disease states can impact respiratory depth. An example is the patient in a diabetic coma. Such an individual will involuntarily exhibit a respiratory pattern that is rapid and deep.

Patient Education

Modifying Heart Rate and Blood Pressure

Measurement of a patients vital signs commonly creates a great opportunity for teaching because many patients want to know what normal values should be and what their vital sign values are. If the patients resting heart rate and blood pressure is abnormally high, he may be interested in hearing about what he can do to bring them back to normal. Here is a simple list of commonsense strategies the medical assistant can share with the patient for modifying his heart rate and blood pressure: Exercise regularly, including aerobic activity, such as walking briskly, jogging, swimming, or bicycling several times a week for at least 20 to 30 minutes at a time (or as recommended by your physician). Stop smoking or other tobacco use. Achieve and maintain optimal weight for height. Learn and use stress reduction measures, such as meditation and relaxation activities. Eat a healthy, well-balanced, low-fat diet. Keep alcohol intake to 2 drinks per day or less (or as recommended by your physician).

Blood Pressure
Blood pressure is one of the most common measurements taken in the medical ofce. It reects the pressure exerted against arterial walls by blood and is recorded as a fraction. The systolic pressure, the top numbers, indicates the highest pressure, or tension, exerted against arterial walls during ventricular contraction. Diastolic pressure, the lower number, represents the lowest pressure exerted against the arterial walls when the heart is at rest between contractions. The difference between the two is the pulse pressure and should be 30 to 50 mm Hg. Hypertension is dened as sustained blood pressure readings above 140/90 mm Hg. (See Nonmodiable risk factors for hypertension.) However, ideal blood pressure for all adults is below 120/80 mm Hg. (See Modifying heart rate and blood pressure.) Blood pressure normally varies from person to person. Normal diurnal variations also alter blood pressure in the same person during the day. Lower readings are common in the morning when metabolism is slower. Blood pressure rises throughout the day, typically peaking in the late

Nonmodiable risk factors for hypertension

Although some risk factors for hypertension, such as diet and exercise, are modiable, there are several nonmodiable risk factors for hypertension, including: age gender genetics. situation changes. Adult men tend to have higher blood pressures than adult women. However, at more advanced age, the situation reverses and postmenopausal women have higher blood pressures than elderly men.

Genetics
There is some evidence that some of the physical contributors to hypertension and heart disease may be genetic. Therefore, a person whose parents both died of heart disease in their 50s would be at a higher-than-average risk for developing the same disorders. Along the same lines, some ethnic groups have a higher incidence of specic diseases and disorders, including hypertension. For example, African Americans have a higher risk of developing hypertension than other ethnic groups, and those who develop it have a higher risk for such complications as stroke, heart attack, and death.

Age
Normal values for blood pressure slowly increase with age until individuals reach adulthood. Blood pressure may continue to increase with advancing age as atherosclerosis and other disorders develop. However, as more is learned about the risk that hypertension poses for other disorders, most physicians are taking a more aggressive approach to managing it.

Gender
Blood pressure measurements in boys and girls do not differ signicantly, but once they reach adulthood the

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afternoon or evening. The medical assistant must be aware of the many factors that impact blood pressure. Those that cause a temporary elevation in blood pressure, such as exercise, must be accounted for whenever possible. Therefore, if the patient just climbed a ight of stairs to enter the medical ofce, the medical assistant should ensure that he sits and rests for 20 to 30 minutes before checking his blood pressure. (See Factors that affect blood pressure.) Medications can also impact blood pressure. Therefore, the medical assistant should record all medications in the patients medical record. Even if altering blood pressure is the desired effect of the medication, the physician must be aware of the medication in order to make an accurate evaluation.

Korotkoff Sounds
The sounds heard when listening to blood pressure vary. This fact was rst noted and reported by Russian neurologist Nikolai Sergeyevich Korotkoff. He divided the sounds, now known as Korotkoff sounds, into ve categories. (See Figure 21-4.) These categories, or phases, include:

Evaluating Blood Pressure

The medical name for the blood pressure cuff is sphygmomanometer. It includes a cuff with an inner inatable bladder, a bulb with a control valve, and a gauge. When inated, the cuff compresses the brachial artery and cuts off blood ow. As it slowly deates, it measures the pressure exerted by the blood pumping back through the artery and into the arm. Measuring blood pressure is a very common task for the medical assistant. Therefore, she must be procient in this skill. However, she may nd it a challenge to obtain an accurate blood pressure measurement in some people. When facing such a situation, the medical assistant can use special strategies to increase her chances of obtaining an accurate measurement. (See Strategies for accurate blood pressure measurement.)

Phase I is the rst sound heard as blood begins to surge back into the constricted artery. This sound is usually a sharp tapping sound that may begin faintly and progressively grow louder. This rst tapping sound is the systolic pressure. Phase II occurs as the tapping sound takes on a swishing or murmuring quality. This sound is more quiet and muffled and, in some cases, disappears completely. When it disappears, it is known as the auscultatory gap. The needle may continue to drop another 30 mm Hg or so before the sound returns. This absence may lead an inexperienced medical assistant to believe she was mistaken about hearing the first sound. However, the experienced medical assistant learns to trust what is heard

Strategies for accurate blood pressure measurement

Obtaining an accurate blood pressure reading can be challenging in some patients. Here are some strategies the medical assistant can use to increase her success in this important skill: Eliminate room noise, such as talking or music. Use a good-quality stethoscope with ear pieces that t snugly and comfortably.

Factors that affect blood pressure

In addition to the normal diurnal variations in a persons blood pressure, other factors can have a temporary impact on blood pressure.

Use a cuff that is an appropriate size for the patients arm. Position the patient in a comfortable sitting or lying position. Have the patient remove her arm from clothing, rather than rolling up a sleeve tightly. Avoid placing the cuff or stethoscope diaphragm over layers of clothing. Make sure the cuff is positioned correctly on the patients arm. Make sure the patients arm is fully extended yet relaxed. Place the stethoscope rmly against the patients arm at the correct spot (identied by palpating the brachial pulse). Inate the bulb to an appropriate level for the patient and deate it slowly enough to clearly hear the correct systolic sound.

Temporary increase
emotions, such as fear, anger, anxiety, and excitement severe pain exercise or physical exertion

Temporary decrease
uid volume decit, such as from hemorrhage or dehydration sudden position change, such as moving from lying down to sitting or standing (most severe if uid volume decit is also present) some medications, such as general anesthesia or opiate analgesics

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Phase I Sharp tapping

Phase II Swishing or murmuring

Phase III

Phase IV

Phase V No sound

Louder, crisper Softer, fainter, tapping more muffled

150

120 mm Hg

80 FIG 21-4 Korotkoff sounds.

PROCEDURE 21-8

Measuring blood pressure

Task Measure and record blood pressure. Conditions Sphygmomanometer (blood pressure cuff ) Antiseptic wipes Stethoscope Waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will accurately measure and record the patients blood pressure. Performance Standards 1. Seat the patient in a quiet room for several minutes prior to checking her blood pressure to ensure an accurate reading. 2. Wash or sanitize your hands to ensure infection control and assemble supplies. 3. Greet and identify the patient, introduce yourself, and explain the procedure to ease patient anxiety. 4. Minimize room noise by turning off music (if playing) and asking the patient to refrain from talking to ensure accuracy in hearing blood pressure. 5. Roll up the patients sleeve about 5 above the elbow or assist the patient in removing her arm from clothing because a tightly rolled sleeve may interfere with circulation and the accuracy of measurement. 6. Select the proper size cuff for each patient. The cuff bladder should be long enough to wrap around 80% of the patients arm and wide enough to cover two-thirds of the upper arm. A cuff that is too large or too small will result in a less accurate measurement. 7. Apply the deated cuff to the patients upper arm with the arrow over the brachial artery and the lower cuff edge at least 1 above the bend of the elbow to ensure accuracy. 8. Position the gauge so you can easily read it because it is difcult to move the gauge after you begin. 9. Palpate the brachial pulse with one hand and tighten the valve on the ination bulb with the other hand. Then inate the cuff and note the reading on the gauge when you are no longer able to palpate the pulse to help identify the approximate systolic blood pressure. 10. Deate the cuff and apply the stethoscope to the area of the brachial pulse, making sure the earpieces t snugly and comfortably in your ears and are pointed forward and downward. A correct t improves the ability to hear blood pressure sounds. 11. Place the stethoscope diaphragm directly on the patients skin over the site of the brachial artery to ensure accuracy in hearing blood pressure. 12. Make sure the patients arm is relaxed at heart level. With the patients arm fully extended, hold the stethoscope over the brachial pulse with your thumb while pressing the back of the elbow with your index and middle nger, which brings the brachial artery closer to the surface and the stethoscope.

With the patients arm fully extended, hold your stethoscope over the brachial pulse.

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PROCEDURE 21-8contd

13. Position the stethoscope tubing so that it hangs freely without rubbing on anything to eliminate noise interference. 14. Quickly inate the bulb until the gauge measures approximately 30 mm Hg higher than the palpated reading to ensure that the systolic reading can be heard. 15. Release the pressure at a steady rate of 2 to 3 mm Hg per second. Releasing the pressure too fast or too slow may result in falsely high or low readings. 16. Note when the rst sounds are heard (phase I) and record this measurement as the systolic pressure even if the sounds disappear and then return again (auscultatory gap) because the auscultatory gap may be considered a normal nding. (Be sure to note the auscultatory gap in the patients medical record because, depending on the patient, it could be an abnormal nding.) 17. Note when the sounds completely disappear and record this as the diastolic pressure. 18. Measure and record blood pressure in both arms during an initial patient assessment and whenever the reading is in doubt to ensure accuracy.

19. Wait at least 1 minute between measurements if a repeat blood pressure measurement is required because repeating blood pressure measurement too quickly may result in an inaccurate reading. 20. Because the blood pressure gauge is marked in even numbers, record blood pressure in even numbers and as a fraction (such as 132/72). 21. Remove the cuff from the patients arm and return it to the appropriate place. Clean the stethoscope earpieces with alcohol or another antiseptic solution as dictated by ofce policy and return it to its appropriate place so that it will be clean and available for the next use. 22. Wash or sanitize your hands to ensure infection control. 23. Record the patients blood pressure measurement in the medical record, including the date and time, to ensure accurate documentation and make the information available to the physician.
Date 05/26/09; 9:52 a.m. BP: 132/84. -------------------------------------------- S. Lind, CMA

and confidently reports the first sound as the systolic pressure. Because an auscultatory gap is sometimes present with hypertension and some forms of heart disease, it should be noted in the medical record or verbally reported to the physician. Phase III occurs as the sound reappears (if it disappeared) or becomes louder and more crisp. This sound continues in a rhythmic pattern. Phase IV begins as the sounds become softer and fainter and take on a more mufed quality. Occasionally, these soft, mufed sounds continue to zero. The point at which the sounds become noticeably softer and fainter should be recorded as the diastolic reading in children. When this change occurs in adults, the physician may want the medical assistant to record three numbers. For example, in the pressure measurement 118/78/62 mm Hg, the number 118 represents the systolic reading, the number 78 represents phase IV, and the number 62 represents the diastolic reading. Phase V occurs when the sounds completely disappear. This is recorded as the diastolic sound. (See Procedure 21-8: Measuring blood pressure.)

orthostatic hypotension. To measure postural vital signs, the medical assistant must check the patients pulse and blood pressure in two or three positions (lying supine, sitting, and standing). Throughout the procedure, she must leave the blood pressure cuff in place. Some physicians ask the medical assistant to record pulse and blood pressure immediately after each position change. Others want the medical assistant to wait for 1 to 3 minutes after the position change before measuring vital signs. Therefore, the medical assistant must communicate with the physician to clarify his expectations. The data gathered from checking postural vital signs can help the physician determine if patients are volume depleted or suffering from some other condition that makes them prone to dizziness or syncope (fainting) upon sitting up or standing. Thus, when measuring postural vital signs, the medical assistant should be sure to ask the patient about such symptoms as dizziness, lightheadedness, or vertigo.

Oxygen Saturation
Measurement of arterial oxygen saturation (SpO2) is becoming more common in acute care and ambulatory care settings. This measurement, done with a pulse oximeter, allows indirect measurement of oxygen bound to hemoglobin on

Postural Vital Signs

Occasionally, a physician may ask a medical assistant to check postural vital signs, which are vital signs that test for

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red blood cells. The oximeter includes a probe with an LED and a photodetector. (See Figure 21-5.) The lightwaves from the LED are absorbed differently by hemoglobin, depending on how well it is saturated with oxygen. This difference is sensed by the photodetector and is calculated into the SpO2 reading by the oximeter. To obtain an accurate SpO2 reading, the medical assistant must select a pulse oximeter probe that is appropriate for the patient. The medical assistant can clip a digit probe onto the patients nger and an earlobe probe onto the patients ear. Disposable sensor pads may be used on an adults nose or an infants foot. Normal adult values for the SpO2 are 95% to 100%. However, long-time smokers and those with chronic lung disease tend to run lower baseline values. The medical assistant should consult with the physician to identify a desirable SpO2 goal for such patients. While the oximeter is a valuable tool, the medical assistant should understand its limitations. For example, the accuracy of pulse oximeter readings decreases as arterial oxygen levels drop below 70%. Other variables also impact the accuracy of the oximeter reading. (See Factors that affect pulse oximeter readings.) Therefore, the medical assistant must use good judgment in order to obtain

FIG 21-5 Pulse oximeter.

Factors that affect pulse oximeter readings

This table lists the most common factors that interfere with pulse oximeter readings and the corrective measures the medical assistant can take.

Interfering Factors
Outside light source Carbon monoxide (CO) caused by smoke inhalation or poisoning (articially elevates SpO2 reading) Motion of patients hand or nger Jaundice (yellowish skin color due to liver disease) Intravascular dyes (methylene blue) (articially lowers SpO2 reading) Pale, cool hand and ngers of patient

Corrective Measures
Close blinds or curtains Do not use oximeter. Draw blood (per the physicians order) to obtain arterial blood gases. Hold the patients arm and hand to provide support and minimize movement. Consider obtaining arterial blood gases (per the physicians order). Consider using a backup measurement, such as arterial blood gases (per the physicians order). Promote circulation by hanging the patients arm and hand dependently (lower than the heart) for several minutes. Warm the patients hand and ngers for several minutes with a warm moist towel. Alternatively, take another reading using a probe on the patients ear or nose.

Edematous hands and ngers of patient Excessively tight probe on patients nger LED reading of questionable accuracy

Use a probe on the ear or nose. Use a probe on the ear or nose or slightly open the nger clip while holding it on the patients nger. Compare with the reading on another nger or on the ear or nose using the appropriate probe. Alternatively, apply the probe to your own nger and see what your reading is. If it is consistent with your baseline, then the oximeter is probably working ne.

CHAP TER 21

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341

PROCEDURE 21-9

Measuring oxygen saturation using a pulse oximeter

Task Measure and record arterial oxygen saturation using a pulse oximeter. Conditions

Pulse oximeter with probe Acetone or nail polish remover Antiseptic wipe Pen Patients medical record

Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure the patients oxygen saturation with a pulse oximeter. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify your patient and introduce yourself to ease patient anxiety. 3. Explain the procedure and reassure the patient that it will not hurt to ease patient anxiety. 4. Clean the probe with an antiseptic wipe to ensure infection control. 5. Identify the patients baseline reading, if available in the medical record, to provide a basis for comparison. 6. Identify the most appropriate site for the sensor probe and select the appropriate probe to ensure accurate measurement.

7. Position the patient comfortably and instruct him to breathe normally. 8. If a digital sensor is used on the finger, remove any nail polish and support the patients lower arm because nail polish and movement may interfere with the reading. 9. Apply the probe and activate the oximeter. Wait several seconds and observe the pulse waveform and audible beep. Note the LED reading when it reaches a constant value. If necessary, check the radial pulse to verify accuracy. 10. Remove the probe and clean it with a disinfectant wipe to prevent transmission of pathogens to the next patient. 11. Return the oximeter to its correct location so that it will be available for the next use. 12. Wash or sanitize your hands to ensure infection control. 13. Record the SpO2 level in the patients medical record, including the date and time. Include data regarding oxygen use and the presence of fever to ensure accurate documentation and make the information available to the physician.
Date 09/01/08; 1:50 p.m. SpO2 97%, O2 @ 2 L per NC, Temp 99.8 F -------------------------------------------------------------------------------- S. Gonzales, CMA

the most accurate reading possible. She should also remember the guideline, treat the patient, not the machine. Because machines and technology of any kind are tools, they are not foolproof. The medical assistant must always remember to look at the patient. If he looks well and states that he feels well, the medical assistant should double-check the equipment and get another reading. If the patient is symptomatic or if a low reading is still obtained, the medical assistant should consult with a nurse or physician right away. (See Procedure 21-9: Measuring oxygen saturation using a pulse oximeter.)

Chapter Summary

Body temperature is regulated by the hypothalamus and is an important part of homeostasis. A number of factors

may affect temperature, including infection, dehydration, exercise, and environment. Fever is a common symptom of illness caused by bacterial or viral infection. Depending on the cause and severity of a fever, the physician may elect not to treat it. Onset of a fever may be rapid or slow. The course of a fever follows one of three patterns: continuous, intermittent, or remittent. There are several types of thermometers, including glass, digital, tympanic, chemical, and temporal. The medical assistant should always disinfect nondisposable thermometers any time they have come into contact with body uids. The pulse is generated by the heart each time it contracts to create a heartbeat. Some of the factors that affect pulse rate, rhythm, and strength include age, gender, emotional state, and metabolism.

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Cardiac arrhythmias may cause an irregular pulse and may cause some pulsations to be stronger than others. Pulse sites are present where a supercial artery is palpated against a bone. Common locations of pulse sites include the temporal, carotid, brachial, radial, apical, femoral, popliteal, dorsalis pedis, and posterior tibialis pulses. External respiration is the process of moving air into and out of the lungs. Inspiration, or the act of breathing in, occurs when the diaphragm and other muscles contract, pulling the thorax upward and outward. Expiration, which is usually passive, occurs when respiratory muscles relax and expel air from the lungs. Characteristics of respiration include rate, rhythm, and depth. These characteristics are all impacted by many variables, including age, physical activity, medications, and illness. Blood pressure is one of the most common measurements taken in the medical ofce. It reects the pressure exerted against the walls of the arteries and is recorded as a fraction, with the systolic pressure represented by the top number and the diastolic pressure represented by the lower number. Hypertension is dened as sustained readings above 140/90 mm Hg. However, ideal blood pressure for all adults is below 120/80 mm Hg. Blood pressure may vary between persons and uctuate even within the same day for the same person. Some factors that affect blood pressure include age, gender, and genetics. These factors are also nonmodiable risk factors for hypertension and heart disease. Factors that may temporarily affect blood pressure include emotions, pain, physical exertion, uid volume, and body position. Medications may also affect blood pressure. Such effects may be intentional, as with antihypertensive medication, or simply the adverse effect of a medication, such as an opiate analgesic. Measuring blood pressure is one of the most common procedures a medical assistant performs. She can achieve prociency with practice. When listening to the patients blood pressure, the medical assistant may notice ve different types of sounds, known as Korotkoff sounds. Measurement of the arterial oxygen saturation level (SpO2) with a pulse oximeter is becoming more common in acute care and ambulatory care settings. This measurement allows indirect measurement of oxygen bound to hemoglobin on red blood cells. The pulse oximeter is a useful tool, but good technique must be used to obtain reliable data.

screening of vital signs. Some potential locations include a shopping mall or senior center. Be sure to obtain permission from the owners or managers of the facility. Divide responsibilities among team members so that the following tasks are accomplished: a. appropriate and timely contact with facility managers and obtaining permission b. making logistical plans (identifying physical location for screening; obtaining tables, chairs, and equipment; and clarifying plans for transport and setup of equipment) c. organizing scheduling so that the table is staffed throughout the day (for example, team members may wish to work in pairs in 2-hour blocks of time) d. designating who is responsible for clean up at the end of the day and how it will occur e. identifying appropriate informational and resource literature and obtaining it to keep on hand f. creating a plan for when a client has signicantly abnormal vital signs as well as advice that might be offered to the client (clarify the parameters of what constitutes signicant with your instructor). Note: Medical assisting students cannot dispense medical advice. However, they can inform patients that a diagnosis cannot be made based on one isolated reading and that they should follow up with their health care providers if any concerns arise. g. keeping a written record of each persons age, gender, and vital signs (to turn in to the instructor per her instructions). 2. Divide into ve teams. From cards prepared by the instructor (one card each for temperature, pulse, respiration, blood pressure, and SpO2), each team must draw one card. Each team will role-play two versions of a scenario in which the medical assistant obtains the vital sign measurement from the patient. In version one, the medical assistant must make every common mistake possible that might affect the accuracy of the measurement. In version two, the team members must demonstrate correct technique that will ensure the accuracy of the measurement and review helpful tips for ensuring accuracy.

Case Studies
1. Miko Ono is a certied medical assistant (CMA) who works in an internal medicine ofce. One morning, she obtains vital signs and a weight on a new patient. His weight is 212 lb. However, ofce policy requires her to record patient weight in metrics. How should Miko record this patients weight? Because the physician suspects this patient may be dehydrated, she asks Miko to obtain a set of postural vital signs. Describe how Miko will obtain these vital signs.

Team Work Exercises

1. Divide into teams determined by your instructor and identify a location within the community to provide free

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2. Jim Walker is a CMA who works in a family practice clinic. One day, he is helping provide care for an elderly patient who has Parkinson disease as well as diabetes. When attempting to check the patients oxygen saturation with a pulse oximeter, Jim has difculty obtaining a reliable reading. Explain some of the physical factors that might be hindering this process. List some troubleshooting strategies that Jim might employ to get a reliable reading.

Resources

Practical guide to vital signs measurement: medicine.ucsd .edu/clinicalmed/vital.htm Taking vital signs: http://healthfieldmedicare.suite101 .com/article.cfm/taking_vital_signs__temperature Vital signs information: www.healthsystem.virginia.edu/ uvahealth/adult_cardiac/vital.cfm

CHAPTER

Physical Examination
Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell key terms in the Glossary describe the purpose of the physical examination list and describe six examination techniques commonly used by the physician list the supplies and equipment most commonly used in the physical examination and describe the purpose of each item discuss the medical assistants role in preparing the patient examination room describe the medical assistants role in preparing a patient for an examination explain how the medical assistant helps the physician and patient during an examination demonstrate how to assist a patient into nine different positions for examination demonstrate how to measure a patients height and list at least one reason such a measurement is taken and documented demonstrate how to measure a patients weight and list at least three reasons such a measurement is taken and documented. Patient Care
Prepare and maintain examination and treatment areas Prepare patients for and assist with routine and specialty examinations Prepare patients for and assist with procedures, treatments, and minor ofce surgeries Inspection Palpation Percussion Auscultation Mensuration Manipulation

22
Chapter Outline
Purpose of the Physical Examination Physical Examination Techniques Components of a Physical Examination Preparing for the Physical Examination
Preparing the Examination Room Preparing the Patient Physical Examination Supplies and Equipment

General Competencies Legal Concepts

Document appropriately

Patient Instruction
Provide instruction for health maintenance and disease prevention

ABHES Competencies
Clinical Duties
Prepare patients for procedures Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries

Assisting with the Physical Examination

Positioning and Draping

Procedures
Assisting with physical examination Assisting the patient to the sitting position Assisting the patient to the supine and dorsal recumbent positions Assisting the patient to the Sims position Assisting the patient to the lithotomy position Assisting the patient to the semiFowler and Fowler positions Assisting the patient to the Trendelenburg position Assisting the patient to the kneechest position Measuring weight and height

Measurement of Weight and Height

Measuring Weight Measuring Height

Chapter Summary Team Work Exercises Case Studies Resources

CAAHEP Competencies
Clinical Competencies Fundamental Principles
Practice standard precautions

345

Key Terms
auscultation

Method of listening to body sounds with a stethoscope

dorsal recumbent position

Purpose of the Physical Examination

In order to diagnose and treat disorders and diseases, health care providers must gather information about the patient. The information-gathering process involves three phases:

Position in which the patient is lying at with the knees bent and feet on the examination table
Fowler position

Position in which the patient sits with his head as close to 90 degrees as possible and his legs resting outstretched on the examination table
inspection

history taking physical examination diagnostic testing.

Process of gathering information about the patient through observation

jack-knife position

Position in which the patient sits on a special examination table in a semi-sitting position with the thighs exed to 90 degrees
knee-chest position

Position in which the patient sits on her knees with her chest and face and arms resting forward and her buttocks in the air
lithotomy position

Position in which the patient reclines face up, with legs apart and feet in stirrups
manipulation

In some cases, the physical examination will be brief and limited in scopefor example, the patient who complains of a simple sore throat. In such a case, the physician may ask a few questions; examine only the patients respiratory system, including the ears, nose, mouth, throat, and lungs, and be done in as little as 10 minutes. Diagnostic testing may or may not be done. On the other hand, a new patient visiting a primary care physician for the rst time to establish regular care will likely undergo an examination that could take up to an hour and cover all body systems. Depending on the patients age, diagnostics might include blood tests, urinalysis, routine mammography, colonoscopy screening, and other tests. (See Scheduling the physical examination.)

Application of touch to assess joint symmetry and passive range of motion or the therapeutic application of force to increase mobility and realign dislocated joints
mensuration

Physical Examination Techniques

The medical assistant commonly interacts with the patient before the physician does. Therefore, she must be alert to clues about the patients concerns. Some characteristics she might note include the patients general appearance, posture, gait (manner of walking), skin condition, willingness to make eye contact, indicators of pain or difculty breathing, and issues related to hygiene and grooming. If the medical assistant has signicant concerns based on these observations, she should communicate them to the physician. The physician generally conducts a brief interview prior to the examination, which provides an opportunity for the patient and physician to further discuss the patients concerns. During the physical examination process, the physician generally uses some specic, predictable techniques known as inspection, palpation, percussion, auscultation, mensuration, and manipulation.

Measurements of body parts, including height, length, and circumference

palpation

Examination of the patients body by touching it with the hands and pads of the ngers
percussion

Tapping on the body surface with the ngers or a small hammer and noting the sound elicited to determine the position, size, or density of underlying structures
semi-Fowler position

Position in which the patient reclines at 45 degrees with legs outstretched

Sims positon

Position in which the patient lies on his side with the upper arm forward on the table, lower leg exed slightly, and upper leg exed sharply
skin turgor

Resistance of the skin to deformation when grasped between the ngers that is used to assess the state of hydration
supine position

Inspection
Inspection involves gathering information about the patient through observation. The physician notes the patients general appearance and behaviors, including how she walks, talks, speaks, and makes eye contact; her tone of voice; and other behaviors. In the course of the physical examination, the physician visually examines each body part before and during the hands-on examination.

Position in which the patient is lying at, face up toward the ceiling
Trendelenburg position

Position in which the patient lies with her head approximately 30 degrees lower than her outstretched legs and feet

CHAP TER 22

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Front ofceBack ofce connection

Percussion
Percussion involves tapping on body structures with the ngers or a small hammer to note the sound elicited. The nature of the sound reveals information about the structures beneath. For example, the abdomen will usually have a more tympanic (high-pitched, vibrating) sound due to greater air content; the area over the liver usually sounds more dull due to its denser, vascular structure. Direct percussion involves tapping directly on the patients skin. Indirect percussion involves laying the nondominant hand or nger on the patients skin and then tapping it with the ngers of the dominant hand. (See Figure 22-2.)

Scheduling the physical examination

Administrative and clinical medical assistants must communicate with one another so that everyones time can be used most effectively. This rule is especially true when it comes to the scheduling of physical examinations. While a brief, focused examination might take only 5 or 10 minutes, a comprehensive annual physical examination might take up to an hour. Thus, most physicians prefer to have them scheduled at specic times and intervals, such as one appointment rst thing in the morning and one immediately following lunch. Some physicians prefer a maximum of just two or three such examinations per day so that they will have time for more urgent patient needs. The times and intervals will vary with physician preferences and specialties. The time and duties required of the clinical medical assistant will vary as well. Therefore, the administrative medical assistant should communicate with the physician and the clinical medical assistant to determine scheduling preferences.

Auscultation
Auscultation involves listening to body sounds with a stethoscope. The physician commonly auscultates the patients lungs to determine whether they sound clear or have abnormal sounds due to narrowed airways or the presence of uid. He also auscultates the patients abdomen to assess bowel sounds. Normal sounds include stomach gurgling caused by intestinal peristalsis, the progressive, wavelike, involuntary movement that propels the contents forward. The physician also auscultates heart and vascular sounds, noting the rhythm as well as the presence of such abnormal sounds

Palpation
Palpation involves examination of the patients external body through touch with the hands and pads of the ngers. Light palpation of the skin reveals information about temperature, moisture, and texture. Deep palpation may be used to feel the size, shape, symmetry (similarity in shape and size on both sides of the body), and rmness of organs to detect the presence of masses. A great deal of information can be obtained through direct touch. For example, checking skin turgor (resistance of the skin to deformation when grasped between the ngers) provides information about a patients hydration state. (See Figure 22-1.)

FIG 22-1 Palpating the abdomen.

FIG 22-2 Percussing the lungs.

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as murmurs (blowing or swishing sound in the heart) and bruits (abnormal arterial or venous swishing sounds heard on auscultation). (See Figure 22-3.)

Mensuration
Mensuration involves various body measurements that may include height or, in the case of an infant, length. The circumference of the head, chest, abdomen, and extremities are sometimes measured as well. Measurements of joint motion may also be taken to determine degree of exion and extension.

Manipulation
Manipulation involves the application of hands-on techniques to assess joint symmetry and note passive range of motion. It may also be used to employ therapeutic force to increase joint mobility and realign dislocated joints. Manipulation may be done with or without anesthesia or sedation.

Components of a Physical Examination

The medical assistants presence may not be required for every examination or treatment. However, in cases where

the physician and patient are of the opposite gender especially when the procedure involves areas of the body usually considered privatethe medical assistant should remain in the room. The presence of a second professional in the room provides reassurance to the patient and protects the physician from potential lawsuits. In order to anticipate the patients and physicians needs, the medical assistant must understand the format of a routine physical examination. The medical assistant can usually predict the sequence that the physician will follow and, thus, predict his needs. The standard physical examination is organized according to body system and, to some extent, follows a head-to-toe order. However, the physician may vary the examination depending on many factors, including the patients age, chief complaint, and purpose for the visit. After the medical assistant works with a physician for a short time, she will become more adept at developing a system that works smoothly. The physical examination generally includes components in this order:

general appearance skin arms and hands head and neck eyes ears nose mouth and pharynx chest and lungs cardiovascular function breasts abdomen genitalia and rectum legs and feet mental status.

The physician will examine each component for normal and abnormal ndings. (See Common physical examination ndings.)

Preparing for the Physical Examination

The medical assistant helps with the examination process in three key ways. She keeps the examination room ready at all times, prepares the patient for examination, and assists the physician as needed.

Preparing the Examination Room

FIG 22-3 Auscultating lung sounds.

The medical assistant plays a vital role in helping ensure a smooth, efcient workow in the medical ofce. Her

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Common physical examination ndings

The following table lists common normal and abnormal ndings for each component of the physical examination.

Component
General appearance

Normal Findings
Healthy and well-nourished Well-groomed Upright posture and a steady gait

Abnormal Findings
Malnourished or cachectic (extreme state of malnutrition and muscle wasting) Morbidly obese Poor posture or gait

Skin

Warm, dry, intact, and supple Appropriate color for ethnicity Free of lesions Normal turgor

Rashes, scales, or lesions Wounds Pale, erythematous (reddened), cyanotic (bluish), dusky (poor coloring such as mild cyanosis), or jaundiced (yellowish) Moist or diaphoretic (profuse sweating) Taut or edematous (swollen) Scaly

Arms and hands

Smooth, supple skin with appropriate color for ethnicity Absence of rashes or lesions Present, strong, regular pulses Full, active range of motion (ROM) with symmetrical and optimal strength and coordination Smooth, clear nails with convex curve and normal angle of the nail bed to the skin

Rashes or lesions Abnormal skin color Weak, irregular, or absent pulses Muscle weakness, lack of coordination, or decreased ROM Absent, brittle, ridged, cracked, yellowed, thickened, or cyanotic nails Clubbing (enlargement of distal ends of the ngers with no angle from the nail bed to the skin, due to excessive soft tissue growth caused by chronic lung and heart disease)

Head and neck

Symmetrical head shape Lustrous or shiny hair that is evenly distributed with a clean scalp that is free of scales or lesions Supple neck that is free of lumps or tenderness and a nonpalpable thyroid

Asymmetrical or abnormally sized head Hair loss Lumps, scales, lesions, lice, or nits (egg of a louse or any other parasitic insect) on the scalp Lymphadenopathy (abnormal condition of the lymph glands that causes them to become swollen and tender) in the neck Enlarged thyroid

Eyes

Accurate visual acuity and color vision Intact visual eld and extraocular movements (EOM) Pupils that are equal, round, and reactive to light and accommodation (PERRLA) White, clear sclera that is free of drainage

Poor visual acuity, blindness, or color-blindness Decreased visual eld, cloudy lens, or decreased EOM Pupils that are dilated, constricted, dull, unequal, or slow to react or nonreactive to light or have poor accommodation Blepharoptosis (drooping of the eyelid) Sclera that is jaundiced, inamed, or tearing excessively Purulent drainage Exophthalmos (abnormal protrusion of the eyeballs)

Continued

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Common physical examination ndingscontd

Component
Ears

Normal Findings
Intact hearing Ears that are symmetrical and normally placed Pink, patent (wide-open, evident, or accessible) ear canal with minimal cerumen Pink to pearly gray tympanic membrane that is semitransparent and intact

Abnormal Findings
Hearing loss or deafness Ears that are asymmetrical or low-set Ear canal that is impacted with cerumen or inamed Perforated, inamed, blistered, retracted, or bulging tympanic membrane Deviated septum Nonpatent nares Mucous membranes that are inamed, edematous, boggy, or dry Purulent drainage Anosmia (loss of sense of smell) Polyps (small growths)

Nose

Straight nose with a midline septum Patent nares Pink, moist mucosa Absent or scant, clear drainage Intact odor identication

Mouth and pharynx

Structures and membranes that are pink, moist, smooth, and free of lesions Teeth present with good dental hygiene Pink, rm gums Intact gag reex Pink tonsils without swelling or exudate (any uid released from body tissues that has a high concentration of protein cells or solid debris; sometimes containing pus)

Inammation, lesions, ulcerations, or dry (tacky) mucous membranes Dental caries (cavities), loose or absent teeth, loose dentures, or poor oral hygiene Gingivitis (inamed gums) Absent gag reex Inamed, enlarged tonsils with exudate

Chest and lungs

Symmetrical chest shape with normal anteriorposterior (AP) dimension Clear lungs Regular, unlabored respirations

Asymmetrical, barrel-like chest with increased AP dimension Decreased lung sounds Crackles (abnormal sound heard with a stethoscope caused by secretions or sudden opening of tiny collapsed airways) Rhonchi (low-pitched wheezing, snoring, squeaking, or gurgling sound, caused by mucus or other secretions, heard on auscultation of the lungs with a stethoscope) Pericardial friction rub (creaking, grating, scratchy, or leathery sound made by inamed membranes surrounding the heart as they move during the heart beat) Pleural friction rub (creaking, grating, scratchy, or leathery sound made by inamed membranes surrounding the lungs as they move during respiration) Wheezes (continuous musical sound caused by air movement through narrowed respiratory passages) Irregular or labored respirations

CHAP TER 22

Physical Examination

351

Common physical examination ndingscontd

Component
Cardiovascular

Normal Findings
Regular heart rhythm S1 and S2 heart sounds present Palpable, regular peripheral pulses Capillary rell (return of normal color in a nail bed or digit after blanching due to pressing on it) less than 3 seconds Blood pressure within normal range Normal sinus rhythm (NSR) on electrocardiogram (ECG)

Abnormal Findings
Irregular heart rhythm Distant heart sounds, murmur, and S3 and S4 heart sounds Diminished or absent peripheral pulses Slow or absent capillary rell Hypertension or hypotension Abnormal rhythm on ECG

Breasts

Soft with irregular feel of deep tissue Symmetrical size, shape, and color of breasts and nipples Free of lumps, lesions, dimpling, or nipple drainage Nonpalpable axillary lymph nodes

Lumps Abnormal tenderness (although mild tenderness may be normal due to hormonal uctuations) Nipple discharge or nipple inversion Retraction or dimpling of breast tissue or orangepeel appearance Enlarged axillary lymph nodes

Abdomen

Soft, nontender, active bowel sounds in all four quadrants Nonpalpable liver and spleen Absence of hernias

Firm, distended, tender abdomen Hypoactive, hyperactive, or absent bowel sounds Masses, lesions, or hernias Hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen)

Genitalia and rectum

Absence of rashes or lesions Purulent (forming or containing pus) or foul drainage Smooth skin Pink, moist, smooth mucous membranes Good pelvic oor muscle tone Smooth, rm, movable testicles Intact anal sphincter tone Absence of hemorrhoids or anal ssures (painful linear ulcers on the margin of the anus) Absence of blood in stool

Abnormal tenderness Rashes, lesions, vesicles, or ulcerations Purulent or foul drainage Inamed, edematous, or dry mucous membranes Weak pelvic oor muscles with prolapse (falling or dropping down) of bladder, rectum, or uterus Asymmetrical or enlarged testicles Poor anal sphincter tone Hemorrhoids or ssures Positive stool for blood on rectal examination

Legs and feet

Smooth, supple skin with appropriate color for ethnicity Absence of rashes, lesions, ulcerations, or edema Present, strong, regular pulses Capillary rell less than 3 seconds Full, active ROM with symmetrical and optimal strength and coordination Smooth, clear nails Intact pulses

Abnormal skin coloring Rashes, lesions, or edema Weak, irregular, or absent pulses Varicosities (condition of having veins that are enlarged and dilated) Slow capillary rell Muscle weakness, lack of coordination, or decreased ROM Nails that are absent, brittle, ridged, cracked, yellowed, or thickened

Continued

352

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Clinical

Common physical examination ndingscontd

Component
Mental status

Normal Findings
Alert and oriented to person, place, and time (A&O 3) Appropriate identication of sensory data (such as sharp, dull, soft, and painful) Intact reexes

Abnormal Findings
Confusion or inappropriate verbal responses Lethargy or agitation Aphasia (inability to speak) or dysphasia (difculty speaking) Short- or long-term memory loss Diminished or absent reexes or sensation Poor coordination Complaints of vertigo (sensation of moving around in space, or dizziness)

responsibilities include making sure that examination rooms are cleaned, disinfected, and restocked as needed between patients. The medical assistant should check the schedule ahead of time and note the purpose of each patients visit in order to anticipate the equipment and supplies that will most likely be needed. Having all items ready and close at hand saves time and earns the respect and appreciation of the physician and patient. The patient will also appreciate attention paid to his comfort and privacy needs. The medical assistant must also keep safety and hygiene equipment stocked, including antibacterial soap or cleanser, paper towels, examination gloves, biohazard waste containers, sharps containers, gowns, and masks. The patient who must wait for a few minutes will also appreciate the medical assistant who provides reading material. Such material should include educational pamphlets as well as an assortment of magazines.

Front ofceBack ofce connection

Patients with Special Needs

The administrative medical assistant or receptionist should immediately inform the clinical medical assistant of any patients who arrive with special needs (such as a patient who is weak, frail, dizzy, or using such mobility aids as a cane, walker, or wheelchair). Doing so allows everyone to make necessary adjustments to the routine so that extra care and attention can be given to the patient. This small but signicant addition to the communication process ensures patient safety, facilitates a smooth workow, decreases staff stress, and fosters a spirit of cooperation among health care team members.

Preparing the Patient

The medical assistant should prepare the patient by inquiring about the purpose of the visit, making sure the information in the chart is current, and measuring height, weight, and vital signs. In some cases, she collects urine or blood specimens prior to the examination. If not, the medical assistant should invite the patient to visit the restroom to empty her bladder prior to the examination. Emptying the bladder can help make the examination process more comfortable for the patientespecially when an examination of the abdomen or pelvis will occur. The medical assistant should also provide instructions for undressing and positioning and assist the patient with changing into the examination gown if necessary. (See Patients with special needs.)

Physical Examination Supplies and Equipment

The medical assistant must ensure that examination supplies and equipment are ready, organized, and close at hand and are restocked or disinfected between patients. (See Physical examination equipment and supplies.)

Assisting with the Physical Examination

During the examination, the medical assistant acts as a helper to the physician and an advocate for the patient. She helps the physician by handing him needed supplies and

CHAP TER 22

Physical Examination

353

Physical examination equipment and supplies

Here are some of the items usually used during a physical examination, along with a description of their most common uses.

Supplies
Alcohol padscleaning the skin prior to an injection or cleaning some medical equipment Cotton ballsapplying medication or stopping minor bleeding Cotton-tipped applicatorsapplying medication or collecting a specimen Emesis basincollecting vomitus or sputum from patient Gauze padsdressing a wound, stopping bleeding, or applying medication Lubricantreducing anticipated discomfort from speculum insertion or rectal or vaginal examinations or easing suppository insertion Tongue depressordepressing the tongue for easier examination of the throat

Equipment
Glass slidesholding specimens that are viewed under a microscope Laryngeal and pharyngeal mirrorsexamining the pharynx and larynx Nasal speculumexamining the nose and nasal mucous membranes Otoscopeexamining the ear Ophthalmoscopeexamining the eye Penlightexamining the pupils and providing additional light for examination of the throat or other body parts Reex hammertesting reexes Specimen bottlesholding tissue specimens that will undergo laboratory analysis Sphygmomanometermeasuring blood pressure Stethoscopemeasuring blood pressure and auscultating heart, lungs, and bowel sounds Tape measuremeasuring the length and circumference of various body parts Thermometermeasuring body temperature Vaginal speculumassisting in opening a vagina more fully to facilitate examination

Tongue depressors Cotton balls

Cotton swabs

Alcohol pads Lubricating jelly

Gauze pads Thermometer

Sphygmomanometer

Ophthalmoscope and otoscope

Pen light

Reflex hammer

Vaginal speculum

instruments. (See Procedure 22-1: Assisting with the physical examination, pages 354 and 355.) She also pays close attention to the patient and offers reassurance, instruction, and assistance with positioning and draping as needed. After the examination, she may conduct additional diagnostic testing and help schedule the patient for further tests,

referrals, or follow-up visits. (See The teachable moment, page 355.)

Positioning and Draping

The medical assistant helps with the examination process by instructing and assisting the patient in assuming

354

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Clinical

PROCEDURE 22-1

Assisting with the physical examination

Task Assisting the physician with a physical examination. Conditions Examination table Specic supplies and equipment for the type of examination being performed Drape Patient examination gown Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist the physician with the physical examination of a patient. Performance Standards 1. Prepare the examination room, ensuring adequate room temperature and lighting. 2. Wash or sanitize your hands to ensure infection control. 3. Assemble supplies and equipment in the order in which they will be used to ensure a smooth ow to the examination procedure. 4. Obtain the patients medical record, greet and identify the patient, and introduce yourself to prevent errors and ease patient anxiety. 5. Obtain the patients weight and height if needed and escort her to the examination room. 6. Review the record with the patient, making sure that the medication list and allergy information are current. 7. Inquire about the purpose of the visit. Record the patients complaint and symptoms to the degree of detail preferred by the physician. 8. Obtain the patients vital signs to ensure that important data is current and allow time for the patient to explain and conrm the reason for the visit. 9. Draw blood if needed for laboratory tests. Perform an ECG if ordered. 10. Invite the patient to empty her bladder. If a urine specimen is needed, provide instructions and a specimen container to decrease patient discomfort during the examination and obtain preliminary results of some tests during the patients visit. 11. Provide the patient with an examination gown and drape. Instruct her to remove all clothing, pointing out where she may hang or lay her clothing. Explain that the gown should be worn with the opening in the front and how the drape should be used. 12. Explain that the patient should sit on the end of the examination table and that the physician will be with her soon to ensure patient understanding. 13. Leave the room so the patient may change in privacy to demonstrate respect for her privacy. However, if she is elderly, weak, or frail or has any symptoms of dizziness, remain in the room to assist her. Help her sit in a regular chair to wait for the physician to prevent falls and ensure the safety of a weak or symptomatic patient. 14. Place the medical record in the designated place for the physician to retrieve and let him know that the patient is ready. 15. Return to the room when directed by the physician to allow time for the physician to interview the patient, if preferred, for a few minutes prior to the examination. (The medical assistants presence is usually not required for this.) 16. Assist the physician with a general body system examination, including: a. Assist the patient into a sitting position on the end of the table if she is not already there. Arrange the drape over her lap. b. As the physician examines the patients upper body (eyes, ears, nose, mouth, throat, and chest), be prepared to hand her items as needed, such as the otoscope, ophthalmoscope, penlight, and tongue depressor. c. Dim the lights if directed when the physician examines the patients eyes to help dilate the patients pupils. d. Throughout the remainder of the examination, continue to hand needed items to the physician and assist the patient in assuming the positions directed by the physician. e. Follow standard precautions and take care to handle potentially contaminated items from the physician (such as a tongue depressor, a speculum, and swabs) in a manner that prevents exposure to you. f. Dispose of all waste in appropriate containers. g. Place specimens in appropriately labeled containers. 17. Upon completion of the examination, assist the patient down from the table and instruct her to get dressed. Leave the room for a few minutes so the patient may change in privacy unless she requires your assistance to show respect for the patients privacy and protect her safety. 18. Provide the patient with educational information or instructions as directed by the physician and answer questions she may have. Consult the physician or nurse if you are unsure of the answer to a patients question to ensure that the patient receives the correct information, which is critical.

CHAP TER 22

Physical Examination

355

PROCEDURE 22-1contd

19. Schedule ordered follow-up tests or appointments. 20. Direct the patient back to the reception area. Assist her if needed. 21. Document patient education, instructions, or scheduled tests in the medical record to ensure that the medical record is thorough and accurate.

22. Clean, sanitize, and restock the examination room as needed to prepare the room for the next patient.
Date 11/01/08; 9:05 a.m. Pamphlet titled Ten ways to Lower Your Cholesterol given to patient, mammogram scheduled for 11/05/08 ---------------------------------------------------------------------------- S. Gonzales, CMA

various positions. The purpose of each position is to allow the physician better access to and visibility of the body part being examined. To help promote patient privacy and comfort, the medical assistant should provide careful draping. Here are the 10 examination positions, along with the most common reasons for placing the patient in each:

The sitting position is commonly used for examination of the upper body, including the head, eyes, ears, nose, throat, neck, chest, lungs, arms, and hands. Common reasons for examining the patient in this position include upper respiratory symptoms (such as a sore

Patient Education

The Teachable Moment

Although their time is limited, health care providers, including medical assistants, have many opportunities to provide patient education on a wide range of subjects. To capitalize on what educators refer to as the teachable moment, the medical assistant must be observant and take notice when a patient expresses interest in a particular subject or concern about an actual or potential health problem. This teachable moment is a time when a patient is especially likely to pay attention to the message shared. Such opportunities commonly arise when a patient visits for a routine examination. The medical assistant should answer whatever questions she can, consult with the physician on those she cannot, and always try to send the patient home with some type of literature on the subject. Doing so conveys a desire to meet the patients needs and provides teaching in two different formats: verbal and written. Many brochures also include websites, addresses, and phone numbers where patients can nd additional information.

throat, sinus pressure, a cough, and an earache) and painful or inflamed joints of the arms, hands, and fingers. (See Procedure 22-2: Assisting the patient into the sitting position, page 356.) The supine position, also called the horizontal recumbent position, is commonly used for examination of the breasts, anterior chest, heart, abdomen, and lower extremities. This is a position in which the patient is lying at, face toward the ceiling. Common reasons for examining the patient in this position include breast cancer screening, heart problems, or pain in the abdomen, lower leg, or foot. The dorsal recumbent position is sometimes used for rectal and vaginal examinations, particularly if the patient cannot tolerate lying on her back with her feet in stirrups. In the dorsal recumbent position, the patient is lying flat or nearly flat with legs apart, knees bent, and feet near the side edges of the examination table. It may also be used for patients with back or abdominal pain, because bending the knees relieves stress on the lower back and facilitates relaxation of abdominal muscles. It is useful for patients undergoing routine examinations and for those with vaginal or rectal pain, burning, or unusual discharge. It is also useful for those complaining of abdominal, pelvic, or back pain. (See Procedure 22-3: Assisting the patient into the supine and dorsal positions, page 357.) The Sims position, also called the side-lying or lateral position, is used for anal and rectal examinations, some vaginal examinations, and such procedures as administering rectal suppositories and enemas. In this position, the patient lies on his side with the upper arm forward on the table, lower arm behind, lower leg exed slightly, and upper leg exed sharply with his knee resting forward on the examination table. The medical assistant should also consider using this position for a female patient who needs a urinary catheter inserted but cannot tolerate lying supine. In such a case, a second person will be required to support the patients upper leg. However, the extra effort is worthwhile because the patient with back pain or

356

UNIT 3

Clinical

PROCEDURE 22-2

Assisting the patient into the sitting position

Task Assist the patient into the sitting position. Conditions Examination table Table paper Examination gown Disposable drape or sheet Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist the patient into the sitting position. Performance Standards 1. Greet and identify the patient, introduce yourself, and explain the procedure to prevent errors and ease patient anxiety. 2. Wash or sanitize your hands to ensure infection control. 3. Provide the patient with an examination gown. Describe how fully the patient should undress. Point out where the patient may hang or lay his clothing. Explain that the gown should be worn with the opening in the front. 4. Pull out the footrest of the examination table and explain that he should sit securely on the end of the table with the drape over his lap to ensure patient understanding, proper positioning, and patient safety and comfort. 5. Leave the room for a few minutes so the patient may change in privacy unless he requires your assistance to demonstrate respect for the patients privacy and safety. 6. Assist the physician as needed with the examination. 7. Upon completion of the examination, assist the patient down from the table and instruct him to get dressed. 8. Return the table footrest to the normal position. Leave the room for a few minutes so the patient may change in privacy unless he requires your assistance to ensure the patients safety and privacy. 9. Clean, sanitize, and restock the examination room as needed to prepare the room for the next patient.

Patient in the sitting position

shortness of breath will better tolerate the procedure in this position. Additionally, this position commonly facilitates a better view of the patients urethral opening. (See Procedure 22-4: Assisting the patient into the Sims position, page 358.) The lithotomy position is primarily used for vaginal examinations and is especially useful when a speculum is required to examine the cervix and collect a specimen for a Papanicolaou (Pap) smear. In this position, the patient reclines face up, with legs apart and feet placed in stirrups. It is used for routine female gynecologic examinations and when women have complaints of pelvic pain or unusual vaginal pain, burning, or discharge. (See

Procedure 22-5: Assisting the patient into the lithotomy position, pages 358 and 359.) The semi-Fowler position is similar to the Fowler position with the head of the examination table at only 45 degrees. The patient reclines with legs outstretched on the examination table. This position is used for many purposes, including examination of the chest and heart, or for patients who need to rest in a semi-reclining position for comfort reasons. The Fowler position is similar to the upright sitting position, except that the head of the examination table is elevated as close to 90 degrees as possible to provide support for the patient to lean against and the legs to

CHAP TER 22

Physical Examination

357

PROCEDURE 22-3

Assisting the patient into the supine and dorsal recumbent positions
Task Assist the patient into the supine and dorsal recumbent positions. Conditions Examination table Table paper Examination gown Pillow Disposable drape or sheet Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist the patient into the supine and dorsal recumbent positions. Performance Standards 1. Greet and identify the patient, introduce yourself, and explain the procedure to prevent errors and ease patient anxiety. 2. Wash or sanitize your hands to ensure infection control. 3. Provide the patient with an examination gown. Describe how fully the patient should undress. Point out where the patient may hang or lay her clothing. Explain that the gown should be worn with the opening in the front to ensure patient understanding. 4. Pull out the footrest of the examination table and explain to the patient that she should sit securely on the end of the table with the drape over her lap to ensure patient understanding. 5. Leave the room for a few minutes so the patient can change to ensure patient privacy unless she requires your assistance. 6. When you reenter the room, instruct the patient to lie back and rest her head on the pillow. As she does so, pull out the table extension to support her legs. 7. Ensure that she is lying at and the drape is positioned properly over her abdomen and legs to ensure proper positioning and the patients safety, privacy, and comfort.

Patient in the supine position

8. To assist the patient into the dorsal recumbent position, instruct her to place the soles of both feet at on the table with her knees exed.

Patient in the dorsal recumbent position

9. Assist the physician as needed with the examination. 10. Upon completion of the examination, assist the patient down from the table and instruct her to get dressed. Return the table footrest to the normal position. 11. Leave the room for a few minutes so the patient may change in privacy unless she requires your assistance to ensure the patients safety and privacy. 12. Clean, sanitize, and restock the examination room as needed to prepare the room for the next patient.

rest outstretched on the examination table. It is used for the same reasons as the sitting position and is particularly useful for patients who are feeling short of breath, because the upright position facilitates maximal lung expansion. (See Procedure 22-6: Assisting the patient into the semi-Fowler and Fowler positions, page 360.) In the Trendelenburg position, the patient lies with her head approximately 30 degrees lower than her outstretched legs and feet. This position is rarely used in the

medical ofce. It may be useful for patients experiencing shock or dangerously low blood pressure. It is sometimes used for abdominal surgery because gravity causes abdominal contents to shift somewhat toward the chest. Many patients do not tolerate this position well or for long since it makes breathing more difcult. Therefore, the medical assistant should consult with the physician before assisting a patient into this position. (See Procedure 22-7: Assisting the patient into the Trendelenburg position, page 361.)

358

UNIT 3

Clinical

PROCEDURE 22-4

Assisting the patient into the Sims position

Task Assist the patient into the Sims position. Conditions Examination table Table paper Examination gown Pillow Disposable drape or sheet Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist the patient into the Sims position. Performance Standards 1. Greet and identify the patient, introduce yourself, and explain the procedure to prevent errors and ease patient anxiety. 2. Wash or sanitize your hands to control infection. 3. Provide the patient with an examination gown. Describe how fully the patient should undress. Point out where the patient may hang or lay his clothing. Explain that the gown should be worn with the opening in the back. 4. Leave the room for a few minutes so the patient may change in privacy unless he requires your assistance to ensure patient comfort, privacy, and safety. 5. Assist the patient onto the table and into a sitting position. Then instruct him to lie back and rest his head on the pillow. As he does this, pull out the table extension to support his legs. 6. Pull out the footrest and instruct the patient to turn onto his left side. Provide support as needed to ensure that he does not accidentally roll off the table. 7. Position him with his left arm behind his body and his right arm forward with his elbow bent. Instruct him to ex his left leg slightly and his right leg sharply. Place a pillow between his knees. 8. Ensure that the drape is positioned properly to ensure proper positioning and patient safety, privacy, and comfort.

Patient in Sims position

9. Assist the physician as needed with the examination. 10. Upon completion of the examination, assist the patient down from the table and instruct him to get dressed. Return the table footrest to the normal position. Leave the room for a few minutes so the patient may change in privacy unless he requires your assistance. 11. Clean, sanitize, and restock the examination room as needed to prepare the room for the next patient.

PROCEDURE 22-5

Assisting the patient into the lithotomy position

Task Assist the patient into the lithotomy position. Conditions Examination table Table paper Examination gown Pillow Disposable drape or sheet Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist the patient into the lithotomy position. Performance Standards 1. Greet and identify the patient, introduce yourself, and explain the procedure to prevent errors and ease patient anxiety. 2. Wash or sanitize your hands to ensure infection control. 3. Provide the patient with an examination gown. Describe how fully the patient should undress. Point out where the patient may hang or lay her clothing. Explain that the gown should be worn with the opening in the front. 4. Leave the room for a few minutes so the patient may change in privacy unless she requires your assistance.

CHAP TER 22

Physical Examination

359

PROCEDURE 22-5contd

5. Pull out the footrest and assist the patient onto the table into a sitting position. Then instruct her to lie back and rest her head on the pillow. As she does this, pull out the table extension to support her legs. Next, pull out the stirrups and adjust their position to the patients size. Instruct her to slide down to the bottom of the table and guide her feet into the stirrups. 6. Adjust the drape so that it lies in a diamond formation with one corner draped between the patients legs to ensure proper positioning and patient safety, privacy, and comfort. (The physician can lift the corner of the drape as needed just prior to the examination.)

7. Assist the physician as needed with the examination. 8. Upon completion of the examination, assist the patient down from the table and instruct her to get dressed. Return the table footrest to the normal position. 9. Leave the room for a few minutes so the patient may change in privacy unless she requires your assistance to ensure patient safety and privacy. 10. Clean, sanitize, and restock the examination room as needed to prepare the room for the next patient.

Patient in the lithotomy position

In the knee-chest position, the patient sits on his knees with his chest and face resting forward on a pillow, his arms lying to either side of his head and his buttocks in the air. This position may be awkward, embarrassing, and difcult for many patients to assume. Therefore, the medical assistant must help the patient with positioning and remain with him the entire time to provide stability and emotional support. This position is used for rectal and sigmoid colon examinations and, rarely, for vaginal examinations. (See Procedure 22-8: Assisting the patient into the knee-chest position, page 361.) The jack-knife position requires a special table and is rarely done anywhere but in a urology department. It should be done with the head-up position for patient comfort and ease in breathing. In this position, the patient is in a semi-sitting position with his thighs exed to 90 degrees. It is useful for male urologic examinations and procedures. (See Figure 22-4.)

FIG 22-4 Patient in the jack-knife position.

because changes over time may indicate a signicant change in a patients health status.

Measuring Weight
In most acute and long-term care settings patients are weighed in kilograms. In ambulatory care settings, such as medical ofces, patients may be weighed in pounds or kilograms, depending on ofce policy. However, the trend is changing toward using metrics across the board. Therefore, medical assistants must become familiar with the metric system and learn the formulas required for conversion. (See Weight conversion formulas, page 362.) In many cases, the patients weight is

Measurement of Weight and Height

The medical assistant commonly measures a patients weight and height. The accuracy of this data is important

360

UNIT 3

Clinical

PROCEDURE 22-6

Assisting the patient into the semi-Fowler and Fowler positions

Task Assist the patient into the semi-Fowler and Fowler positions. Conditions Examination table Table paper Examination gown Pillow Disposable drape or sheet Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist the patient into the semi-Fowler and Fowler positions. Performance Standards 1. Greet and identify the patient, introduce yourself, and explain the procedure to prevent errors and ease patient anxiety. 2. Wash or sanitize your hands to control infection. 3. Provide the patient with an examination gown. Describe how fully the patient should undress. Point out where the patient may hang or lay his clothing. Explain that the gown should be worn with the opening in the front. 4. Leave the room for a few minutes so the patient may change in privacy, unless the patient requires your assistance. 5. Pull out the footrest and assist the patient onto the table into a sitting position. Then assist him into the semi-Fowler position by raising the head of the examination table to a 45-degree angle. 6. To assist the patient into the Fowler position, raise the head of the examination table to 90 degrees. 7. Then instruct the patient to lie back and rest his head on the pillow. As he does this, pull out the table extension to support his legs. 8. Ensure that the drape is positioned properly to ensure proper positioning and patient safety, privacy, and comfort.

Patient in Fowler position

9. Assist the physician as needed with the examination. 10. Upon completion of the examination, assist the patient down from the table and instruct him to get dressed. Return the table footrest to the normal position. 11. Leave the room for a few minutes so the patient may change in privacy unless he requires your assistance to ensure patient safety and privacy. 12. Clean, sanitize, and restock the examination room as needed to prepare the room for the next patient.

Patient in semi-Fowler position

CHAP TER 22

Physical Examination

361

PROCEDURE 22-7

Assisting the patient into the Trendelenburg position

Task Assist the patient into the Trendelenburg position. Conditions Examination table Table paper Examination gown Pillow Disposable drape or sheet Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist the patient into the Trendelenburg position. Performance Standards 1. Greet and identify the patient, introduce yourself, and explain the procedure to prevent errors and ease patient anxiety. 2. Wash or sanitize your hands to control infection. 3. Provide the patient with an examination gown. Describe how fully the patient should undress. Point out where the patient may hang or lay her clothing. Explain that the gown should be worn with the opening in the front. 4. Pull out the footrest of the examination table and explain that the patient should sit securely on the end of the table with the drape over her lap. 5. Leave the room for a few minutes so the patient may change in privacy unless the patient requires your assistance.
Patient in the Trendelenburg position

6. Adjust the table so that the head of the table is tilted downward. Ensure that the drape is positioned properly to ensure proper positioning and patient safety, privacy, and comfort. Alternatively, the footrest may be tilted downward so that the knees bend to enhance patient comfort.

7. Assist the physician as needed with the examination. 8. Upon completion of the examination, assist the patient down from the table and instruct her to get dressed. Return the table footrest to the normal position. 9. Leave the room for a few minutes so the patient may change in privacy unless she requires your assistance to ensure patient safety and privacy. 10. Clean, sanitize, and restock the examination room as needed to prepare the room for the next patient.

PROCEDURE 22-8

Assisting the patient into the knee-chest position

Task Assist the patient into the knee-chest position. Conditions Examination table Table paper Examination gown Disposable drape or sheet Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist the patient into the knee-chest position. Performance Standards 1. Greet and identify the patient, introduce yourself, and explain the procedure to prevent errors and ease patient anxiety. 2. Wash or sanitize your hands to ensure infection control. 3. Provide the patient with an examination gown. Describe how fully the patient should undress. Point out where the patient may hang or lay his clothing. Explain that the gown should be worn with the opening in the back. 4. Leave the room for a few minutes so the patient may change in privacy unless the patient requires your assistance.
Continued

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Clinical

PROCEDURE 22-8contd

5. Pull out the footrest and assist the patient to a sitting position. Then ask him to move back on the table as you pull out the table extension. Assist him into the supine position and then into the prone position by turning onto his side and then onto his stomach. Be sure that he rolls toward you rather than away from you to ensure proper positioning and patient safety, privacy, and comfort. 6. Place a drape over him diagonally with one corner draped over his buttocks and another one over his back to protect patient privacy and modesty and to enable the physician to lift one corner of the drape when ready to begin the examination. 7. Instruct the patient to bend his elbows and rest his arms along side of his head, then to raise his buttocks and chest off the table. 8. Place a pillow beneath his chest for support and instruct him to lower his chest while keeping his buttocks elevated and his back straight. 9. Instruct him to separate his knees and lower legs approximately 12" to ensure proper positioning and provide a wider base of support for safety and comfort.

Patient in the knee-chest position

10. Assist the physician as needed with the examination. 11. Upon completion of the examination, assist the patient down from the table and instruct him to get dressed. Return the table footrest to the normal position. Leave the room for a few minutes so the patient may change in privacy unless he requires your assistance to ensure patient safety and privacy. 12. Clean, sanitize, and restock the examination room as needed to prepare the room for the next patient.

Weight conversion formulas

This table lists the formulas for converting a patients weight from pounds to kilograms and vice versa.

since his last visit should be brought to the physicians attention because it may indicate a health problem.

Measuring Height
Methods for measuring height vary, depending on the age and size of the patient. Infants and children are measured on each visit so that their growth can be plotted on growth charts. Infants are measured lying down and the measurement is recorded as length in centimeters. When the child reaches toddlerhood and is capable of standing, a standing measurement may be taken. Adult height is typically measured in feet and inches and is done on the rst visit and then only as neededfor example, when there is concern about osteoporosis or degenerative changes of the vertebrae. A slight decrease in the height of an elderly patient is not unusual, but may indicate a problem. (See Procedure 22-9: Measuring weight and height.)

Conversion
Pounds to kilograms

Formula
lb 2.2 kg

Example
The patient weighs 220 lb. 220 2.2 100 kg

Kilograms to pounds

kg

2.2

lb

The patient weighs 80 kg. 80 2.2 176 lb

measured with each ofce visit. Accuracy in measuring and recording a patients weight is very important, because medications and procedures are commonly based on a patients weight. A childs weight is plotted on a growth chart along with his height to identify whether growth patterns are normal. A pregnant womans weight is carefully noted on each visit as part of the data needed to monitor the pregnancy. A patient on a weight-loss program must also have his weight closely monitored to determine the effectiveness of his weightloss activities. Any signicant change in a patients weight

CHAP TER 22

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363

PROCEDURE 22-9

Measuring weight and height

Task Measure the patients weight and height. Conditions Upright balance scale or digital standup scale Pen Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure the patients weight and height. Performance Standards 1. Check the scale to be sure that the pointer oats in the center of the balance frame when all weights are on zero. If the scale is digital, check to make sure it is properly zeroed to ensure that the scale is working properly. 2. Greet and identify the patient, introduce yourself, and explain the procedure to prevent errors and ease patient anxiety. 3. Wash or sanitize your hands to ensure infection control. 4. Instruct the patient to remove her coat or sweater, shoes, and purse (if holding one). Place a paper towel on the scale to provide a clean surface for the patient to stand on and instruct the patient to step onto the scale. Provide assistance as needed to ensure an accurate weight. 5. Instruct the patient to stay still to avoid interfering with the balancing of the scale. 6. Slide the large lower weight to the right to the furthest notched groove that does not cause the pointer to drop to the bottom of the balance frame. Make sure that the weight is securely seated in the groove to avoid incorrect placement of the lower weight, which results in an inaccurate measurement. 7. Slide the smaller upper weight to the right until the pointer is balanced in the center of the balance frame. 8. Add the numbers from the bottom and top together to arrive at the patients weight to the nearest 1/4 lb. If the scale is digital, note the reading when patient is standing still on the scale. 9. Assist the patient off the scale. Some upright balance scales require that the patient step off so that the calibration rod can be moved upward. 10. Slide the calibration rod up above the patients approximate height and open the height bar. 11. Assist the patient back onto the scale with her back to it and instruct her to look straight forward to ensure an accurate measurement. 12. Adjust the height bar so that it just touches the top of the patients head.

Instruct the patient to stand on the scale with her back to it.

13. Instruct the patient to step off the scale while ensuring that the height bar does not move. 14. Read the measurement where the stationary calibration rod and moveable calibration rods meet to the nearest 1/4. 15. Chart the patients height and weight in the medical record. Record the weight in pounds or kilograms, depending on ofce policy to ensure thoroughness and accuracy of the medical record.
Date 01/15/09; 11:05 a.m. Wgt 138 1/4 lb, Hgt: 5 7 1/4 ---------------- C. Brown, CMA

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Chapter Summary

Health care providers gather information that enables them to diagnose and treat a patients disorders and diseases. The physical examination is a critical piece of this data-gathering process. The standard physical examination is organized according to body system. However, the physician may vary the examination sequence and technique, depending on the patients age, chief complaint, and purpose of the visit. Although the physician conducts the physical examination, the medical assistant must also be alert for clues about potential patient problems and communicate concerns to the physician. Physicians use some specic, predictable techniques to examine patients. These techniques are known as inspection, palpation, percussion, auscultation, mensuration, and manipulation. The examination format is fairly routine, making it easier for the medical assistant to predict the sequence to be followed and, thus, to predict the needs of the physician and patient. The medical assistant helps with the examination process in three key ways. She keeps the examination room ready at all times, prepares the patient, and assists the physician as needed. The medical assistant plays a vital role in helping ensure a smooth, efcient workow, including making sure that examination rooms are cleaned, disinfected, and restocked as needed between patients. The medical assistant prepares the patient for the examination and may collect specimens, such as urine and blood. The medical assistant must ensure that examination supplies and equipment are ready, organized, and close at hand. The medical assistant must become familiar with the equipment most commonly used for physical examinations. During the examination, the medical assistant acts as a helper to the physician and as an advocate for the patient. She hands the physician supplies and instruments and pays close attention to the patient and offers reassurance, instruction, and assistance with positioning and draping. The medical assistant helps with the examination process by instructing and assisting patients in assuming various positions that allow the physician better access to and visibility of the body part being examined. These positions include the sitting, supine, dorsal recumbent, Sims, lithotomy, semi-Fowler, Fowler, Trendelenburg, kneechest, and jack-knife positions.

To help promote patient privacy and comfort, the medical assistant provides careful draping. The medical assistant commonly measures the weight and height of patients. Accuracy in obtaining and recording these data is important, because changes over time may indicate a signicant change in a patients health status.

Team Work Exercises

1. Divide into groups of three students. The instructor will write each of the examination positions on a card or small piece of paper and fold it so that it cannot be easily read. Each team will draw one or more cards until all are drawn. After a brief preparation period (as determined by the instructor), each team will present a role-playing scenario in which the medical assistant positions the patient for examination by the physician. Presentations will continue until all positions have been demonstrated. 2. Divide into teams of three or four students. Each team must brainstorm and come up with a plan to deal with the following scenario: You are medical assistants in a busy family practice clinic. An inuenza epidemic has hit town and is affecting your patient population as well as the staff at your clinic. You are short-staffed today because your lead nurse, the ofce manager, and one of the two receptionists are out sick. To make matters worse, you are overbooked because so many of your patients are ill. You each have a strong preference for working in the back ofce or the front ofce. However, you are all certied medical assistants and, as such, have been trained to work in both areas. Given the challenges that you all face today, put your heads together and come up with a plan that will help everyone work together effectively to provide good-quality patient care and get the work done. You will have a designated amount of time (as determined by the instructor). Then each of the teams must rejoin the class and share their ideas for coping with this challenging situation.

Case Studies
1. Hachi Macha is a 57-year-old patient who has arrived for his annual health examination. He has been conned to a wheelchair since becoming a double amputee in the Vietnam War. He is a large man who has good use of his arms and hands. The medical assistant needs to measure Mr. Machas weight and take him to an examination room. What special challenges might be involved in the examination of this patient? Describe some creative solutions to these challenges. 2. Odessa Naia is a 37-year-old woman who is visiting the clinic today for her annual physical examination. She will undergo a pelvic examination and Papanicolaou (Pap)

CHAP TER 22

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test. Describe the positions that she might be placed in for this part of her examination and list the advantages and disadvantages of each position.

Resources

Physical examination overview: www.en.wikipedia .org/wiki/Physical_examination Physical examination techniques: http://health.allrefer .com/health/physical-examination-info.html Bickley, L.S., and Szilagyi, P.G.: Bates Guide to Physical Examination and History Taking, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2007.

Dillon, P.M.: Nursing Health Assessment: A Critical Thinking, Case Studies Approach, 2nd ed. Philadelphia: F.A. Davis Company, 2007. Dillon, P.M.: Nursing Health Assessment: Clinical Pocket Guide, 2nd ed. Philadelphia: F.A. Davis Company, 2007. Jarvis, C.: Physical Examinations and Health Assessment, 5th ed. Philadelphia: Saunders, 2007. Seidel, H. M., et al.: Mosbys Physical Examination Handbook, 6th ed. St. Louis: Mosby, 2006. Zator Estes, M.E.: Health Assessment and Physical Examination, 3rd ed. Clifton Park, NY: Delmar Cengage Learning, 2006.

CHAPTER

Essentials of Medical Terminology

Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell key terms listed in the Glossary discuss the origins of medical language describe medical word elements and how they are combined to create medical terms list the three steps used to translate medical terms describe seven methods of creating plural word forms list seven pronunciation tips and give examples of seven words in the singular and plural forms explain the purpose of directional terms and write ve statements that use at least one directional term in each.

23
Chapter Outline
Origins of Medical Language Medical Word Elements
Combining Forms Prexes Sufxes Abbreviations Pathological Terms

CAAHEP Competencies
General Competencies Professional Communications
Respond to and initiate written communications Recognize and respond to verbal communications

Patient Instruction
Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention

ABHES Competencies
Communication
Use appropriate medical terminology

Translating Terms Pronunciation and Plural Forms Directional Terms Memorize and Practice Chapter Summary Team Work Exercises Case Studies Resources

367

Key Terms
combining form

Origins of Medical Language

Patients sometimes comment that health care providers seem to speak a foreign language. Thus, medical assistants must take care to use language easily understood by the average patient. (See Be a translator.) The language of medicine contains many terms that have their origins in a variety of other languages, primarily Greek and Latin. For example, the currently used term nephro, which means kidney, is based on the Greek term nephros. The currently used term oro, which means mouth, is based on the Latin term oris. The term hygiene was derived from the name of the Greek goddess of health, Hygeia. Over time, many other terms have been created as well. Some anatomical terms were named after the person who rst identied them, such as the fallopian tubes, which were named after Gabriele Fallopius, a 16th-century Italian student of human anatomy. Recent advances in medical technology have caused a signicant increase in the number of new terms and abbreviations. Some examples include:

Word element created by joining a word root with a combining vowel

combining vowel

Vowel placed between word parts to link them together and make the term easier to pronounce
directional term

Term used to indicate specic areas on the body

pathological term

Term that refers to a disease or disorder of the body

prex

Word element placed at the beginning of a word that modies the words meaning
sufx

Word element placed at the end of a word that modies the words meaning
word root

Main stem of a word that conveys the words meaning

magnetic resonance imaging (MRI), a type of diagnostic radiography that uses a powerful magnetic eld to make images of tissues and organs percutaneous transluminal coronary angioplasty (PTCA), the surgical repair of a vessel of the heart in which a catheter is inserted into a narrowed vessel and a tiny balloon is inated to widen it, thereby restoring adequate blood ow to heart muscle.

Regardless of whether a medical assistant is more interested in working in administrative or clinical areas, her effort to learn medical terminology now is a wise investment of her time and energy. Mastering the language of medicine will enable her to communicate uently with other members of the health care team and record data clearly and accurately in the medical record. Whether she works in a family practice ofce, pediatrics, sports medicine, or another area of health care, uency in medical terminology will enhance the medical assistants effectiveness and her image as a professional.

Medical Word Elements

Understanding medical language begins with learning about common word elements and the categories they fall into. There are ve main categories of word elements:

combining forms prexes sufxes abbreviations pathological terms.

CHAP TER 23

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369

Patient Education

Be a Translator
Because a common complaint of the patient population is that health care providers speak in a language they cannot understand, medical assistants should be prepared to translate the medical language for their patients. There are several ways to help patients understand tricky medical terms, including being prepared to explain terminology and providing other means of learning, including using printed materials.

Ofce literature
The medical assistant can use the time that a patient spends waiting in the reception area as an opportunity for patient education. In addition to other literature, the medical assistant can provide cards or pamphlets with translations of terms commonly used in the ofce. For example, pamphlets placed in a pulmonology department might include such terms as bronchitis and pulmonologist and abbreviations such as COPD for chronic obstructive pulmonary disease and TB for tuberculosis. Pamphlets placed in the cardiac department might include such terms as tachycardia and electrocardiogram and abbreviations such as ASHD for atherosclerotic heart disease and DVT for deep venous thrombosis. Ready access to this type of literature enables patients to begin learning some terminology, increasing their understanding and feelings of empowerment. An added bonus is a decrease in the time the medical assistant must spend translating and explaining medical terms.

Sensitivity with skills

The medical assistants knowledge of medical terminology makes her, in a sense, bilingual. While this knowledge is a great advantage to her professional career, it can become a barrier for patients if she forgets that most of them do not share her language skills. Therefore, as a patient advocate, the medical assistant must be sensitive to the needs of patients and avoid using medical jargon when speaking with them. Additionally, the medical assistant should always offer to translate or explain any terms the patient nds confusing.

Combining Forms
Combining forms are created by joining word roots with combining vowels. A word root is the main stem of the word and is the part of the word that conveys the most meaning. For example, in the word walking, the root, or main stem, is walk. The purpose of a combining vowel, which is usually an o is to make terms easier to pronounce. The combining vowel has no impact on the meaning of the term and is placed between word parts to link them together. For example, the word root therm means heat. If this word root is joined to an o, the result is the combining form thermo. A combining vowel should be used when the following word element begins with a consonant, as with the word thermometer. However, in cases where the next word element begins with a vowel (a, e, i, o, u), no combining vowel is needed. For example, when the word root arthr, which means joint, is combined with -itis, which means inammation, no combining vowel is needed because itis begins with a vowel. The newly created term arthritis means inammation of a joint. Note that the key meaning of joint, which is inherent in the root arthr, remains. However, the newly added -itis has modied the meaning. (See Knowing when to use a combining vowel.)

Knowing when to use a combining vowel

Remembering the purpose of the combining vowel makes it easier to understand when to use one. The combining vowel has no inherent meaning of its own. Its only purpose is to act like the link of a chain to connect other word parts together and make them easier to pronounce. Therefore, if a vowel is already present at the beginning of the next word part, then no additional vowel is needed. On the other hand, if no vowel is present (the next word part begins with a consonant) then a combining vowel is necessary. Here are two examples in which one term uses a combining vowel and the other does not. micr (small) o (combining vowel) used to view) microscope scope (instrument appendicitis

appendic (appendix) itis (inammation) (inammation of the appendix)

Prexes
Prexes are word elements located at the beginning of words that modify the word meaning. For example, when the prex

diplo (double or twin) is placed before the term opia (vision), the new word diplopa is created, which means double vision. When the prex dys, which means bad, painful, or difcult, is placed before the term uria, which means urine, the new term dysuria is created. The literal translation of this new term is bad, painful, or difcult urine. However, in common usage it means painful urination. As this

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example indicates, the literal translation of terms and their common meanings are sometimes slightly different. (See Common prexes.)

Sufxes
Suffixes are word elements located at the end of a word. Like prefixes, suffixes always modify the meaning of the

term in some manner. For example, when the suffix -dynia (pain) is placed after the term pharyng/o (pharynx) the term pharyngodynia is created, which means pain in the throat. When the suffix -dynia is placed after the combining form cervic/o (neck) the new term cervicodynia is created, which means neck pain. (See Common suffixes.)

Common prexes
The following table lists the most common prexes used in medical terminology. Some prexes share the same meaning and are listed together.

Prex
aananteantibibradycircumdiatransdiplodysendoepieuexextrahemihypersuprahyposubinfraintermacromicro-

Meaning
without, absence of

Example
aphasia (a-FA-ze-a): absence of speech anurea (an-U-re-a): absence of urine antenatal (an-te-NA-tal): before birth antidiarrheal (an-t-d-a-RE-al): against diarrhea (medication) bilateral (b-LAT-er-al): toward two sides bradypnea (brad-p-NE-a): slow breathing circumoral (ser-kum-O-ral): pertaining to around the mouth diarrhea (d-a-RE-a): ow through transurethral (trans-u-RE-thral): through the urethra

before, in front of against two slow around through, across

double, twin bad, painful, or difcult in, within above, upon good, normal away from, external

diploid (DIP-loyd): resembling two or twins dysmenorrhea (ds-men-o-RE-a): bad, painful or difcult menstrual ow endocervical (en-do-SER-v-k al): in or within the cervix epicardia (ep--KARD-e-a): above or upon the heart euthyroid (u-THI-royd): good or normal thyroid exotropia (eks-o-TRO-pe-a): turning away from extraocular (eks-tra-OK-u-lar): external to the eye

half excessive, above normal

hemigastrectomy (hem-e-gas-TREK-to-me): surgical removal of half of the stomach hyperesthesia (h-per-es-THE-ze-a): excessive sensation supracostal (soo-pra-KOS-tal): pertaining to above the ribs hypocalcemia (h-po-kal-SE-me-a): below normal blood calcium substernal (sub-STER-nal): pertaining to beneath the sternum infrapatellar (n-fra-pa-TEL-ar): pertaining to beneath the patella

below normal, beneath

between large small

intercellular (n-ter-SEL-u-lar): between cells macroplasia (mak-ro-PLA-ze-a): large formation or growth microcardia (m-kro-KAR-de-a): small heart

CHAP TER 23

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Common prexescontd
Prex
multipolyneooligoparaperipostpreprimiquadrisyntachytoxuniafter, following before, in front of rst four union, together, or joined rapid poison one new decient near, beside, or around

Meaning
many, much

Example
multigravida (mul-t-GRAV--da): woman with many pregnancies polyneuritis (pol-e-nu-RI-ts): much nerve inammation neonatology (ne-o-na-TOL-o-je): study of newborns oligospermia (ol--go-SPER-me-a): a condition of decient sperm parahepatic (par-a-he-PAT-k): pertaining to near, beside, or around the liver perianal (per-e-A-nal): pertaining to near, beside, or around the anus postnasal (post-NA-zal): after or following the nose premenstrual (pre-MEN-stroo-al): before menses primigravida (pr-m-GRAV--da): woman in her rst pregnancy quadriplegia (kwod-r-PLE-je-a): paralysis of four (extremities) syndesis (sn-DE-ss): binding together tachycardia (tak-e-KAR-de-a): rapid heart (beat) toxemia (tok-SE-me-a): poison blood unicellular (u-n-SEL-u-lar): pertaining to one cell

Common sufxes
This table lists the most common sufxes used in medical terminology. Some sufxes share the same meaning and are listed together.

Sufx
-al -ac -ar -ary -ic -eal -ous -tic* -tous* -asthenia -algia -dynia -arche

Meaning
pertaining to

Examples
dermal (DERM-al): pertaining to the skin cardiac (KAR-de-ak): pertaining to the heart ocular (OK-u-lar): pertaining to the eyes urinary (U-r-nar-e): pertaining to urine gastric (GAS-trk): pertaining to the stomach esophageal (e-sof-a-JE-al): pertaining to the esophagus cutaneous (ku-TA-ne-us): pertaining to the skin cyanotic (s-an-OT-k): pertaining to blue (color) edematous (e-DE-ma-tus): pertaining to edema

weakness, debility pain

myasthenia (m-as-THE-ne-a): muscle weakness arthralgia (ar-THRAL-je-a): joint pain otodynia (o-to-DIN-e-a): ear pain

beginning

menarche (men-AR-ke): beginning of menses

*The sufx -tic is a variation of -ic and the sufx -tous is a variation of -ous.

Continued

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Common sufxescontd
Sufx
-blast -cele -centesis -cephaly -cide -clast -cyte -derma -desis -dipsia -ectomy -edema -emia -emesis -esthesia -genesis -gram -graph

Meaning
embryonic cell hernia surgical puncture head kill, destroy to break, surgical fracture cell skin binding, xation thirst excision, surgical removal swelling condition of the blood vomiting sensation creating, producing record recording instrument

Examples
osteoblast (OS-te-o-blast): embryonic bone cell rectocele (REK-to-sel): rectal hernia arthrocentesis (ar-thro-sen-TE-ss): surgical puncture of a joint microcephaly (m-kro-SEF-a-le): small head bacteriocide (bak-TER--o-sd): destroying bacteria osteoclast (OS-te-o-klast): breaking a bone spermatocyte (sper-MAT-o-st): sperm cell cyanoderma (s-a-no-DER-ma): blue skin pleurodesis (ploo-ro-DE-ss): binding of the pleurae polydipsia (pol-e-DIP-se-a): much thirst appendectomy (ap-en-DEK-to-me): excision of the appendix blepharedema (blef-ar-e-DE-ma): swelling of the eyelids hypoglycemia (h-po-gl-SE-me-a): a condition of low blood sugar hyperemesis (h-per-EM-e-ss): excessive vomiting anesthesia (an-es-THE-ze-a): without sensation hematogenesis (he-mat-o-JEN-e-ss): creating or producing blood electrocardiogram (e-lek-tro-KAR-de-o-gram): record of heart electricity electroencephalograph (e-lek-tro-en-SEF-a-lo-graf): instrument for recording brain electricity

-graphy -gravida -ia -ism -iasis

process of recording pregnancy condition

electromyography (e-lek-tro-m-OG-ra-fe): process of recording muscle electricity multigravida (mul-t-GRAV--da): multiple pregnancies pneumonia (nu-MO-ne-a): condition of the lungs hypothyroidism (h-po-THI-royd-zm): condition of decreased thyroid (function) cholelithiasis (kol-o-lth-I-as-s): a condition of gall stones

pathological condition or state, commonly related to the presence of a stone

-ist -itis -kinesis -kinesia -lith -logist -logy

specialist inammation movement

dentist (DEN-tst): specialist in teeth arthritis (ar-THRI-ts): inammation of a joint hyperkinesis (h-per-k-NE-ss): excessive movement hypokinesia (h-po-k-NE-ze-a): decreased movement

stone specialist in the study of study of

nephrolith (NEF-ro-lth): kidney stone cardiologist (kar-de-OL-o-jst): specialist in the study of the heart nephrology (ne-FROL-o-je): study of the kidneys

CHAP TER 23

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Common sufxescontd
Sufx
-lysis -malacia -megaly -meter -oid -ole -ule -oma -opia -orexia -osis -oxia -para -paresis -pathy -pause -penia -pepsia -pexy -phagia -phasia -phobia -phoria -plasm -plasia -plasty -plegia -pnea -prandial -ptosis -rrhage -rrhagia surgical repair paralysis breathing meal drooping, prolapse bursting forth tumor vision appetitie abnormal condition oxygen to bear offspring slight or partial paralysis disease cessation, stopping deciency digestion surgical xation eating, swallowing speech fear feeling formation, growth

Meaning
destruction of softening enlargement instrument for measuring resembling small

Examples
hemolysis (he-MOL--ss): destruction of the blood chondromalacia (kon-dro-mal-A-she-a): softening of the cartilage hepatomegaly (hep-a-to-MEG-a-le): enlargement of the liver arthrometer (ar-THROM-e-ter): instrument for measuring joints lipoid (LIP-oyd): resembling fat arteriole (ar-TE-re-ol): small artery venule (VEN-ul): small vein lipoma (l-PO-ma): fatty tumor diplopia (dp-LO-pe-a): double vision anorexia (an-o-REK-se-a): absence of appetite vaginosis (vaj-n-OS-ss): abnormal condition of the vagina hypoxia (h-POKS-e-a): low level of oxygen primipara (pr-MIP-a-ra): rst pregnancy hemiparesis (hem-e-par-E-ss): partial paralysis of half of the body orchiopathy (or-ke-OP-ath-e): disease of the testes menopause (MEN-o-pawz): cessation of menses erythrocytopenia (e-rth-ro-s-to-PE-ne-a): deciency of red blood cells dyspepsia (ds-PEP-se-a): bad, painful, or difcult digestion mastopexy (MAS-to-peks-e): surgical xation of the breasts dysphagia (ds-FA-je-a): bad, painful, or difcult swallowing aphasia (a-FA-ze-a): absence of speech hemophobia (he-mo-FO-be-a): fear of blood euphoria (u-FOR-e- a): good feeling neoplasm (NE-o-plazm): new growth dysplasia (ds-PLA-ze-a): bad, painful, or difcult growth rhinoplasty (RI-no-plas-te): surgical repair of the nose quadriplegia (kwod-r-PLE-je-a): paralysis of four extremities orthopnea (or-THOP-ne-a): upright breathing postprandial (post-PRAN-de-al): after meals hysteroptosis (hs-ter-op-TO-ss): prolapse of the uterus hemorrhage (HEM-e-rj): bursting forth of blood menorrhagia (men-o-RA-je-a): bursting forth of menses

Continued

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Common sufxescontd
Sufx
-rrhaphy -rrhea -salpinx -scope -scopy -spasm -stenosis -stomy -therapy -tocia -tome -tomy -tripsy -trophy -tropia -uria

Meaning
suture, suturing ow, discharge tube (fallopian or eustachian) instrument to view visual examination contraction, tension, spasm narrowing, stricture mouthlike opening treatment childbirth, labor cutting instrument cutting into, incision crushing nourishment or growth turning urine

Examples
vasorrhaphy (vas-OR-a-fe): suturing of a vessel rhinorrhea (r-no-RE-a): ow from the nose hemosalpinx (he-mo-SAL-pnks): blood in a tube (fallopian or eustachian) laparoscope (LAP-a-ro-skop): instrument to view the abdomen arthroscopy (ar-THROS-ko-pe): visual examination of a joint arteriospasm (ar-TE-re-o-spazm): spasm of an artery esophagostenosis (e-sof-a-go-sten-O-ss): stricture of the esophagus tracheostomy (tra-ke-OS-to-me): mouthlike opening in the trachea hydrotherapy (h-dro-THER-a-pe): treatment with water dystocia (ds-TO-se-a): bad, painful, or difcult labor crainiotome (KRA-ne-o-tom): instrument for cutting the cranium hysterotomy (hs-ter-OT-o-me): incision into the uterus lithotripsy (LITH-o-trp-se): crushing stones atrophy (AT-ro-fe): absence of growth exotropia (eks-o-TRO-pe-a): turning away from hematuria (he-ma TU-re-a): blood in the urine

Abbreviations
Abbreviations are another type of word element used frequently in health care settings because they save time and simplify the speaking and writing of large, difcult-to-pronounce terms. For example, the abbreviation CAD stands for coronary artery disease, which is a narrowing of the lumen of the arteries of the heart. Another example is EGD, which is the abbreviation for the term esophagogastroduodenoscopy. (See Common abbreviations.) Abbreviations are so numerous in health care that they can cause confusion and even mistakes when not used appropriately. For example, an abbreviation in one specialty area might have a different meaning in another specialty area. Therefore, medical assistants must take care to use only approved abbreviations and should always ask when unsure of what an abbreviation means. (See Abbreviation miscommunication, page 376.) Symbols are also often used as a means of reducing the amount of documentation. Examples of commonly used symbols are those for male (?) and female (/).

Although many abbreviations are commonly used in health care, there are abbreviations that should no longer be used. Medical assistants must be familiar with these abbreviations in order to correctly interpret past charting as well as to be sure to avoid using them when completing documentation. (See Discontinued abbreviations, page 377.)

Pathological Terms
Pathological terms are used extensively in health care and refer to diseases and disorders of various body systems. An example of a pathological term is multiple sclerosis, a chronic disease of the central nervous system in which nerves are damaged and may temporarily or permanently lose the ability to transmit messages to muscles and organs. Another example is impetigo, which is a highly contagious bacterial infection caused by group A Streptococcus or Staphylococcus aureus that develops most commonly in young children. Some students struggle to learn pathological terms as well as abbreviations. Learning these terms requires basic memorization, which

CHAP TER 23

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Common abbreviations
The following table lists common abbreviations used in most areas of health care along with their corresponding medical terms.

Abbreviation
BM bid C Ca, CA tid qid c s c/o Dx FH g gtt PMH Hx h, hr ID IM INR IV K Kg, kg L Mg, mg ml Na

Term
bowel movement twice a day Celsius calcium, cancer three times a day four times a day with without complaint of diagnosis family history gram drops prior medical history history hour intradermal intramuscular International Normalized Ratio intravenous potassium kilogram liter magnesium, milligram milliliter sodium

Abbreviation
NPC NPO NG N&V NPO OTC P, p pc PO PE PR q qam qh qhs

Term
nonproductive cough nothing by mouth nasogastric nausea and vomiting nothing by mouth over-the-counter pulse, after after meals by mouth physical examination per rectum every every morning every hour every day at bed time (or each evening)

R RR Rx stat supp Sx T tab Tx

respiration respiratory rate prescription immediately suppository symptom temperature; tablespoon tablet treatment

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Front ofceback ofce connection

Abbreviation Miscommunication
Medical assistants become well versed and comfortable with abbreviations used in the area in which they work. However, they may become confused by abbreviations used by providers in other work areas. Thus, the medical assistant must be especially careful with documentation when she oats to an area different from where she normally works. Perhaps she normally works in a family practice department and is asked to oat to oncology, neurology, obstetrics, or pediatrics. In addition, a clinical medical assistant might be asked to oat to an administrative area or vice versa. Whatever the case, each organization should keep a master list of approved abbreviations for all employees and each department should keep a list of commonly used specialty abbreviations (consistent with the master list) for its employees. When the medical assistant oats to a new area, she should be sure to ask for a copy of these abbreviations to refer to as she completes her documentation duties. Doing so ensures the accuracy of her charting and protects her and her patients from the unpleasant consequences of errors. This table lists some examples of the many medical abbreviations with multiple meanings.

Abbreviation
BC Ca, CA CCU ECF ED

Multiple Meanings
bone conduction; birth control calcium; cancer coronary care unit; critical care unit extended care facility; extra-cellular uid emergency department; erectile dysfunction

Mg, mg P, p PA PI PND

magnesium; milligram pulse; after posteroanterior; pernicious anemia present illness; previous illness postnasal drip (drainage); paroxysmal nocturnal dyspnea

RR RT T TLC

respiratory rate; recovery room radiation therapy; respiratory therapy temperature; tablespoon tender loving care; thin layer chromatography; total lung capacity

takes time and effort. However, this effort pays big rewards later in the form of uency in medical terminology. (See Memorizing medical terms.)

between the word elements. After practicing the steps a few times, students will nd that it is no longer necessary to use the slashes. To translate esophag / o / gastr / o / duoden / o / scopy, the student should follow the three steps: 1. identify and translate the last term, -scopy, which means visual examination 2. identify and translate the rst term, esophag/o, which is a combining form that means esophagus 3. identify and translate the remaining terms in order from left to right a. rst, translate the term gastr/o, which is a combining form that means stomach b. next translate the term duoden/o, which is a combining form that means duodenum (the rst part of the small intestines). Using the translations in the steps above, the student will determine that the meaning of the medical term esophagogastroduodenoscopy is visual examination of the esophagus, stomach, and duodenum.

Translating Terms
Learning prexes and sufxes provides signicant benets because it enables students to decipher and translate medical words. There are three simple steps to follow when translating a medical term: 1. identify and translate the last word element 2. identify and translate the rst word element 3. identify and translate the remaining word elements in order from left to right. For example, the term esophagogastroduodenoscopy is a large, somewhat intimidating term for most students. However, it can easily be translated using the three steps just described. Beginning students may nd it helpful to place slashes

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Discontinued abbreviations
The Joint Commission, formerly called the Joint Commission on Accreditation of Health Care Organizations (JCAHO), has identied several abbreviations used in health care as confusing or easily misinterpreted. They have determined that use of these abbreviations could lead to serious errors and possible injury to the patient. Thus, the Joint Commission strongly recommends discontinuing their use in health care practice and documentation. This table lists these abbreviations, along with the reason for their discontinuance and what to use in their place.

Abbreviation
U IU QD, Q.D, q.d., qd QOD, qod, Q.O.D., q.o.d. Trailing zero (X.0 mg) or lack of leading zero (.X mg) MS MSO4, MgSO4

Reason Discontinued
Mistaken for zero, the number 4 or cc Mistaken for IV or the number 10 Mistaken for each other Period after Q and the o mistaken for I Decimal point possibly missed

Replacement
Write out unit instead. Write out international unit instead. Write out daily. Write out every other day. Write X mg and 0.X mg

Can mean morphine sulfate or magnesium sulfate Confused for one another

Write out morphine sulfate or magnesium sulfate. Write out morphine sulfate or magnesium sulfate.

Pronunciation and Plural Forms

Most students need a lot of practice before they feel at ease pronouncing medical terms. However, developing good pronunciation habits early can help speed up the process. One step a student can take early on is to memorize the sounds for certain common letter combinations and other rules of pronunciation. (See Pronunciation guidelines, page 378.) Another common obstacle to using correct medical terminology is the rules for changing singular terms to plural terms. Because many terms originate from foreign languages, such as Latin and Greek, the rules for plural terms are not always simple. The student who reviews and

understands these rules will achieve a higher level of ease with and understanding of medical terminology. (See Changing singular to plural, page 378.)

Directional Terms
Directional terms indicate and describe specic areas on the body. The medical assistant must be able to understand and correctly use directional terms in order to accurately communicate descriptive data when speaking with other health care providers and when documenting in the patients chart. (See Common directional terms, page 379.)

Memorizing medical terms

Many medical assisting students nd memorizing prexes, sufxes, combining forms, abbreviations, and pathological conditions requires a great deal of time and effort. To be more effective in the process of memorizing these terms, the student should follow these guidelines: Make or purchase ready-made ashcards. Study a few cards each day and keep them handy. Use extra time (when waiting in line at the store or waiting for an appointment) to pull them out and review them. Write down several terms and their meanings and give them to friends or family members you see daily. Ask them to quiz you on their assigned terms each time they see you. Complete the terminology-related student disc activities for this chapter. Complete the terminology-related student disc activities for each of the body systems chapters. Complete the terminology-related website activities for this chapter and for each of the body systems chapters.

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Pronunciation guidelines
This table lists common letter combinations and other pronunciation guidelines to aid in the pronunciation of medical terminology, along with examples.

Letters
ps pn g and c

Guidelines
Pronounce only the s. Pronounce only the n. Pronounce the soft sound for the letter when used before e, i, and y.

Example
psychology (s-KOL-o-je) pneumonia (nu-MO-ne-a) gelatin (JEL-a-tn) -kl) cycle (SI gastric (GAS-trk) caffeine (KAF-en) pleurae (PLOO-re) alveoli (al-VE-o-l)

g and c

Pronounce the hard sound for the letter when it is used in front of letters other than e, i, and y.

ae and oe i

Pronounce as a long e sound. When used at the end of a word, pronounce as a long i or long e sound. (This letter at the end of a word generally indicates a plural.)

es

Pronounce as a separate syllable when used at the end of some words.

nares (NA-rez)

Changing singular to plural

This table lists singular word endings that are common in medical terminology along with their plural forms, the rule for changing each to plural, and examples.

Singular Form
a ax is ix, ex um us y

Plural Form
ae aces es ices a i ies

Rule
Retain the a and add e. Drop the x and add ces. Drop the is and add es. Drop the ix or ex and add ices. Drop the um and add a. Drop the us and add i. Drop the y and add ies. vertebra thorax diagnosis appendix

Example Singular Plural

vertebrae thoraces diagnoses appendices diverticula thrombi ovaries

diverticulum thrombus ovary

Memorize and Practice

The value to a medical assistant of memorizing medical terms and practicing translating skills is immeasurable. Although such practice requires a fair amount of time and energy up front, it makes so many tasks easier in the long run. Just a few

of the benets enjoyed by those who achieve uency in medical terminology include:

increased understanding and enjoyment when reading medical subject manner improved test scores because of improved understanding of subject matter and test questions

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Common directional terms

This table lists commonly used directional terms along with their combining form or prex and meaning. Note that most of these terms are listed with their opposites.

Chapter Summary

Term
proximal

Word Element
proxim/o

Meaning
Nearer to the origin or point of attachment

distal

dist/o

Further from the origin or point of attachment

medial

medi/o

Toward the midline; nearer to the middle

lateral

later/o

Away from the midline; toward the side

superior

super/o

Above or nearer to the head

inferior

infer/o

Beneath or nearer to the feet

anterior

anter/o

Toward or near the front; ventral

posterior

poster/o

Towards or near the back; dorsal

ventral dorsal abduction adduction

ventr/o dors/o abad-

Front, anterior Back; posterior From, away from Toward

more accurate verbal communication with other health care professionals more accurate medical documentation increased level of professionalism.

This chapter introduced some combining forms and the many prexes and sufxes the medical assistant needs to know. Additional combining forms, as well as abbreviations and pathological terms, are introduced in each of the chapters that review body systems and their medical specialties. (See Chapters 25 through 36.) Selected prexes and sufxes are reviewed in those chapters as well.

Patients sometimes comment that health care providers seem to speak a foreign language. This observation is essentially true because the language of medicine contains many terms that have their origins in a variety of other languages, primarily Greek and Latin. Additionally, recent advances in medical technology have caused a signicant increase in the number of new terms and abbreviations. Understanding medical language begins with learning about the common word elements, including combining forms, prexes, sufxes, abbreviations, and pathological terms. A combining form is created by joining a word root, which is the part of the word that conveys the most meaning, with a combining vowel, which make the term easier to pronounce. A prex is a word element located at the beginning of a word that modies the words meaning. A sufx is a word element located at the end of a word that also modies the words meaning. Abbreviations are used frequently in health care to save time and simplify the speaking and writing of large, difcult-to-pronounce terms. Pathological terms refer to diseases and disorders of various body systems. There are three simple steps in the process of translating medical terms. The rst step is to identify and translate the last word element. The second step is to identify and translate the rst word element. The third step is to identify and translate the remaining word elements in order from left to right. Developing good pronunciation habits early can help enhance a medical assistants ease in using medical terms. In addition, understanding the rules regarding converting singular medical terms to plural will help her achieve a higher level of ease with and understanding of those terms. Directional terms indicate and describe specic areas on the body. The value to a medical assistant of memorizing medical terms and practicing translating skills is immeasurable. Although such practice requires a fair amount of time and energy up front, it increases the medical assistants understanding of medical literature and helps her with test taking and, most importantly, accuracy, effectiveness, and professionalism on the job.

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This chapter provides an introduction to medical terminology. To become more uent in the language of medicine, students must study the medical terminology sections of Chapters 25 through 36.

Resources

Team Work Exercises

1. Divide into small teams of three or four students for a friendly competition. The instructor will give each team a list of 10 medical terms. The rst team to accurately translate or dene all 10 of the terms wins the competition. 2. Divide into small teams of three or four students for a friendly competition. The instructor will give each team a list of 10 singular terms. The rst team to accurately convert all 10 of the terms to their correct plural forms wins the competition.

Case Studies
1. Alicia Mendoza is a clinical medical assistant who works in a sports medicine clinic. She has noticed on several occasions that another medical assistant frequently uses abbreviations that Alicia does not recognize. When she asked her coworker about it, his reply was Well, sometimes I make up my own because I just dont have time for all of this documentation we have to do. Alicia is concerned about this response and wants to discuss the subject further. Make a list of all the reasons why making up abbreviations might be a bad idea. Describe how Alicia might approach her coworker to discuss this issue without offending him. 2. The following paragraph contains 29 abbreviations that you must dene. Some are located in this chapter and others are located in other clinical chapters. On a separate piece of paper, write each of the abbreviations in the order in which they appear in the story and then write the meaning next to them. Anatoly Fedor is a 71-year-old ?. His PMH includes HTN, BPH, and ASHD. He also has a recent Hx of a MI two months ago. After ve days in the hospital, he was discharged home and underwent several weeks of PT. Today he came to the clinic c c/o of SOB, frequent NPC, and occasional PND. The medical assistant checked Mr. Fedors VS and noted that his BP was 166/94, his T was 37C, his RR was 28, and his weight was 76 Kg, up 3 Kg from his last visit. After a thorough PE and tests, which included a CXR, CBC, and lytes, the physician diagnosed Mr. Fedor with heart failure. The physician ordered an RT Tx for him before he leaves today and also wrote an Rx for furosemide and K supplement to be taken bid PO.

Free online medical terminology course: www.free-ed .net/free-ed/HealthCare/MedTerm-v02.asp Online medical dictionary: www.medterms.com/script/ main/hp.asp Medical terminology online course: davisplus.fadavis .com/MTO.cfm Chabner, D.: Medical Terminology: A Short Course, 4th ed. New York: W.B. Saunders, 2005. Collins, C.: A Short Course in Medical Terminology. Philadelphia: Lippincott, Williams & Wilkins, 2007. Eagle, S.: Medical Terminology in a Flash! Philadelphia: F.A. Davis Company, 2006. Gylys, B.A., and Masters, R. M.: Medical Terminology Simplified: A Programmed Learning Approach by Body Systems, 3rd ed. Philadelphia: F.A. Davis Company, 2005. Hutton, A.: Pocket Medical Terminology. New York: Churchill Livingstone, 2004. Venes, D., ed.: Tabers Cyclopedic Medical Dictionary, 20th ed. Philadelphia: F.A. Davis Company, 2005.

CHAPTER

Surgical Asepsis and Assisting with Minor Surgery

Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell terms related to surgical asepsis and minor surgery describe the role of the medical assistant when assisting with minor surgical procedures describe categories of surgical instruments and give examples of instruments in each category list common features of surgical instruments describe common features of surgical scissors and list at least three types describe common types of graspingclamping instruments discuss common features of grasping-clamping instruments describe common types of dilatingprobing instruments list at least three types of specialty instruments discuss eleven principles of sterile technique.

24
Principles of Surgical Asepsis
Sterile Technique Surgical scrub Sterile eld Sterile gloving

ABHES Competencies
Clinical Duties
Apply principles of aseptic technique and infection control Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries

Minor Surgical Procedures

Cryosurgery Microsurgery Laser Surgery Electrosurgery Endoscopy The Medical Assistants Role in Minor Surgery Patient Preparation and Postoperative Care Wound Care Sutures Staples Wound Care Supplies Dressings Bandages Creams, ointments, and solutions Anesthetics

Procedures
Performing a surgical scrub Setting up a sterile eld Applying sterile gloves Assisting with minor surgery Performing suture removal Removing a dressing and applying a new sterile dressing

Chapter Outline
Surgical Role of a Medical Assistant Surgical Instruments
Cutting Instruments Scissors Scalpels Grasping-Clamping Instruments Probing and Dilating Instruments Specula Scopes Probes, retractors, and dilators Specialty Instruments

Chapter Summary Team Work Exercises Case Studies Resources

CAAHEP Competencies
Clinical Competencies Patient Care
Prepare patients for and assist with procedures, treatments, and minor ofce surgeries

Biopsy Equipment

381

Key Terms
anesthesia

Absence of sensation
approximation

Surgical Role of a Medical Assistant

A medical assistant will commonly assist with minor surgical procedures. These procedures usually take place in a procedure room, rather than a typical examination room. Such rooms are generally more spacious, allowing for easy movement of personnel and equipment, and stocked with surgical supplies and equipment. The medical assistants role involves preparing the room for procedures, assisting the physician during procedures, providing postprocedure care to patients, and tidying and sanitizing the room after procedures. To be able to fulll these duties effectively, the medical assistant must be familiar with commonly used supplies and instruments, the principles of surgical asepsis, and the procedures commonly performed in the medical ofce.

Bringing wound edges together closely and evenly

bandage

Nonsterile material applied over the top of dressings to secure them

cryosurgery

Technique that destroys tissue by subjecting it to very cold temperatures; also called cryotherapy
dressing

Material placed in or on a wound

electrosurgery

Use of high-frequency electric current to cut, remove, or destroy tissue; also called electrocautery
endoscopy

Use of a specialized scope to visually examine a structure

laser surgery

Treatment of tissue by means of colored light beams

microsurgery

Surgical Instruments
The medical assistant should become familiar with the surgical instruments used in the ofce in which she works. There are more than 30,000 different types of surgical instruments designed to serve a variety of purposes. Most can be categorized as:

Any procedure completed with the use of a special operating microscope

sterile technique

Method that involves performing invasive procedures in a manner that protects patients from pathogens
sterile toss

Technique for placing sterile items on the sterile eld without contaminating either one
surgical asepsis

Destruction of all pathogenic organisms before they enter the body

suture

Material used to sew wound edges together or the act of sewing wound edges together
swage

cutting instruments, such as scalpels and scissors grasping-clamping instruments, such as needle holders, clamps, hemostats, and forceps probing and dilating instruments, such as dilators, specula, probes, scopes, and retractors specialty instruments, including those that do not t into the other categories and those designed for specic procedures. (See Identifying surgical instruments.)

To fuse a suture to a needle

Front ofceBack ofce connection

Identifying Surgical Instruments

A medical assisting student who plans to work as an administrative medical assistant might think that identifying surgical instruments is not relevant to her. However, she should strive to learn and remember as much as she can about surgical equipment, instruments, and procedures. Doing so will not only make her a more knowledgeable, versatile, and valuable member of the team, it will also allow her to respond professionally and appropriately if she is one day asked to: help out by calling for or retrieving certain instruments from storage

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Front ofceBack ofce connectioncontd

help inventory and order clinical supplies, including surgical instruments borrow a piece of clinical equipment from another department oat to the back ofce and help the physician with an examination or procedure help assemble procedure trays for packaging and sterilization.

slightly rounded points. (See Figure 24-2.) Bandage scissors, also called dressing scissors, have one rounded tip and one blunt tip so they can be inserted beneath a patients bandage without risk of skin injury. Suture scissors, sometimes called stitch scissors, have a notch at the end of the blade that is inserted under the suture before cutting. Iris scissors have small, sharp, straight or curved blades that were originally designed for eye surgery but are now used for various procedures. (See Figure 24-3.)

Cutting Instruments
The two most common types of cutting instruments are scissors and scalpels.

Scissors
Scissors come in many sizes and shapes. Surgical scissor types include those with straight or curved blades that are both sharp (s/s), both blunt (b/b), or one sharp and one blunt (s/b). (See Figure 24-1.) Mayo dissecting scissors may be straight or curved with tips that have a beveled edge and

FIG 24-2 Mayo scissors.

F C

FIG 24-1 Surgical scissors. (A) Straight s/s. (B) Straight s/b. (C) Straight b/b. (D) Curved s/s. (E) Curved s/b. (F) Curved b/b.

FIG 24-3 Bandage scissors (A). Suture scissors (B). Iris scissors (C).

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Scalpels
Scalpels are cutting instruments commonly used to create surgical incisions. A scalpel includes a very sharp blade attached to a handle. They are available as single-use disposable or as handles to which blades may be attached. Both scalpels and handles come in a variety of sizes and shapes. (See Figure 24-4.)

Grasping-Clamping Instruments
The large category of grasping-clamping instruments includes a wide variety of forceps, hemostats, needle holders, and clamps. Forceps are used to grasp tissue during procedures. (See Figure 24-5.) Hemostats and hemostatic forceps are used in surgical procedures to clamp blood vessels in order to stop bleeding. Needle holders are similar to hemostats with a slight variation in design that allows them to securely hold a needle without crushing it. (See Figure 24-6.) Towel clamps are used to fasten sterile towels and drapes in place to secure the sterile eld. B

Probing and Dilating Instruments

Probing and dilating instruments are designed for procedures in which the physician examines body cavities. Such

B
FIG 24-5 Forceps. (A) Tissue forceps. (B) Splinter forceps. (C) Allis tissue forceps. (D) Alligator forceps.

instruments include specula, scopes, probes, retractors, and dilators.

Specula
Two of the most common types of speculum are vaginal and nasal. The vaginal speculum may be made of disposable, clear plastic or reusable metal and is designed to hold the collapsible walls of the vagina apart so the physician may examine the uterine cervix. A nasal speculum is designed to open the nares (nasal openings) wider to aid the physician in examination of the nasal passages. (See Figure 24-7.)

FIG 24-4 Scalpels. (A) Disposable. (B) Handles.

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FIG 24-6 Grasping-clamping instruments. (A) Hemostats. (B) Needle holders. (C) Towel clamp.

Scopes
Scopes are lighted instruments designed to aid in the visualization of body cavities, such as the ear, esophagus, stomach, rectum, colon, abdomen, or even the inside of joints. They are generally named for the body part they are designed to examine. For example, the otoscope is used to examine the ear, the arthroscope is used to examine the inside of joints, A

and the anoscope is used to examine the inside of the anus and the rectum. (See Figure 24-8.)

Probes, Retractors, and Dilators

As their name implies, probes are used to probe deep into wounds or body cavities. Sounds are instruments similar to probes but may be longer and are used to investigate an area for size and shape as well as for the presence of foreign bodies. Retractors are used to pull wound edges back to allow the physician a better view of and access to the area. They come in a variety of sizes and shapes, depending on their intended use. Dilators are metal rods with smooth rounded tips on either end. They come in a range of sizes. Smaller to larger sizes may be used to slowly enlarge an opening, such as the uterine cervix. (See Figure 24-9.)

FIG 24-7 Specula. (A) Vaginal speculum. (B) Nasal speculum.

FIG 24-8 Anoscope.

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A B

A C
FIG 24-9 Probe, retractor, and dilator. (A) Grooved director probe. (B) Volkmann retractor. (C) Uterine dilator.

Specialty Instruments
A variety of specialty equipment is designed for specialty examinations and procedures. For example, some instruments are designed specically for gynecological examinations and procedures. The speculum is used to open the walls of the vagina so that the vagina and cervix may be examined. Foerster sponge forceps are used to hold gauze pads to sponge the surgical site and absorb blood or other uid. A curette is used to scrape the inner walls of the uterus to remove the endometrial lining and abnormal growths. A uterine sound is used to examine the inside of the uterus for size and shape as well as the presence of foreign bodies. A uterine tenaculum is used to grasp and position the cervix for better examination, tissue removal, or other procedures. (See Figure 24-10.) Other specialty equipment includes items designed for eye and ear examinations and procedures. For example, the laryngeal mirror allows the physician to inspect the larynx and other structures deep in the throat. (See Figure 24-11.)

FIG 24-10 Specialty instruments. (A) Foerster sponge forceps. (B) Curette. (C) Uterine sound. (D) Tenaculum.

The physician will commonly collect a uid specimen by aspiration with a needle and syringe. (See Figure 24-12.)

Biopsy Equipment
A biopsy is a procedure in which a physician collects a tissue specimen from a patient to test for cancer or other abnormalities. The most common method for obtaining such a specimen is excision (cutting) with a scalpel or biopsy punch.

Principles of Surgical Asepsis

Surgical asepsis is the practice of destroying all pathogenic organisms before they enter the body. More specically, surgical asepsis refers to the protection of patients from pathogenic

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microorganisms during invasive procedures. Invasive procedures are those in which the patients normal protective barriers are punctured or disrupted in some manner. Examples of some procedures that require surgical asepsis include injections, urinary catheterization, wound care, and such surgical procedures as tissue biopsy or repair and suturing of lacerations. Surgical asepsis differs from medical asepsis, which refers to methods of performing procedures and providing patient care to prevent transmission of pathogenic organisms from the ill patient to other patients or anyone else. Adherence to medical asepsis involves the use of standard precautions. (For more information about medical asepsis, see Chapter 19, Infection Control and Medical Asepsis, page 287)

Sterile Technique
To adhere to the principles of surgical asepsis, the health care team must understand and follow sterile technique. Sterile technique, also called aseptic technique, is a manner of performing specic tasks and procedures that protects patients from pathogenic organisms to the fullest extent possible. When a medical assistant rst learns sterile technique, she B

FIG 24-11 Laryngeal mirror.

FIG 24-12 Biopsy equipment. (A) Biopsy punch for obtaining a tissue specimen. (B) Syringe and large gauge needle for aspirating a uid specimen.

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may nd the many rules confusing and difcult to remember. The most important rule to remember is that sterile may only touch sterile and nonsterile may only touch nonsterile. Thus, the medical assistant must know which surfaces are sterile and nonsterile and be sure to protect the sterile eld from pathogenic microorganisms. (See Figure 24-13.) Whenever sterile

and nonsterile items touch one another, contamination occurs, and the team must take corrective steps before the procedure can continue. (See General rules of sterile technique.)

Surgical Scrub
Prior to assisting with certain surgical procedures, the medical assistant may need to perform a surgical scrub. This procedure is a type of hand washing that is much more thorough than regular hand washing and follows specic steps. Although the human skin can never be fully sterilized, the surgical scrub is designed to reduce the number of pathogenic microorganisms on the hands and forearms to the greatest extent possible. Ideally, this scrub should take place at a large, deep surgical sink that allows the medical assistant to lean forward and hold both arms upright within the scrub area. Such sinks have automatic controls or ones that can be powered by the feet or knees. This allows the medical assistant to complete the scrub without touching any part of the sink. However, most medical assistants work in ofces that have standard sinks, rather than deep surgical sinks. In such a case, the medical assistant must use the best technique possible under the circumstances. (See Procedure 24-1: Performing a surgical scrub.)

Sterile Nonsterile

Sterile Field
Any member of the health care team involved in a sterile procedure must ensure that the supplies or instruments used in an invasive manner during the sterile procedure remain sterile. The rst step in ensuring that such instruments are sterile is to understand how to properly sterilize and package such items in advance. (For more information on proper sterilization and packaging procedures, see Chapter 19, Infection Control and Medical Asepsis.) In addition, when medical assistants or other health care providers open and handle such items, they must adhere to the rules of sterile technique so that the items do not come into contact with any nonsterile items. After hand washing, the next step in preparing for any sterile procedure is always the arrangement of the sterile eld with all necessary supplies and equipment. Medical assistants are commonly required to set up sterile eldsfor their use or the use of other health care providers. A sterile eld is created to form a sterile work area when a sterile procedure must be performed. There are many variations of the sterile eld but they all have certain principles in common. In the medical ofce, a medical assistant will commonly use a portable device, such as a mayo stand or other mobile stand, for the work surface. The medical assistant must lay down some form of a sterile barrier to create a sterile work surface. In the operating room, a much larger sterile eld is created with the use of numerous drapes or towels. When the medical assistant establishes the sterile eld, she must

FIG 24-13 The sterile eld and nonsterile areas.

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General rules of sterile technique

This table lists some of the most common rules of sterile technique along with their rationales.

Principle
The health care provider should never turn his back on the sterile eld. Hair should be tied back and not allowed to fall forward. Members of a sterile team should always face each other when working, but if they must pass one another in close quarters then they should do so back-to-back or front-to-front. The outer 1'' border of sterile drapes and any sterile wrap must be considered contaminated. Any item below waist level must be considered contaminated. Sterile surfaces that become wet must be considered contaminated unless they include a waterproof layer. The longer a sterile surface is exposed to the air, the more contamination occurs. Reaching over the eld should be avoided whenever possible. Contaminated items should not be passed over the sterile eld. Coughing, sneezing, and even talking over the sterile eld should be avoided. When pouring sterile solutions into other sterile containers, the bottle should be held high enough to avoid touching any other surface, yet low enough to avoid splashing onto the sterile eld.

Rationale
Contamination to the eld might occur without the health care providers knowledge. Hair contains microorganisms that will fall onto the eld if hair hangs over it. Facing one another keeps the sterile eld in everyones view. Passing back-to-back or front-to-front prevents touching of sterile to nonsterile body surfaces. The edge of the drapes are in contact with nonsterile surfaces and are, therefore, contaminated. A 1'' border creates a safety margin. Areas below waist level are commonly out of view and may, therefore, become contaminated without the health care providers knowledge. Microorganisms from the surface below can move up through a wet layer of paper or cloth and contaminate the eld. Microorganisms in the air will begin to settle onto the sterile eld. Microorganisms from the arm or clothing may fall onto the sterile eld. Contaminated debris and microorganisms may fall onto the sterile eld. Airborne microorganisms from the individuals mouth may fall onto the sterile eld. The outer rim of the bottle is contaminated and will contaminate any surface it touches. Areas of the eld that get wet will draw microorganisms into it unless it has a waterproof layer.

PROCEDURE 24-1

Performing a surgical scrub

Task Perform a surgical scrub. Conditions Deep sink or a surgical sink with foot, knee, or arm controls (if available) Surgical soap Nail le or ngernail stick Surgical scrub brush Clean or sterile towels Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform a surgical scrub. Performance Standards 1. Remove all jewelry on hands and arms because jewelry harbors pathogens. 2. Roll long sleeves up above elbows to prevent clothing from getting wet and expose hands and arms for scrubbing. 3. Examine hands and ngernails for breaks or rough areas, because jagged nails can puncture surgical gloves and breaks in the skin put you at risk for exposure to pathogens. 4. Turn on the water to a warm temperature, because warm water more effectively kills pathogens than cold water. Avoid touching your body to the sinks edge to prevent water and microorganisms on the sinks edge from touching your clothes.
Continued

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PROCEDURE 24-1contd

5. Wet your hands under the water while holding them upright above waist level so that pathogens will rinse off in a one-way direction.

Clean under all ngernails with a ngernail stick.

Wet your hands while holding them upright.

6. Clean under all ngernails with a nail le, ngernail stick, or the nail attachment of the scrub brush, if provided.

7. Discard the le or stick without lowering your hands to prevent reintroducing pathogenic microorganisms to your ngernails. 8. Rinse nails by continuing to hold hands upright, allowing water to run over your hands from nails downward and off of your elbows. 9. Apply surgical soap or use a disposable brush impregnated with surgical soap and scrub the palms of your hands in a circular motion. 10. While continuing to hold your hands and ngers upward, follow a set pattern as you scrub the thumbs and each nger, taking care to scrub the base, along each side, and across the nails to ensure thoroughness. 11. Scrub the back of each hand in a circular motion. Total scrub time for each hand should be a minimum of 5 minutes to ensure thoroughness.

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PROCEDURE 24-1contd

Scrub the back of each hand in a circular motion.

Allow the water to run downward and off of your elbows.

12. Scrub the wrists and the forearms from the distal to the proximal side, which scrubs pathogens from the more clean to the less clean area. 13. Rinse each arm separately by continuing to hold hands upright, allowing the water to run downward and off of your elbows.

14. Discard the scrub brush. 15. Turn off the water using a clean paper towel (or the foot or knee lever on a surgical sink) to maintain cleanliness of the hands. 16. Continue to hold your hands upright and dry one hand and arm with a towel, moving from the distal to the proximal side. If sterile gowning and closed gloving are required, be sure to use a sterile towel for drying to prevent reintroduction of pathogens to the hands and arms. 17. Using the other end of the towel, repeat the drying process on the other hand and arm because the unused end of the towel is cleaner. 18. Avoid touching anything by keeping your hands above your waist to prevent introducing pathogens before gloving.

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open all needed supplies and add them to the eld, arranged in an organized manner that facilitates effective performance of the procedure. Next, she must create a sterile barrier using sterile disposable drapes, sterile towels, or even the sterile wrap that encloses some types of supplies. When she creates the barrier, she must open other needed sterile items and drop them onto the eld using a technique called the sterile toss. To perform this technique, the medical assistant must open the sterile wrapped item or packet away from the eld without touching the contents. Then she must hold the wrapper just near enough to the eld to carefully toss the items onto it. In this way, sterile items are placed on the sterile eld

without contaminating either one and without the need to wear sterile gloves. After all needed items are on the eld, the medical assistant or other health care provider may put on sterile gloves and organize items on the eld as desired in preparation for the procedure. Commonly, the medical assistant will use the wrap that encloses an item as the underlying sterile barrier. When opening this or any other sterile wrapped item, the medical assistant should always open the wrap away from the body rst, then to each side, and, lastly, toward the body.(See Procedure 24-2: Setting up a sterile eld.) Following these rules of sterile technique prevents unnecessary reaching over the sterile eld. (See Patients and the sterile eld, page 394.)

PROCEDURE 24-2

Setting up a sterile eld

Task Setting up a sterile eld. Conditions Mayo stand or other small table on wheels Sterile drape Waste receptacle Other supplies, as needed for the procedure, such as (used in this example): Sterile solution, such as saline or povidone-iodine (Betadine) Sterile transfer forceps Small sterile cup or basin Two sterile, wrapped 4 4 sponges Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully set up a sterile eld, add items to the eld by sterile toss, use sterile transfer forceps to add an item to the eld, and pour a sterile solution. Performance Standards 1. Select a clean, dry surface above waist level, such as a mayo stand. Items below the waist are considered nonsterile. 2. Assemble the necessary supplies and check the expiration dates on the packages. After the expiration date, a package is considered nonsterile. Also check the label on each one to ensure the package contains the needed items. 3. Place the waste receptacle within easy reach of the work area. 4. Wash or sanitize your hands to ensure infection control. 5. Lay a sterile wrapped drape on the surface in front of you with the top ap pointing toward you; position facilitates correct opening of the package. 6. Grasp and remove the sterilization seal or tape. 7. Grasp the top ap of the wrap by the outer surface near the tip. Then lift and open it away from you.

Open the top ap of the wrap away from you.

8. Grasp the side ap by the outer surface near the tip. Then lift and open it to the side. 9. Grasp the other side ap by the outer surface near the tip. Lift and open it to the side, taking care not to touch any of the sterile contents with your ngers. Following the sequence (top, side, side) avoids the need to extend the arm over the sterile eld.

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Lift the side ap, taking care not to touch the sterile contents.

10. Carefully pick up top edge of remaining corner of the folded drape. The outer 1'' is considered nonsterile, so you may touch it as necessary.

Open the package outward, taking care not to touch the contents.

14. When you have opened the package approximately three-quarters of the way, move over the sterile eld and gently toss or drop the item onto the eld, taking care not to touch any nonsterile item to the eld.

Carefully pick up the top edge of the remaining corner of the folded drape.

11. Lift the drape and let it unfold itself by gravity, rather than shaking it, and make sure that it does not touch anything to avoid contamination. 12. Holding the drape by the outer top corners, lay it over the work surface. 13. If using sterile 4'' 4'' gauze pads, take a wrapped pad and grasp each ap of the wrapper between your thumbs and ngers and open the package outward, taking care not to touch the inner contents with nonsterile ngers to prevent contamination.

Gently toss or drop the item onto the sterile eld. Continued

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15. Dispose of the outer wrap in the waste receptacle. 16. Repeat steps 12 to 14 to add any other needed items to the eld. 17. Open the package containing the sterile basin but leave the basin on its sterile wrapper. Using sterile transfer forceps 18. Open the package containing the sterile transfer forceps and grasp them by the handles only to maintain sterility of the tips. 19. Using sterile forceps, grasp the sterile basin and place it in the sterile eld where desired. Pouring a sterile solution onto the sterile eld 20. Grasp the sterile container, remove the seal, and then remove the cap. Hold the cap with the open side downward in your nondominant hand or place it nearby (but not on the sterile eld) with the open side up to minimize the risk of contamination to the cap. 21. Carefully pour in the required amount of solution, holding the bottle between 1'' and 4'' above the basin to minimize the risk of contamination from touching the bottle to the basin, while also minimizing the risk of splashing.

Hold the bottle 1'' to 4'' above the basin.

22. Recap the sterile bottle and set it aside but not on the sterile eld.

Patient Education

Sterile Gloving
Application of sterile gloves is one of the most common sterile procedures that medical assistants perform. Therefore, it is extremely important for the medical assistant to learn how to apply sterile gloves properly and maintain good technique. Regardless of what happens during a procedure, if the medical assistant begins a procedure with contaminated gloves, she contaminates everything she touches and puts the patient in jeopardy. (See Procedure 24-3: Applying sterile gloves.)

Patients and the Sterile Field

Well-meaning patients may unwittingly contaminate a sterile eld by touching items out of curiosity or a desire to be helpful. Therefore, the medical assistant should tactfully request that the patient keep his hands away from the sterile drapes and instruments. The medical assistant can explain to the patient that all items have been carefully sterilized with the goal of sparing the patient the unpleasant complications an infection might cause. If the patient is unpredictable (such as a small child), the medical assistant must be aware of the childs movements in order to intervene if necessary. A parent or guardian might also be enlisted to hold the childs hands during the procedure.

Minor Surgical Procedures

Many minor surgical procedures are done in the medical ofce. Common procedures include suturing, suture removal, incision and drainage (I&D) of infections, and removal of

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PROCEDURE 24-3

Applying sterile gloves

Task Apply sterile gloves. Conditions Package of sterile gloves in the appropriate size Clean, dry surface such as the top of a mayo stand Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully apply sterile gloves. Performance Standards 1. Wash your hands with warm water and soap. Dry thoroughly to ensure infection control. 2. Open the outer wrapper, remove the inner pack, and lay the inner pack on the table in front of you, slightly above waist level. Items below waist level are considered contaminated. 3. Grasp paper fold in each hand and open outward without disturbing the gloves inside.
Grasp the cuff of the glove by touching only the inside surface.

6. Insert your dominant hand into the glove while carefully pulling it on with your nondominant hand.

Insert your dominant hand.

Open the paper outward without disturbing the gloves.

7. With your sterile-gloved, dominant hand, slip your ngers under the cuff of the other glove, touching only the sterile side, because only sterile may touch sterile, and lift it off the table.

4. Identify the right and left glove. 5. With the rst two ngers and thumb of your nondominant hand, grasp the cuff of the dominant hand glove by touching only the inside surface to keep the outside of glove sterile.

Slip your ngers under the cuff, touching only the sterile side. Continued

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8. Insert your nondominant hand into the glove and carefully pull it on by pulling upward and outward under its cuff with the ngers of the other hand. Be very careful not to touch your sterile-gloved ngers or thumb to any nonsterile surface to prevent contamination. Keep your gloved thumb abducted so it does not touch the other arm.

Pull the cuff upward until it encircles your sleeve cuff.

10. After you have applied the second glove, interlock your hands and adjust the ngers of the gloves if necessary to ensure a smooth t. Removing gloves 11. Grasp the outer cuff of one glove with the other hand. Do not touch your wrist with the ngers of the contaminated glove to avoid spreading pathogens to your bare skin.

Pull upward and outward under the cuff and keep your thumb abducted.

9. If you are wearing long sleeves, continue pulling the cuff upward in the manner described above until the cuff encircles your sleeve cuff to prevent sleeves from falling too low over the glove and contaminating the wrist area.

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Grasp the outer cuff of one glove without touching your wrist.

Place your ngers under the cuff next to the skin and pull the glove off.

12. Pull the glove off, turning it inside out, and wad it up in the other gloved hand. 13. Place the ngers of your ungloved hand under the cuff of the gloved hand (next to the skin) and pull the glove off, turning it inside out while enclosing the other glove in the process.

14. Discard in waste receptacle.

ingrown toenails or sebaceous cysts. (See Figure 24-14.) There are some procedures the medical assistant may perform herself if the physician has given the order to do so, including suture or staple removal and application of dressings. There are many types of surgical procedures that medical assistants may be asked to assist with. Those that involve the use of extreme cold are sometimes called cryosurgery. Those performed with the use of specialized microscopes are called microsurgery. Those that involve cutting or destroying tissue by the application of electricity are called electrosurgery.

circulating through it. This procedure is commonly used in ambulatory settings for a wide range of needs, including treating cancer and precancerous conditions. Cryosurgery may be used internally on liver, prostate, bone, or cervical cancer or externally to remove skin lesions. This treatment has fewer adverse effects than many other forms of treatment and usually has a shorter recovery time.

Microsurgery
Microsurgery is a general term that refers to any procedure completed with the use of a special operating microscope. It is useful for delicate procedures on the eyes, nose, sinuses, larynx, genitourinary tract, and any structures with tiny blood vessels and nerves. It is especially useful in the reattachment of severed body parts and organ and tissue transplantation.

Cryosurgery
Cryosurgery, also called cryotherapy, is a technique that destroys tissue by subjecting it to very cold temperatures, usually 20C (4F), using a probe that has liquid nitrogen

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A
Epidermis

Sebum Dermis

emission of radiation. The lasers beams are so precise that they enable the surgeon to target structures with little injury to surrounding tissues, resulting in minimal scar formation. Lasers were initially most common in the treatment of eye disorders but have become a popular tool for various procedures. Lasers are particularly useful for cosmetic surgery, including the removal of vessels, moles, warts, and other lesions. Improper operation or handling of laser equipment could result in injury. Therefore, medical assistants should undergo special training before assisting with laser surgery or handling laser equipment.

Electrosurgery
Electrosurgery, also called electrocautery, involves the use of an electrosurgical unit (ESU) or high-frequency electric current to cut, remove, or destroy tissue. It is a popular method of removing skin tags (small noncancerous growths), tumors, and warts in dermatology and is commonly preferred over laser surgery or cryosurgery. The ESU has a small, electried probe that burns or vaporizes tissue with minimal bleeding. The device also includes disposable tips for the probe, a grounding cable, and a pad.

Endoscopy
Endoscopy is becoming a popular method of performing internal examinations and procedures. It involves the use of a specialized scope containing a tiny camera and light source to visually examine a structure, such as the upper gastrointestinal (GI) system (esophagus, stomach, duodenum), lower GI system (rectum, colon), respiratory system (trachea, larynx, bronchi), urinary system (urethra, bladder, ureters), inside of the abdomen, and inside of various joints. During such procedures, physicians carefully examine structures, obtain tissue for study, and perform surgical interventions. Just a few examples of common endoscopic procedures include tubal ligation (female sterilization), cholecystectomy (gallbladder removal), and colonoscopy. Scopes may be rigid, semirigid, or exible. The scopes and associated equipment are expensive and delicate and, thus, require special handling and care. Therefore, medical assistants should be properly trained before handling them or assisting with endoscopic procedures.

FIG 24-14 Sebaceous cyst (A) and ingrown toenail (B).

Plastic surgeons use microsurgery to perform repair and reconstructive surgeries. The microscope allows the surgeon to operate on structures that would otherwise be difcult to see by magnifying them up to 40 times their normal size. There are many types of microscopes that can be mounted on the oor or ceiling. All have a set of lenses with zoom functions, a high-intensity light source, and a video camera that displays images on a screen. The physician can operate the microscope using foot or mouth controls. The physician must also use special microsurgical instruments that allow manipulation of delicate structures. Some of these instruments include specialized forceps, scissors, needle holders, clamps, irrigators, and vessel dilators. Specialized suture material is also used with suture thread as small as 12-0 (0.001 mm). Suture needles for microsurgery also come in many sizes and with different points. Sizes are generally less than 0.15 mm in diameter.

The Medical Assistants Role in Minor Surgery

The medical assistant performs many duties when assisting with minor surgery. She must always examine the room to be sure it has been properly cleaned and prepared. She must familiarize herself with the physicians she works with and note their preferences for room arrangement and supplies. She must be familiar with the procedures to be performed in order to do these tasks. (See Procedure recipe cards.) She must set up the sterile eld for the physician so that, once

Laser Surgery
Laser surgery is the treatment of tissue by means of a laser. The term laser is an acronym for light amplied by stimulated

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begun, the procedure can be completed smoothly and efciently. The medical assistant should make sure that she does not leave opened sterile materials exposed to the air or unattended because contamination may occur. Therefore, she should set up the sterile eld just prior to the procedure. However, in some ofces it is acceptable to set up trays up to 1 hour ahead of time and cover them with a sterile drape until the procedure begins. When the procedure begins, the medical assistant plays two key roles: 1. Assist the physician by: a. handing him needed supplies or instruments (See Safe instrument exchange.) b. observing the eld and the procedure for any breaks in sterility and notifying the physician if it occurs. 2. Attend to the patient by: a. providing instruction about positioning b. explaining what is happening c. offering reassurance. (See Procedure 24-4: Assisting with minor surgery, page 400 to 402.)

prepared. To do so, the medical assistant must make sure the patient understands the procedure, the physician has satisfactorily answered all of the patients questions, all preoperative laboratory work has been completed, and the patient has signed an informed consent form. It is the physicians legal responsibility to inform the patient about the procedure and obtain the patients signature. If this step has not been completed, the medical assistant must alert the physician. After completion of the surgical procedure the patient may need time to rest, especially if a sedating medication is administered. The medical assistant should make sure the patient is positioned comfortably and safely while resting. She should also ensure that there is a person with the patient to supervise him carefully when he gets up, dresses, and travels home to prevent injury. (See Preoperative and postoperative education, page 402.)

Front ofceBack ofce connection

Patient Preparation and Postoperative Care

Prior to any surgical procedure, the medical assistant must make sure that the patient has been properly informed and

Procedure Recipe Cards

Most medical assistants who have moved or temporarily oated to a new department have stories of frustration about trying to locate items and understand physician preferences. Such situations are especially frustrating when a medical assistant is attempting to set up and assist with a procedure. Clinical medical assistants can make the back ofce oat-friendly for others by creating (and keeping up-to-date) a recipe book of all of the procedures commonly done in the ofce. Using a threering binder makes it easy to remove, replace, and update information. Be sure all information in the book is consistent with ofce policy. A list of physicians glove sizes should be located in the front of the book. Each procedure listed in the book should include step-by-step instructions for procedures commonly performed by medical assistants, along with the following information: location within the ofce of commonly needed items physician preferences regarding instruments or procedure kits physician preferences for room arrangement and patient positioning physician preferences for whether the medical assistant is to remain in the room to assist or wants to complete the procedure on her own

Safe instrument exchange

To hand the physician sharp instruments, such as scissors, hold them by their tips and extend the handles toward the physician so that he can securely grasp them in his palm or ngers. Doing so protects the physician from injury and enables him to grasp them securely, reducing the risk of dropping them.

Hold on to the tip of the instrument and extend the handle toward the physician.

typical postprocedure patient education length of time usually required for the procedure.

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PROCEDURE 24-4

Assisting with minor surgery

Task Prepare patient for and assist physician with minor surgery, including application of sterile gloves, setup of the sterile eld, and surgical skin preparation. Conditions Mayo stand Needles and syringes for anesthesia Betadine solution and preparation bowls or cups (at least 2) Sterile saline solution Sterile gauze sponges Scalpel and blade Operating scissors Fenestrated drape Hemostats, curved and blunt Thumb dressing forceps Thumb tissue forceps Needle holder Suture pack Transfer forceps Side table Package of sterile gloves Labeled biopsy containers (with formalin) Laboratory requisition Anesthesia vial Alcohol wipes Dressing materials, including tape, bandages, and 4 4 gauze pads Biohazard container Betadine solution Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist with a minor surgical procedure. Performance Standards 1. Select a clean, dry surface above waist level, such as a mayo stand, because items below the waist are considered nonsterile. 2. Check the room for cleanliness to ensure infection control. 3. Assemble the supplies for the procedure, inspecting each item for expiration date or contamination to ensure infection control. 4. Wash your hands to ensure infection control. 5. Set up a side table with nonsterile items to avoid contaminating sterile items with nonsterile items. 6. Set up a sterile eld on a clean, dry surface. 7. Add sterile items to the sterile eld as needed. 8. Apply sterile gloves. 9. Arrange the sterile instruments according to order of use to avoid needing to pass dirty instruments over sterile ones during the procedure. 10. Cover the sterile eld with a sterile towel if not used immediately to prevent dust and other airborne microorganisms from settling on the sterile eld. 11. Identify the patient and explain the procedure to ease patient anxiety, prevent misidentification of the patient, and facilitate patient compliance. Surgical skin preparation 12. Prepare the patients skin according to ofce procedure or following these steps: a. Apply clean examination gloves. b. Remove hair from the operative site by carefully shaving, holding the skin taut and shaving in the direction of hair growth to reduce the risk of cutting the skin or by clipping hair short, because shaving can cause small abrasions, increasing risk of infection.

Remove hair from the operative site by shaving or clipping it short.

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PROCEDURE 24-4contd

c. Rinse the area with sterile saline solution and pat it dry.

f. Clean the area with antiseptic povidone-iodine (Betadine) or alcohol swabs.

Clean the area with antiseptic povidone-iodine swabs. Rinse the area with sterile saline solution.

d. Cleanse the area with an antiseptic solution and a surgical scrub brush by scrubbing gently in a circular motion moving from inward to outward. Do not retrace over the previously scrubbed area. e. Rinse the area with sterile saline saturated gauze pads and blot it dry.

Rinse the area and blot it dry.

g. Allow the area to air dry. h. Remove your gloves. i. Sanitize your hands. 13. Remove the sterile towel from the sterile eld as the physician applies sterile gloves. 14. Assist the physician with the procedure, according to her requests. Communication throughout the procedure is critical to a good outcome. 15. Throughout the procedure: a. Ensure that the physician has the necessary equipment and supplies. b. Ensure that the lighting is adequate for the physician to view the surgical eld. c. Comfort the patient (if awake) during the procedure. d. Hand instruments to the physician as requested. e. Hold the biopsy container for the physician to place the tissue specimen into, if necessary. f. Ensure the biopsy containers or other specimens are properly labeled, tightly covered, and sent to the laboratory with an appropriately completed laboratory requisition form.
Continued

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16. When the physician completes the procedure, assist her as needed with the application of a dressing. 17. Dispose of contaminated supplies and sharps in an appropriate biohazard sharps container to ensure infection control. 18. Rinse used surgical instruments and soak, sanitize, and sterilize them for reuse. 19. Remove and appropriately dispose of your gloves, gown, and other PPE and wash your hands to ensure infection control.

21. 22. 20. 21.

Apply clean gloves and other PPE as needed. Disinfect the treatment area per ofce protocol. Wash your hands to ensure infection control. Be sure to provide the patients medical record to the physician for timely documentation of the procedure.

Patient Education

Preoperative and Postoperative Education

Before a patient undergoes a surgical procedure, the medical assistant must ensure that the patient understands what will happen before and after the procedure. Although patient education for specic procedures will vary, below are general guidelines for preoperative and postoperative patient education. Make sure the patient has made a follow-up appointment if appropriate. Discuss wound care or dressing changes with the patient as appropriate. (The most reliable way to verify patient understanding is to have him perform wound care or a dressing change while you observe.) Be sure to include these points: Mild inflammation is normal and is indicated by slight redness, slight edema, mild warmth, and some tenderness. Observe for signs of infection and call the physician if any appear (increased redness, increased pain, increased heat, and foul drainage as well as fever and decreased function). Keep the wound clean and dry. Wash hands with warm water and soap prior to changing dressings. Perform dressing changes daily or as instructed by the physician. Do not apply creams, ointments, or solutions to the wound except as instructed by the physician. Return for suture or staple removal as directed by the physician. Complete antibiotics or other prescribed medication as directed by the physician. Discuss other signs or symptoms for which the patient should contact the physician. Ask the patient if he has any questions or concerns and answer them or refer them to the physician.

Preoperative
Check to be sure that the patient or legal representative has signed the necessary consent forms. Give the patient instructions for home preparation that must be completed before the procedure, such as bathing, diet, and medications. Call the patient the day before surgery to conrm and remind the patient of such special instructions. Remind the patient to leave valuables at home. Make sure the patient has someone who can drive him home after the procedure.

Postoperative
Make sure the patient has recovered sufciently to be able to travel safely. Obtain postprocedure vital signs according to ofce policy (which may or may not be required for various procedures). Inform the patient about residual effects of local or systemic medications used during the procedure. Educate the patient about postoperative medications he must take.

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Wound Care
When closing a wound, the physicians goals are to promote timely healing and reduce scar formation. These goals are accomplished through the use of aseptic technique and careful approximation of the wound edges (bringing them together closely and evenly). The physician most commonly does this by using sutures or staples.

Sutures
The word suture may be used as a noun or a verb. When used as a noun, it refers to a specic type of material used to sew wound edges together. When used as a verb, it refers to the action of sewing the wound edges together. Although suture material and needles may be packaged separately, they are most commonly packaged together with the suture already swaged (fused) to the needle. Needles are usually curved and are categorized by curve radius, size, shape, and type of point (round taper, blunt, or cutting). (See Figure 24-15.) Swaged needle-suture sets come packaged in a variety of sizes and shapes as well as a variety of suture gauges (sizes) and lengths. Suture sizes range from the smallest gauge (6-0) to the largest gauge (4). Packages are labeled for easy identication. However, the numbers reecting size may be listed as 2-0 or 00, 3-0 or 000, and so on. The physicians selection of a suture type and size depends on the tissue type being sutured. For example, smaller suture material is appropriate for delicate tissue where appearance is important, such as on the face. Manmade synthetic absorbable suture, such as Vicryl or PDS II, is used for internal sutures where later removal is not possible or practical. The older variety of surgical gut suture made from a sheeps intestinal tissue is seldom used. Nonabsorbable sutures made of Dacron, cotton, nylon, silk, or even stainless steel are used for external suturing where they can be easily removed. When the patients wound has healed, suture removal is usually easily accomplished with suture scissors and forceps. The physician will commonly delegate this task to the medical assistant. (See Procedure 24-5: Performing suture removal, page 404.)

FIG 24-15 Suturing equipment. (A) Suture packs. (B) Swaged needle.

Wound Care Supplies

Every medical facility stocks the most commonly used supplies and equipment used for surgery and wound care for its patient population. Many of these items are disposable and intended for one-time use only. The medical assistant may be required to sanitize and sterilize other items for reuse.

Dressings
Dressings are materials placed in or on a wound and are usually made of gauze. They must be sterile and completely cover the wound. In some cases, a specic type of dressing material, called a surgical wick or a wound packing strip, such as Iodoform, is used to promote drainage of uid from an infected wound. Such material may be packaged individually or in a long, narrow strip of sterile material packaged in a bottle. When using this type of material, the medical assistant must take special care to maintain the sterility of the wick that remains in the bottle. Other common types of dressings include gauze pads or sponges of various sizes. The most common sizes of gauze pads are 4" 4" (4" square) and 2" 2" (2" square), although other sizes are available. (See Figure 24-17.) They may be packaged individually in peel-apart sterile packages

Staples
In recent years, staples have become a popular choice for wound closure because they are effective, safe, and enable quick, easy wound closure. (See Figure 24-16.) This may be especially true when the patient is particularly anxious, fearful of needles, and has difculty holding still. However staples are not appropriate in every case and may only be used for external wound closure. Once the wound has healed the staples are easy to remove with a sterile prepackaged staple remover. The medical assistant places the tips of the staple remover under the staple and squeezes the handle, which lifts the staples out.

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PROCEDURE 24-5

Performing suture removal

Task Perform removal of skin sutures. Conditions Gauze sponges Bandage scissors Biohazard waste container Tape Sponge forceps Suture scissors or staple remover Thumb forceps 4'' 4'' gauze pads Sterile gloves Betadine solution or wash Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully remove sutures from a wound. Performance Standards 1. Wash or sanitize your hands to ensure infection control. 2. Identify the patient and explain the procedure to ease patient anxiety. 3. Open the suture removal kit.
Suture scissors Sutured incision

Thumb forceps

Suture removal kit

4. Apply sterile gloves. 5. Using thumb forceps, gently pick up one knot of a suture. 6. Gently pull upward toward the suture line to avoid cutting the patients skin with the scissors. 7. Insert the curved notch of the suture removal scissors beneath the suture and cut one side of the suture as close to the skin as possible.

8. Pull the suture through the skin, being careful to avoid contaminating the wound with the suture tip to prevent infection. 9. Remove all sutures in the same manner. 10. Place each suture on a sterile gauze sponge to avoid contaminating the thumb forceps and enable an accurate count of sutures. 11. Examine the wound to be sure that you have removed all of the sutures. Leaving a suture in the wound may lead to infection. 12. Apply povidone-iodine solution to the area unless the patient is allergic to iodine to inhibit bacterial growth. 13. Apply a sterile dressing if directed to reduce the risk of infection. 14. Remove your gloves and dispose of them in a biohazardous waste container to ensure infection control. 15. Dispose of all used items per OSHA regulations. 16. Wash your hands to ensure infection control.

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PROCEDURE 24-5contd

17. Explain wound care to the patient, providing written and verbal instructions to promote patient understanding and timely wound healing. 18. Document the procedure to ensure a complete, accurate medical record.

Date 09/01/08; 1:30 p.m. forearm incision ---------------11 sutures removed from ---------------------------------------------------------S. Gonzales, CMA

of two or may be packaged in bulk (one hundred). Some sponges have other material such as cotton or rayon embedded to provide for greater absorption. These are useful when excessive bleeding or uid drainage is an issue. The physician will commonly delegate the application or changing of a dressing to the medical assistant. Occasionally, the physician will give specic instructions but usually lets the medical assistant use her judgment in selecting the most appropriate dressing material. In making her decision, she should consider the wound location, size, amount of drainage, and the patients physical activity level. The dressing must be snug enough to be secure but should be as comfortable as possible and not impede circulation. (See Procedure 24-6: Removing a dressing and applying a new sterile dressing, page 406.)

FIG 24-17 Sterile gauze pads.

Bandages
Bandages are nonsterile material applied over the top of dressings to secure them. They may be made of gauze in the form of an elastic wrap or a roll that can be wrapped around a dressing. (See Figure 24-18.) Tubular gauze is a popular form of bandage material for distal extremities such as ngers, toes, arms, and legs. Its unique shape makes it easy

FIG 24-16 Skin stapler (A). Staple remover (B).

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PROCEDURE 24-6

Removing a dressing and applying a new sterile dressing

Task Demonstrate the removal and application of a sterile dressing. Conditions Sterile gloves Sterile gauze dressings as needed Examination gloves Tape Waste receptacle Sterile saline solution Tape, roller gauze, or elastic net as desired Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully remove an old dressing and apply a new, dry, sterile dressing. Performance Standards 1. Wash or sanitize your hands to ensure infection control. 2. Introduce yourself to the patient and explain the procedure to ease patient anxiety. 3. Note the location, size, and depth of the wound as well as the current dressing material used to determine the amount and type of dressing material needed. 4. Review the physicians order for wound care and dressing change to dress the wound according to the physicians instruction. 5. Gather the needed supplies. 6. Evaluate the patients current degree of discomfort and whether pain medication is needed to ease the patients discomfort during the dressing change. 7. Take measures to ensure privacy for the patient. 8. Position the patient on the examination table in a manner that maximizes patient comfort and provides optimal access to the wound. 9. Wash or sanitize your hands to ensure infection control. 10. Set up a sterile eld and needed supplies. Removing the old dressing 11. Apply clean examination gloves and remove the old dressing by following these steps: a. Stabilize the old dressing with one hand while carefully pulling the tape off toward the wound to minimize patient discomfort. b. Gently remove the dressing in layers. c. Before disposing of the dressing, note the amount and character of drainage on the dressing material because such information is important in determining the status of the wound and the amount of new dressing material to apply. d. Remove your contaminated gloves and dispose of them in the biohazard waste container to ensure infection control. 12. Wash or sanitize your hands to ensure infection control. Applying the new dressing 13. Apply sterile gloves. 14. Note the wounds appearance, including size, depth, and any signs of infection. 15. Clean the wound, as ordered. Use sterile salinemoistened gauze to clean from the most to least contaminated area (from wound outward) and from wound margins outward. Alternatively, irrigate the wound with sterile saline, ushing in one direction. 16. Pat the area dry with dry sterile gauze. 17. Apply a sterile dry dressing material as needed over the wound. 18. Secure the dressing in place with tape or another bandage material, such as roller gauze or elastic net. 19. Document the procedure and any patient education about wound care or signs of infection to ensure a complete, accurate medical record.

Date 06/27/08; 10:56 a.m. (R) forearm dressing changed. Old dressing with moderate amount of serous drainage. No Sx infection noted. Two sterile 4x4s applied and secured with elastic net. Pt. tolerated procedure well, c/o slight pain --------------------------------------------------------------------------------S. Gonzales, CMA

CHAP TER 24

Surgical Asepsis and Assisting with Minor Surgery

407

will use hydrogen peroxide mixed with equal parts of sterile saline solution. (See Figure 24-19.) The physician may occasionally order the use of antibacterial creams or ointments. Creams are easier to remove than ointments if the wound is to be cleaned between dressing changes. Silvadene, an antibacterial cream available by prescription, is often used for burns. It must be applied with a sterile tongue depressor so that the cream in the jar (or tube) maintains its sterility.

Anesthetics
The term anesthesia means absence of sensation. Prior to cleaning or suturing a wound, an anesthetic may be applied to numb the area and reduce patient discomfort. Anesthetics most commonly used in ambulatory care come in topical and injectable forms. Topical anesthetics such as ethyl chloride may be sprayed on or applied with a sponge, cotton ball, or cotton-tipped swab as with EMLA cream. Injectable anesthetics, such as lidocaine (Xylocaine) and procaine (Novocain), are useful for numbing an area before making an incision or suturing. Some products are available with epinephrine, which causes vasoconstriction and is used to reduce bleeding. However, products containing epinephrine should not be used on such body parts as the ngers, toes, nose, earlobes, and other areas with limited circulation. (See Figure 24-20.) Depending on the procedure and the physicians preference, the medical assistant may be asked to draw up the anesthetic and place it near, but not on, the sterile eld. The physician will then administer it before applying sterile gloves. In other cases, the medical assistant may need to place the syringe onto the sterile eld using sterile technique and then hold the anesthetic vial for the sterile gloved physician as he draws anesthetic from it. In either case, the vial must be kept on hand so the physician can verify that the correct type of anesthetic is being used.

FIG 24-18 Roll bandage applied over a dressing.

to apply. Furthermore, it creates bandages that conform securely and comfortably to these body parts.

Creams, Ointments, and Solutions

In some cases, the physician may instruct the medical assistant to clean or treat a wound with a specic type of cream, ointment, or solution. By far the most popular choice of solution for cleaning the inside of a wound is sterile saline. It is safe, gentle on tissues, and hypoallergenic. Another common solution used is povidone-iodine (Betadine). This comes in the form of an antiseptic solution, a surgical soap, a topical solution (skin preparation or paint), and even an ointment. However, because some patients are allergic to iodine, the medical assistant should only use povidone-iodine and other solutions containing iodine when instructed to do so by the physician and after asking the patient about allergies. An alternative to povidone-iodine is chlorhexidine gluconate (commonly known by its brand name, Hibiclens), which does not stain and contains no iodine. Other antiseptic solutions include isopropyl alcohol and hydrogen peroxide. These solutions are generally reserved for external use (not inside the wound) because alcohol has limited effectiveness as an antiseptic and is painful to wounds. Hydrogen peroxide has a harsh, abrasive action on tissues. In some cases, the physician

B D A C

FIG 24-19 Antiseptic solutions. (A) Povidone-iodine. (B) Chlorhexidine gluconate (Hibiclens). (C) Isopropyl alcohol. (D) Hydrogen peroxide.

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FIG 24-20 Anesthetics. (A) Lidocaine without epinephrine. (B) Lidocaine with epinephrine.

Chapter Summary

Medical assistants commonly assist with minor surgical procedures. Their role involves preparing the room for procedures, assisting the physician during procedures, providing postprocedure care to patients, and tidying and sanitizing the room after procedures. Medical assistants should become familiar with the surgical instruments used in the ofces in which they work. Most surgical instruments fall into one of four categories: cutting instruments, grasping-clamping instruments, probing and dilating instruments, or specialty instruments. Design features common to certain categories of instruments include nger ring handles or spring handles, boxlock hinges, closing mechanisms, jaws, serrations, ratchets, and teeth. Scissors are one of the most common cutting instruments and come in many sizes and shapes. Examples include surgical scissors, mayo dissecting scissors, bandage scissors, suture scissors, and iris scissors. Scalpels are also commonly used cutting instruments. The large category of grasping-clamping instruments includes forceps, hemostats, needle holders, and clamps. Probing and dilating instruments include specula, such as a vaginal or nasal speculum; scopes, such as an otoscope or anoscope; probes, such as a grooved director probe; retractors, such as a Volkmann retractor; and dilators, such as a uterine dilator.

Examples of specialty instruments are obstetrical instruments like the vaginal speculum, Foerster sponge forceps, a curette, and a uterine tenaculum. To adhere to the principles of surgical asepsis, the health care team must understand and follow the sterile technique, which is a manner of performing specic tasks and procedures that protects patients from pathogenic organisms to the fullest extent possible. Surgical asepsis and the use of sterile technique are necessary when performing such invasive procedures as injections, urinary catheterization, and wound care and such surgical procedures as tissue biopsy or repair and suturing of lacerations. Prior to assisting with certain surgical procedures, medical assistants may be required to perform a surgical scrub, which is a type of hand washing that is much more thorough than regular hand washing. Medical assistants are commonly required to set up sterile fields for their use or for other health care providers. In doing so, they lay down a sterile barrier and then add all needed supplies to the eld. Application of sterile gloves is one of the most common sterile procedures that medical assistants perform. Therefore, it is extremely important for the medical assistant to learn how to apply sterile gloves properly and maintain good technique. Many minor surgical procedures are done in the medical ofce. Common procedures include suturing, suture removal, incision and drainage (I&D) of infections, and removal of ingrown toenails or sebaceous cysts. There are some procedures the medical assistant may perform herself if the physician has given the order to do so, including suture or staple removal and application of dressings. There are many types of surgical procedures. Those that involve the use of extreme cold are sometimes called cryosurgery. Those performed with the use of specialized microscopes are called microsurgery. Those that involve cutting or destroying tissue by the application of electricity are called electrosurgery. The medical assistant performs many duties when assisting with minor surgery, including preparation of the examination the room, noting physicians preferences for room arrangement and supplies, setting up the sterile eld for the physician, assisting the physician, and attending to the patients needs. Prior to any surgical procedure, the medical assistant must make sure that the patient has been properly informed and prepared. After completion of the surgical procedure, the medical assistant should make sure the patient is positioned comfortably and safely while resting. To prevent injury, she should also ensure that there is a person with the patient

CHAP TER 24

Surgical Asepsis and Assisting with Minor Surgery

409

to supervise him carefully when he gets up, dresses, and travels home. When closing a wound, the physicians goals are to promote timely healing and reduce scar formation. These goals are accomplished through the use of sterile technique and careful approximation of the wound edges by suturing or stapling them. Suture needles may have the suture material swaged to them. Suture sizes range from the smallest gauge (6-0) to the largest gauge (4). Packages are labeled for easy identication. In recent years, staples have become a popular choice for wound closure because they are effective, safe, and enable quick, easy wound closure. Dressings are materials, such as gauze pads, that are placed in or on wounds. They are usually made of sterile gauze and are useful for protecting wounds and absorbing drainage. Bandages are nonsterile material applied over the top of dressings to secure them. They are commonly made of gauze in the form of rolls that can be wrapped around a dressing or elastic wrap. In some cases, the physician may instruct the medical assistant to clean or treat a wound with a specic type of cream, ointment, or solution. Some commonly used solutions are sterile saline, povidone-iodine, Hibiclens, isopropyl alcohol, and hydrogen peroxide. Before cleaning or suturing a wound, an anesthetic may be applied to numb the area and reduce discomfort. Anesthetics most commonly used in ambulatory care are topical forms, such as EMLA cream, and injectable anesthetics, such as lidocaine (Xylocaine) and procaine (Novocaine).

Team Work Exercises

1. Divide into small teams. Each team should select and complete a different assignment from this list: a. Collect examples of medical instruments that possess some or all of the following characteristics: ratchets, ring-handles, spring handle, box lock, jaws, serrations, and teeth. Create a poster to accompany these instruments that illustrates and denes each feature. Present your poster and example tools to the class and then place them on a table and invite the students to take a close look at each instrument. b. Collect examples of cutting instruments and create a poster to accompany these instruments that illustrates and names each of them. Present your poster and instruments to the class and then place them on a table and invite the students to take a close look at each instrument. (Take care to make sure that any sharp points or blades are covered so that no one is injured.) c. Collect examples of grasping-clamping instruments and create a poster to accompany these instruments

that illustrates and names each of them. Present your poster and instruments to the class and then place them on a table and invite the students to take a close look at each instrument. (Take care to make sure that any sharp points are covered so that no one is injured.) d. Collect examples of probing and dilating instruments and create a poster to accompany these instruments that illustrates and names each of them. Present your poster and instruments to the class and then place them on a table and invite the students to take a close look at each instrument. e. Collect examples of specialty instruments and create a poster to accompany these instruments that illustrates and names each of them. Present your poster and instruments to the class and then place them on a table and invite the students to take a close look at each instrument. (Take care to make sure that any sharp points or blades are covered so that no one is injured.) f. Collect examples of biopsy tools and create a poster to accompany these instruments that illustrates and names each of them. Present your poster and instruments to the class and then place them on a table and invite the students to take a close look at each instrument. (Take care to make sure that any sharp points or blades are covered so that no one is injured.) 2. Divide into teams to create presentations that illustrate and emphasize the general rules of sterile technique, listed in the table on page 389. Each team will choose a different type of presentation, including: a. A poster presentation. Be sure to use color, illustrations, or photos and other creative visuals to make it interesting. b. A fun role-playing scenario in which one or more of you create a sterile eld. In the process, you will break as many of the rules of sterile technique as possible. The class will watch and identify as many things as possible that you did wrong. c. The proper way to set up a sterile eld, open a sterile pack, add items to the sterile eld, and pour a solution into a container on the sterile eld. d. An audiovisual presentation, such as a slide presentation or video, that describes the guidelines listed in the table.

Case Studies
1. Anthony is a CMA in a family practice ofce. He has noticed that one of his coworkers, who is also a CMA, checks the physicians schedule for the day to identify any procedures that might be done. He then sets up the procedure trays and puts them in a row in the back room until they are needed. Anthony appreciates his coworkers efforts to get organized for the day but is not sure that preparing all procedure trays for the entire day in the morning is a good idea. List the pros and cons of such a

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practice. Describe how this coworkers routine might be modied to make it better. 2. Ernesto is a patient who came to the urgent care center with a deep laceration on his thumb. He says that he accidentally cut himself with his hunting knife while sharpening it. What supplies and equipment will the medical assistant need to gather for this patient? List everything you can think of. Will the physician want to use lidocaine with or without epinephrine? Why? Betadine should be avoided for this patient if he has what allergy? After the physician has sutured Ernestos laceration, he

asks you to apply a dressing. What materials will you use and why? What instructions will you give to Ernesto before he leaves?

Resources

Encyclopedia of Surgery: www.surgeryencyclopedia.com/ index.html Free online course on infection prevention: www .engenderhealth.org/IP/index.html National Cancer Institute: www.cancer.gov/cancertopics/ factsheet/Therapy/cryosurgery

CHAPTER

Dermatology
Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell terms related to dermatology identify key structures of the integumentary system discuss the roles of protection and temperature regulation played by the integumentary system describe the role of the medical assistant in the dermatology ofce identify common skin diseases and disorders differentiate skin lesions list commonly used word elements related to the integumentary system give at least 10 examples of how new dermatology-related terms may be created by combining prexes, sufxes, and combining forms describe the medical assistants role in assisting with a tissue biopsy list the seven warning signs of cancer identify the characteristics of malignant melanoma describe physical examination techniques used to evaluate the integumentary system list and describe four types of allergy testing discuss the purpose of culture and sensitivity testing in the treatment of infection describe ve types of image enhancement procedures. Clinical Competencies Diagnostic Testing
Perform immunology testing

25
Common Integumentary System Diseases and Disorders
Bacterial Skin Infections Impetigo Acne Cellulitis Folliculitis Viral Skin Infections Warts Herpes viruses Herpes zoster Fungal Skin Disorders Tinea Candidiasis Parasitic Infestations Pediculosis Scabies Hypersensitivity and Inammatory Reactions Eczema Psoriasis Systemic lupus erythematosus Neoplasms Basal cell carcinoma Squamous cell carcinoma Malignant melanoma

Patient Care
Prepare patients for and assist with routine and specialty examination Prepare patients for and assist with procedures, treatments, and minor ofce surgery

General Competencies Patient Instruction

Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention

ABHES Competencies
Administrative Duties
Perform diagnostic coding

Communication
Use appropriate medical terminology

Clinical Duties
Prepare patients for procedures Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries Collect and process specimens Perform immunology testing

Dermatology Procedures
Assisting with Examination Allergy Skin Testing Scratch test Intradermal test Patch test Radioallergosorbent test Culture and Sensitivity Testing Image Enhancement Procedures Dermabrasion and dermaplaning Microdermabrasion Chemical peel Laser resurfacing BotoxTM

Instruction
Teach patients methods of health promotion and disease prevention

Procedures
Performing allergy skin testing

Chapter Outline
Structures and Functions of the Integumentary System
Structures of the Skin Functions of the Skin Protection Temperature regulation

CAAHEP Competencies
Administrative Competencies Process Insurance Claims
Perform diagnostic coding

Medical Terminology Related to the Integumentary System

Chapter Summary Team Work Exercises Case Studies Resources

411

Key Terms
allergen

Substance that produces a hypersensitivity reaction

atopic

Structures and Functions of the Integumentary System

The integumentary system is made up of the skin and related structures, such as hair follicles, tiny blood vessels, fatty tissue, and specialized nerves for detecting heat, cold, pain, and pressure. The integumentary system protects vital organs and helps carry out many essential body functions.

Type of allergic reaction for which there is a genetic predisposition

biopsy

Procedure in which a representative sample of tissue is obtained for microscopic examination

chemical peel

Destruction of supercial layers of the skin using a chemical application in order to remove scars, tattoos, or abnormal pigmentation
cryosurgery

Structures of the Skin

The skin is made up of three layers: the epidermis, the dermis, and the subcutaneous layer. (See Figure 25-1.) The top layer is the epidermis, which is a thin outer layer mostly constructed of nonliving keratinized cells. It is waterproof and provides protection for the deeper layers. The epidermis is thickest on the soles of the hands and feet. The base of this layer, aptly named the basement membrane, is where new skin cells are produced. These cells are pushed upward as even newer cells form beneath them. Eventually, they rise near enough to the top that they die, leaving dry, keratinized (hardened) tissue that becomes a part of the epidermal layer. The dermis lies just beneath the epidermis and is much thicker. It contains a number of structures, including hair follicles, nerves, blood vessels, and some glands. Beneath the dermis is the subcutaneous layer. This layer contains fat tissue as well as the deeper blood vessels, nerves, and hair follicles. It also contains elastin, which provides elasticity, and collagen, which provides strength. The subcutaneous layer provides insulation for deeper structures. Accessory structures of the skin include the sudoriferous (sweat) glands, sebaceous (oil) glands, hair, and nails. Sebaceous glands are found at the base of hair follicles all over the body and secrete an oily substance called sebum. Sudoriferous glands are located throughout the body but are more concentrated in some areas, such as the soles of the feet and palms of the hands.

Surgery with cold probes to destroy cancerous tissue

dermabrasion

Procedure in which outer layers of the skin are removed by abrasion with a wire brush or other device
dermaplaning

Procedure in which a dermatome is used to skim off surface layers of the skin to remove scars, tattoos, and ne wrinkles
dermatome

Band or region of skin supplied by a single sensory nerve

diascopy

Procedure in which a glass plate is held against the skin to observe changes related to pressure application
electrodesiccation

Destructive drying of cells by applying electrical energy

erythema

Redness of the skin

laser resurfacing

Use of short pulses of light to treat some skin conditions

melanocyte

Melanin-forming skin cell

microdermabrasion

Gentle abrasion of the skin to reduce ne lines, age spots, and acne scars and stimulate growth of new skin cells and collagen
patch test

Functions of the Skin

The skin and accessory structures serve several important functions in the body. Its major functions are protection and temperature regulation.

Skin test in which a low concentration of a presumed allergen is applied to the skin beneath an occlusive dressing to see if a reaction occurs
pruritus

Feeling of itchiness
radioallergosorbent test

Protection
The skin protects the body from bacteria and other microorganisms, damaging light from the ultraviolet rays of the sun, and extreme temperatures. Because the outer layer of the skin is waterproof, it prevents organisms from entering even when it gets wet, unless there is a break in the skin. Sebaceous glands secrete an oily substance that inhibits bacterial growth and lubricates the skin to keep it soft and supple. If microorganisms gain entry through breaks in the skin, such

Blood test for allergy that measures small quantities of immunoglobulin E in blood
scratch test

Test in which a dilution of a potential allergen is placed in a lightly scratched area of the skin

CHAP TER 25

Dermatology

413

Touch receptor Hair shaft Sweat gland pore Meissner's corpuscle

Stratum corneum Basal layer

Epidermis

Sebaceous (oil) gland Dermis

Hair follicle Apocrine gland

Nerve

Adipose tissue

Subcutaneous fatty tissue (hypodermis)

Arteriole

Venule

Arrector pili muscle

Pacinian corpuscle

Eccrine (sweat) gland

FIG 25-1 Layers and structures of the skin.

as a laceration (a cut or tear in the esh) or an abrasion (an area where skin or mucous membranes are scraped away), an infection may occur. However as the tissue becomes irritated, a natural inammatory response occurs. This response triggers increased circulation in the injured area, which is responsible for the appearance of such signs as edema, or swelling, and erythema, which is redness that may indicate inammation or injury. Increased numbers of leukocytes (white blood cells) arrive to ght off the invaders and act to engulf the bacteria. The increased circulation also helps speed the process of healing as debris is cleared away and healthy new cells along with scar tissue ll in the injured area. The skin also contains melanocytes, which are melaninforming skin cells. In response to ultraviolet light from the sun, melanocytes secrete melanin, a brown pigment that helps lter ultraviolet light and protect the skin from further damage. These cells are responsible for the browning of the

skin known as a suntan. The amount of melanin in the skin varies depending on the individuals heredity and ethnicity. Because the skin contains a number of different specialized nerves and sensory receptors, it plays a vital role in the ability to perceive cold and heat as well as pressure and pain. These messages signal the individual to take measures to increase physical comfort, such as putting on a coat for warmth. In addition, they also provide an important protective function. If the person accidentally touches a hot surface, the heat and pain receptors immediately send a message to the central nervous system (CNS) and the person responds by pulling her hand away. Such a response is a protective reex, which happens quickly and without conscious thought. Two accessory structures of the integumentary system play a role in protecting the body. The hair of the head, eyebrows, eyelashes, nose, and ears protects the body by ltering out

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dust and debris from the air. Nails help protect the ends of the ngers and toes.

Medical Terminology Related to the Integumentary System

Skin disorders are among the most common problems that lead people to seek medical care. Whether they work in family practice offices, urgent care centers, dermatology clinics, or other areas, medical assistants play an important role in the provision of health care to these patients. To be effective in their role, medical assistants must become well versed in the language and vocabulary that pertain to the integumentary system. The following tables list common medical terminology related to the integumentary system.

Temperature Regulation
The integumentary system also plays an important role in body temperature regulation. It helps to insulate and maintain warmth when the external environment is too cold. As the environment becomes colder, the hands and ngers become pale in color because the blood vessels near the skins surface constrict in order to give off less heat and conserve it for deeper organs. When the environment is too hot, these same blood vessels dilate (expand) in order to give off more heat. This response causes a ushed appearance. In addition, the sweat glands secrete sweat, which evaporates on the skins surface and provides even more cooling.

Table 25.1 |

Word elements

This table contains combining forms, prexes, and sufxes related to the integumentary system, along with examples of terms that use the word element, a pronunciation guide, and a denition for each. Combining Form
adip/o lip/o albin/o leuk/o cutane/o dermat/o derm/o cyan/o cyt/o erythem/o erythr/o melan/o myc/o necr/o onych/o pil/o trich/o scler/o xer/o xanth/o hardening; sclera dry yellow black fungus dead nail hair blue cell red skin white

Meaning
fat

Example
adipoid (AD--poyd) lipoma (l-PO-ma) albinism (AL-bn-zm) leukorrhea (loo-ko-RE-a) cutaneous (ku-TA-ne-us) dermatologist (der-ma-TOL-o-jst) dermoplasty (der-mo-plas-te) cyanosis (s-a-NO-ss) cytology (s-TOL-o-je) erythematous (er--THE-ma-ts) erythrocyte (e-RI TH-ro-st) melanoma (mel-a-NO-ma) mycosis (m-KO-ss) necrosis (ne-KRO-ss) onychomalacia (on--ko-ma-LA-se-a) pilophobia (p-lo-FO-be-a) trichopathy (trk-OP-a-the) sclerosis (skle-RO-ss) xeroderma (ze-ro-DER-ma) xanthoderma (zan-tho-DER-ma)

Meaning
resembling fat tumor of fat condition of (being) white white ow or discharge pertaining to the skin specialist in the study of skin surgical repair of the skin abnormal condition of blue (color) study of cells pertaining to red red (blood) cell tumor that is black in appearance abnormal condition of fungus abnormal condition of dead (tissue) softening of the nail fear of hair disease of the hair abnormal condition of hardening dry skin yellow skin

CHAP TER 25

Dermatology

415

Table 25.1 |

Word elementscontd
Meaning
above, upon below, beneath new

Combining Form
Prexes episubneoSufxes -cyte -derma -oma -plasia -plasty -ist

Example
epidermis (ep--DER-ms) subcutaneous (sub-ku-TA-ne-us) neoplasm (NE-o-plazm)

Meaning
above the dermis pertaining to beneath the skin new growth

cell skin tumor formation; growth surgical repair specialist

adipocyte (AD--po-st) cyanoderma (s-a-no-DER-ma) lipoma (ad--PO-ma) dysplasia (ds-PLA-ze-a) dermoplasty (DER-mo-plas-te) dermatologist (der-ma-TOL-o-jst)

fat cell blue skin fatty tumor bad (abnormal) growth surgical repair of the skin specialist in the diagnosis and treatment of skin disorders

Table 25.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to the integumentary system, along with a pronunciation guide and a brief denition for each. Term
abrasion a-BRA-zhun acne AK-ne actinic keratosis ak-TIN-k ker-a-TO-ss albinism AL-bn-zm alopecia al-o-PE-she-a basal cell carcinoma BA-sal SEL kar-s-NO-ma carbuncle KAR-bung-kl cellulitis sel-u-LI-ts comedo KOM-e-do corn KORN Most common type of skin cancer, which usually begins as a small, shiny papule and eventually enlarges to form a whitish border around a central depression or ulcer that may bleed Skin abscess created by the merger of two or more furuncles (boils) Genetic partial or total absence of pigment in the skin, hair, and eyes

Denition
Scraping away of skin or mucus membranes

Inammatory skin disease of sebaceous follicles common in adolescence that is marked by comedones, papules, and pustules Rough, precancerous macule or papule caused by excessive exposure to ultraviolet light

Absence or loss of hair, particularly on the head

Spreading bacterial infection of the skin and subcutaneous tissue

Small skin lesions of acne vulgaris, commonly called blackhead or whitehead, depending on the color Thickening of keratinized skin caused by pressure or friction

Continued

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Table 25.2 | Term

cyst SIST dysplasia ds-PLA-ze-a ecchymosis ek--MO-ss eczema EK-ze-ma edema e-DE-ma folliculitis fo-lk-u-LI-ts furuncle FU-rung-kl

Pathologic Termscontd
Denition
Closed sack or pouch on or under the skin that contains uid, solid, or semisolid material

Area of abnormal tissue growth

Discoloration of the skin; also called bruise or contusion

General term for pruritic, red rash that that weeps and may become crusted, thickened, or scaly; also called dermatitis When localized or generalized tissue contains excessive uid

Inammation (and sometimes infection) of hair follicles

Skin abscess; also called boil

hemangioma he-man-je-O-ma herpes simplex virus type 1 HER-pez SIM-plex VI-rus herpes simplex virus type 2 HER-pez SIM-plex VI-rus herpes zoster HER-pez ZOS-ter impetigo m-pe-TI-go laceration las-e-RA-shun lentigo len-TI-go malignant melanoma ma-LIG-nant mel-a-NO-ma neoplasm NE-o-plazm nevus NE-vus pediculosis pe-dk-u-LO-ss petechia pe-TE-ke-a postherpetic neuralgia post-her-PET-k nu-RAL-je-a

A dull red, benign lesion present from birth or appearing within 2 or 3 months; sometimes called a strawberry nevus Virus that causes a lesion on the lips

Virus that commonly causes lesions on the genitals

Reactivation of the varicella virus, years after an initial infection with chickenpox, that is marked by a painful, vesicular rash along the associated dermatome; also called shingles Contagious bacterial infection of the skin caused by streptococci or staphylococci that is marked by yellow to red weeping lesions that are crusted or pustular Cut or tear in the esh

Flat brown spot on the skin related to sun exposure, more common in elderly individuals; commonly called liver spots although they are not caused by liver disease Cancerous tumor of darkly pigmented skin cells that spreads aggressively and has a high mortality rate New, abnormal formation of tissue, such as a tumor

Hyperpigmented area of the skin, such as a mole or birthmark

Infestation with lice

Tiny red or purple hemorrhagic spot on the skin

Persistent nerve pain from herpes infection that lasts for months after lesions disappear

CHAP TER 25

Dermatology

417

Table 25.2 | Term

psoriasis so-RI-a-ss scabies SKA-bez

Pathologic Termscontd
Denition
Noncontagious chronic skin disorder in which red scaly plaques with sharply dened borders appear on the bodys surface Contagious infestation of the skin with the itch mite

seborrheic keratosis seb-o-RE-k ker-a-TO-ss squamous cell carcinoma SKWA-mus SEL kar-s-NO-ma tinea TIN-e-a verruca plantaris ver-ROO-ka plan-TAR-s verruca vulgaris ver-ROO-ka vul-GA-rs vitiligo vt-l-I-go

Benign, scaly skin growth that is yellow, gray, or brown and common in older adults

Form of skin cancer that develops in squamous tissue and grows more rapidly and spreads more easily than basal cell carcinoma Fungal skin infection

Wart that grows on the soles of the feet

Common wart

Disorder that causes a patchy loss of skin pigmentation

Common Integumentary System Diseases and Disorders

Table 25.3 |

Abbreviations

In dermatology, as with other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed here save time and effort in documentation and written communications. Abbreviation
Bx HSV-1 HSV-2 ID I&D RAST SLE SubQ, subcu, or subq T ung

There are innumerable diseases and disorders of the integumentary system. Some of the most common include bacterial infections, viral infections, fungal diseases, parasitic infestations, hypersensitivity and inammatory reactions, and neoplasms. Many disorders are identied by the type of lesion they produce on the skin. (See Common skin lesions, page 418.)

Term
biopsy herpes simplex virus type 1 herpes simplex virus type 2 intradermal (injection) incision & drainage radioallergosorbent test systemic lupus erythematosus subcutaneous temperature ointment

Bacterial Skin Infections

Some of the most common bacterial infections of the skin include impetigo, acne, cellulitis, and folliculitis. Here is a summary of each, along with its corresponding ICD-9CM code.

Impetigo
ICD-9-CM code: 684 Impetigo is a highly contagious bacterial infection caused by group A Streptococcus or Staphylococcus aureus. It is most common in young children and accounts for 10% of all cases of children with skin problems who are brought to medical clinics. Areas of the skin that are scraped or scratched are most vulnerable to infection. Lesions may appear anywhere on the body but are most common on the face and extremities. Impetigo appears as tiny vesicles (blisters), which

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Common skin lesions

This table lists some of the most common types of skin lesions, along with a pronunciation guide, a denition, and an illustration for each.

Lesion
macule MAK-ul

Denition
Flat, discolored spot on the skin (such as a freckle)

Example

papule PAP-ul

Small, raised spot or bump on the skin (such as a mole)

nodule NOD-ul

Small node

bulla BUL-l a

Large blister or skin vesicle lled with uid

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Common skin lesionscontd

Lesion
vesicle VES--kl

Denition
Clear, uid-lled blister

Example

scales Skalz

Areas of skin that are excessively dry and aky

ssure FISH-ur

Small, crack-like break in the skin

ulcer UL-ser

Lesion of the skin or mucus membranes marked by inammation, necrosis, and sloughing of damaged tissues

Continued

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Common skin lesionscontd

Lesion
wheal HWEL

Denition
Rounded, temporary elevation in the skin that is white in the center with a red-pink periphery and accompanied by itching

Example

pustule PUS-tul

Small, pus-lled blister

develop into weeping, pruritic (itching, tingling, or faint burning sensation) sores with honey-colored, crusty edges. (See Figure 25-2.) Diagnosis is usually based on medical history and physical examination ndings. Occasionally, culture (propagation of microorganisms in a special growth media) and sensitivity (determining susceptibility of bacteria to antibiotics) testing and a Gram stain may be done.

Treatment includes topical antibiotic ointment for small areas and systemic antibiotics for widespread infection. The lesions should be gently scrubbed daily with an antiseptic soap and covered lightly with a dressing. To help prevent the spread of impetigo, the patients ngernails should be short and clean. Patient education includes discussion of hygiene and avoiding the sharing of linens and towels. In addition, the patient should call the physician if lesions do not begin to heal within 3 days; the skin around the lesions becomes red, warm, and tender; or fever develops. (See Patient with an unidentied rash.)

Acne
ICD-9-CM code: 706.1 Acne is the term used to describe a skin disease of the pilosebaceous units (PSUs) in the skin. PSUs include sebaceous (oil) glands and hair follicles. The exact cause of acne is unclear; however, the PSUs apparently become plugged and develop into comedones, which are small skin lesions of acne that include whiteheads and blackheads. Contributing factors include hormonal inuences, genetics, and use of some medications or oily cosmetics. Exacerbations may be related to hormonal factors, exposure to oily environments, pollution,

FIG 25-2 Impetigo.

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Front ofceBack ofce connection

Patient with an Unidentied Rash

When a patient enters the medical ofce with a rash of unknown cause, the administrative medical assistant must consider the cause to be potentially contagious. This rule is especially true if the patient is febrile, the rash is weepy, or the rash was potentially caused by a parasitic infestation. The medical assistant should take measures to keep the patient separate from other patients. Doing so can be especially challenging when the patient is a child. If necessary, the administrative and clinical medical assistants should consult with one another about placing the patient directly into an examination room. Isolating potentially infectious patients helps minimize exposure to other patients and health care staff.

scars may be removed or minimized by dermabrasion, which is a process in which a plastic surgeon or dermatologist scrapes away the outermost layer of skin using a wire brush or burr impregnated with diamond particles.

Cellulitis
ICD-9-CM code: 682.9 Cellulitis is a bacterial infection of the dermis and subcutaneous tissues. It is usually caused when group A streptococci and Staphylococcus aureus organisms invade the skin through local injury, such as a scrape or cut. It is a common type of skin infection occurring among all races. Facial cellulitis is more common among adults over age 50 and children ages 6 months to 3 years. Perianal cellulitis is more common among children. People at increased risk include those with a weakened immune system, diabetes or other systemic illness, or impaired peripheral circulation and those using corticosteroid medication. Symptoms of cellulitis include localized pain, erythema, edema, warmth, and fever. (See Figure 25-4.) Red streaks may indicate spreading infection. Diagnosis is usually based on physical examination ndings. In more complex cases, laboratory tests may include a complete blood count and blood cultures. In addition, wound secretions may be collected for Gram stain and culture. In severe cases, radiographic studies may reveal gas in the tissues that indicates fasciitis or gangrene, which are surgical emergencies. Treatment includes the administration of antibiotics and, for severe cases, surgical resection. Complications may include loss of localized tissue and septicemia. However, with early diagnosis and appropriate treatment, most people recover fully.

humidity, and stress. As infection sets in, the comedones become pustules that can further develop into nodules and cysts. (See Figure 25-3.) Acne is most common among teenagers of all races and ethnicities but may affect adults as well. Acne occurs most commonly where large numbers of sebaceous glands are located, such as on the face, back, and chest. Over 40% of acne sufferers develop skin problems severe enough to seek medical care. In severe cases, it can be disguring and cause permanent scarring. Diagnosis is based on clinical presentation and symptoms. Over-the-counter (OTC) topical preparations such as benzoyl peroxide provide effective treatment in most cases. However, prescription medication may be needed for more severe cases. Such medications include antibiotics and vitamin A derivatives. Some medications such as isotretinoin (Accutane) are known teratogens (substances known to cause abnormal fetal development), so pregnant women should avoid their use. Oral contraceptives or low-dose corticosteroids may be effective for women whose acne is caused by excess androgen (male) hormones. Patients must be encouraged to have realistic expectations of treatment, as people respond differently and it commonly takes 6 to 8 weeks for a full response. Acne

Folliculitis
ICD-9-CM code: 704.8 Folliculitis is the inammation of hair follicles. It is very common and occurs anywhere on the skin, especially on the face and scalp. Folliculitis develops secondary to irritation caused by the friction of clothing rubbing on the skin or shaving as well as from the blockage of follicles. Infection with Staphylococcus aureus may follow. Symptoms include a rash with comedones, pustules, and itching.

FIG 25-3 Acne. (From Barankin, Freiman, Derm Notes. FA Davis, Philadelphia, 2006, p. 53, with permission.)

FIG 25-4 Cellulitis. (From Barankin, Freiman, Derm Notes. FA Davis, Philadelphia, 2006, p. 74, with permission.)

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Diagnosis is based on physical examination findings and symptoms. Occasionally, a culture may be done to identify the infecting organism. Folliculitis can be prevented or minimized by reducing friction from clothing, avoiding shaving if possible, and keeping the skin clean and dry. Treatment includes application of warm, moist compresses; topical or oral antibiotics; or antifungal medications. Folliculitis generally responds well to treatment but has a tendency to recur. A potential complication is the spread of infection.

Viral Skin Infections

Some of the most common viral skin infections include warts, herpes virus, and herpes zoster. Here is a summary of each, along with its corresponding ICD-9-CM code.

Warts
ICD-9-CM code: 078.10 (general code for common warts), 078.11 (genital) Warts are small, benign skin tumors that are caused by the human papilloma virus (HPV). They are contagious and spread via direct contact. There are many variations of warts, including verruca vulgaris (common warts), commonly found on the hands; venereal (genital) warts, which are sexually transmitted; and verruca plantaris (plantar warts), which grow on the soles of the feet. (See Figure 25-5.) Children and young adults are the populations that commonly get warts. Especially vulnerable are those with weakened immune systems, such as people with acquired immune deciency syndrome (AIDS) and cancer or those taking chemotherapy or other immunosuppressive medications. Experts estimate that genital HPV infection is the most common type of sexually transmitted disease, with 5.5 million new cases reported yearly and at least 20 million people already infected. Physical appearance of warts varies depending on the specic type of virus (there are over 100 different types) and the location involved. Warts may be tiny to medium-sized bumps or may have a cauliower-type appearance. Genital

warts, which develop on the genitalia, may be obvious and extensive or subtle and only perceptible using a Papanicolaou (Pap) test, also called a Pap smear. Diagnosis is based on physical examination ndings. Treatment options include over-the-counter (OTC) topical medications such as salicylic acid and numerous others. If home treatment does not produce satisfactory results, patients may seek treatment from their health care provider. A common treatment choice is cryotherapy, which involves the application of liquid nitrogen to freeze the wart and kill it. Repeated treatments may be needed. Other forms of treatment include application of lactic acid or trichloroacetic acid (TCA). Warts usually disappear without treatment; however, it may take weeks, months, or even years for them to do so. Genital warts in women may cause tissue changes that result in the development of cervical cancer. This development most likely accounts for the growing incidence of cervical cancer among young women. Therefore, the medical assistant should caution patients to use condoms to prevent transmission. Furthermore, women who are sexually active should have regular examinations and Pap tests.

Herpes Viruses
ICD-9-CM code: 054.10 (genital herpes simplex), 054.9 (oral herpes simplex) There are many variations of the herpes virus. Herpes simplex virus type 1 (HSV-1), also known as herpes labialis, most commonly causes lesions on the lips, usually referred to as cold sores or fever blisters. Herpes simplex virus type 2 (HSV-2) most commonly causes lesions on the genitals. (See Figure 25-6.) In either case, the virus causes repeated eruptions of acutely painful vesicles and then spreads along nerve pathways where it lays dormant between outbreaks. Other variations of herpetic outbreaks include herpes corneae (affecting the cornea), herpes facialis (affecting the face), and herpes menstrualis (appearing during menses). HSV-2 is considered a sexually transmitted disease, with an estimated 90 million people infected worldwide. All forms of herpes are contagious and spread via direct contact with secretions. Triggers that may precipitate repeated outbreaks include stress, illness, immunosuppressive medications, and sun or wind (oral herpes). Symptoms commonly include sensations of pain, itching, tingling, and burning prior to an outbreak of vesicles. When the rash appears, it includes a red base with small clusters of painful vesicles and pustules that also itch and burn. Systemic symptoms may include fever and malaise, which is a feeling of discomfort, weakness, fatigue, or feeling generally unwell. Diagnosis is based on medical history, including sexual activity and physical examination ndings. Treatment usually includes antiviral medications, such as acyclovir or penciclovir, which reduce viral shedding and shorten outbreaks. Analgesics may help reduce pain and tenderness

FIG 25-5 Common warts. (A) Plantar warts. (B) (From Barankin, Freiman, Derm Notes. FA Davis, Philadelphia, 2006, p. 171, with permission.)

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Herpes Zoster
ICD-9-M code: 053.9 Outbreaks of herpes zoster, also called shingles, are caused by a reactivation of the varicella virus. After an initial outbreak of varicella (chickenpox), the varicella zoster virus incorporates itself into nerve cells and lies dormant after patients recover from the initial infection until it is reactivated years later. Between 600,000 and 1 million people develop shingles each year. About 50% of people who live to age 80 will have an outbreak at some time in their life. Persons at increased risk are those taking immunosuppressive medications and those with weakened immune systems, including elderly patients and those with AIDS, Hodgkin disease, or diabetes. Symptoms of herpes zoster include unilateral distribution of herpetic vesicles along the affected dermatome (nerve pathway) of a few segments of spinal or cranial peripheral nerves. (See Figure 25-7.) These vesicles usually develop on the trunk or, sometimes, the face or head. Lesions are described as acutely painful and may burn or itch as well. Other symptoms may include fever, chills, headache, and malaise, depending on the dermatomes involved. Diagnosis is based on characteristic appearance. Diagnosis may be conrmed by a culture of secretions or, more rarely, by the presence of antibodies in the blood. Treatment for herpes zoster includes antiviral drugs, such as acyclovir, which reduce viral shedding and the severity and duration of the outbreak if administered within 3 days of onset. Other medications may include corticosteroids, analgesics, and antipruritics. The duration of outbreaks may last from 10 days to 5 weeks. A potential complication of herpes zoster is postherpetic neuralgia, which is persistent nerve pain that lasts for months after lesions disappear. Fortunately, repeated outbreaks of shingles are uncommon.

B
FIG 25-6 Herpes virus. (A) HSV 2 Genital herpes. (From Barankin, Freiman, Derm Notes. FA Davis, Philadelphia, 2006, p. 98, with permission.) (B) HSV 1 Herpes labialis.

caused by the lesions. The medical assistant should counsel patients with genital herpes regarding safe sexual practices to reduce the risk of transmission. There is no cure for herpes and, once acquired, the virus lies dormant in the body until something triggers another outbreak. Individuals should learn to identify their most common triggers and avoid them if possible. They should also take precautions to avoid transmission of the virus to others. Women who are pregnant or are considering becoming pregnant should inform their health care provider if they have genital herpes because transmission during childbirth can result in serious complications for the newborn. (See Patient with a herpetic rash.)

Fungal Skin Disorders

Front ofceBack ofce connection

Patient with a Herpetic Rash

There are many types of lesions caused by different herpes viruses. However, the general public associates the term herpes with genital herpes. Such misinformation can cause confusion and great embarrassment to the patient. Therefore, administrative and clinical medical assistants must be especially careful when checking in and caring for a patient with a herpetic rash. In addition, such sensitivity is one more important reason to keep communications condential, especially at the reception desk, where others might overhear what is said.

Fungal skin disorders are a common complaint. Two of the most common types include the family of tinea infections, which are named for the various parts of the body affected, and candidiasis.

FIG 25-7 Herpes zoster. (From Barankin, Freiman, Derm Notes. FA Davis, Philadelphia, 2006, p. 100, with permission.)

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Tinea
ICD-9-M code: 110.9 (tinea corporis), 110.0 (tinea capitis), 110.1 (tinea unguium), 110.4 (tinea pedis), 110.3 (tinea cruris) Tinea infection, also called dermatophytoses or ringworm, is any fungal skin infection on the body. Various forms include tinea capitis (scalp), tinea corporis (trunk), tinea cruris (genital area, also called jock itch), tinea nodosa (mustache and beard), tinea pedis (feet, also called athletes foot), and tinea unguium (nails). These types of infections are common. Tinea cruris is most common in adult men and tinea corporis is especially common in children. Tinea is caused by a fungus and is, therefore, contagious. It is transmitted via direct contact or by touching infected items, such as shoes, combs, clothing, and shower or pool surfaces. It may also be contracted from pets; cats are common carriers. Tinea thrives in warm, moist areas, and skin with a minor injury (such as a scratch or scrape) is more vulnerable. Symptoms of tinea infection vary, depending on the type and location. Most forms include red, raised, scaly, itchy lesions. (See Figure 25-8.) Patchy hair loss may be evident on the head or, in men, the face. The rash of tinea corporis has circular lesions. Tinea pedis causes the skin of the feet and especially between the toes, to crack, peel, ake, and redden. Patients may complain of itching, burning, and stinging. There may be blisters that break and ooze and become crusty. Affected nails become discolored, thickened, and softened and sometimes crumble. Diagnosis is based on the appearance of lesions and the patients description of symptoms. Diagnosis is conrmed by a skin culture or biopsy, a procedure in which a representative sample of tissue is obtained for microscopic examination via surgery, syringe and needle, endoscopy, punch technique, or other means. Also, examination of the scraping under a blue light (Woods lamp) in a dark room can conrm the diagnosis. Treatment usually includes over-the-counter (OTC) antifungal creams and powders such as miconazole (Monistat, Micatin). Patients should be instructed to continue use for 2 weeks after symptoms have resolved to keep the tinea infection from recurring. They must also keep the affected skin clean and dry, wear clean cotton socks (for tinea pedis),

and wash sheets and pajamas daily. Whats more, they should seek treatment for infected pets. Tinea infections usually respond well to treatment within 3 to 5 weeks, although recurrence is possible. If infection does not respond to OTC medications, evaluation by a health care provider is recommended. Prescription-strength medication may be needed and includes antifungal creams or pills. There is a risk of a secondary bacterial infection such as cellulitis developing due to skin breakdown from scratching.

Candidiasis
ICD-9-CM code: 112.3 (skin and nails), 112.0 (oral thrush), 112.1 (vaginal yeast) Candidiasis, commonly called yeast infection, is an infection of the mucous membranes or skin caused by Candida albicans, which is part of the bodys normal ora. It causes an infection when an overgrowth of the organism develops in warm, moist areas, such as the mouth, vagina, nails, and skin folds. Candidiasis develops when the composition of the bodys normal ora is disrupted, usually due to antibiotic therapy, or when the normal immune defenses are weakened, commonly due to corticosteroid therapy, chemotherapy, or an immune system disorder such as AIDS. Risk factors for candidiasis include diabetes mellitus and pregnancy. Symptoms vary depending on the location of the infection. Oral candidiasis, commonly called thrush, causes raised, white patches on the oral mucous membranes and tongue with an underlying inammation. Candidiasis within skin folds causes a reddened, pruritic rash. Vaginal infections cause a thick cheesy discharge and pruritis, a feeling of itchiness. Diagnosis of candidiasis is based on physical examination ndings, the patients description of symptoms and, occasionally, microscopic examination of skin scrapings or vaginal discharge. Most forms of candidiasis respond to systemic antifungal medication such as oral uconazole (Diucan). Oral infections may also be treated with clotrimazole lozenges (Mycelex) or a nystatin solution (Mycostatin, Nilstat) that is swished in the mouth and then swallowed. Antifungal creams or ointments are sometimes applied topically to affected skin folds, and vaginal suppositories may be used for vaginal infections. Prognosis for most forms of candidiasis is good. Immunocompromised individuals who develop systemic fungal infections may be vulnerable to septicemia, which can be life-threatening if septic shock develops.

Parasitic Infestations
FIG 25-8 Tinea corporis. (From Barankin, Freiman, Derm Notes. FA Davis, Philadelphia, 2006, p. 160, with permission.)

Parasitic infestations include pediculosis (lice) and scabies. Some confusion exists between scabies and lice. Both are skin conditions caused by infestation. Both are very contagious and both cause itching.

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Pediculosis
ICD-9-CM code: 132 (general code; see diagnosis for specic code) Pediculosis is the term used to refer to infestation with a species of louse. There are three species of louse: the head louse, body louse, and pubic louse. Head lice and body lice are very similar in appearance but differ primarily in habitat. Head lice are currently considered the most common human parasitic infestation in the United States and Europe. (See Figure 25-9.) Nits (eggs) are tiny, yellowwhite, and oval in shape. They are rmly attached to the side of the hair shaft near the scalp. They are laid by live lice and cannot be transmitted to others. It takes 7 to 10 days for the eggs to hatch and then another 7 to 10 days for the new females to mature and begin laying their own eggs. Adult lice are about the size of sesame seeds and are reddish-brown, wingless, crawling insects that cannot jump or y. They are rarely found on pets. They feed on human blood and usually live for about 30 days but can only live for 1 to 2 days away from the host. Head lice are common and primarily affect the scalp and, infrequently, the eyebrows and eyelashes. They are transmitted via direct contact with the infected persons head or with personal items such as scarves, hats, coats, brushes, combs, and towels. Personal hygiene and cleanliness in the home is not a factor. Body lice are found on the body and attach their eggs to the inside of clothing, usually along seam lines. Crab lice are found primarily in the pubic and perianal area. Symptoms of pediculosis include itching and sores on the scalp from scratching as well as the sensation of something crawling on the skin. Diagnosis is made by careful examination of the hair and scalp for nits or lice. Treatment includes manually ridding the body of parasites, controlling itching, and disinfecting the home environment. Medication and treatment recommendations are modied frequently. The latest recommendations can be found at http://www .headlice.org.

spreads quickly in crowded conditions where people have close contact, such as in health care institutions. It is transmitted via direct contact with an infected person or by sharing personal items, such as clothing and bed linens. The scabies rash is intensely pruritic and made up of scaly papules, insect burrows, and secondary infected lesions. (Figure 25-10.) It is most prevalent in skin folds at the wrists, elbows, between fingers, under the arms, in the groin, and under the beltline. The scalp, palms of the hands, and soles of the feet may also be affected. Itching is usually worse at night. Diagnosis includes differentiating scabies from other skin conditions, such as folliculitis, dermatitis, and impetigo. It is sometimes identied by the characteristic rash. The most common diagnostic test involves scraping the lesion and examining the tissue microscopically for the presence of mites or eggs. An ink test may also be used in which blue or black ink is applied after which the skin is cleaned. Some of the ink absorbs into the mite burrows thus revealing the lesions. Traditional treatment of scabies involves the application of products containing lindane. However, its use is not advised due to potentially serious adverse effects. A safer alternative is products containing topical 5% permethrin cream (Elimite, Acticin). Application should be repeated in 7 to 10 days when the nits hatch. Other individuals who live in the same household should be treated as well. The home environment should be disinfected as extensively as possible by washing or vacuuming surfaces and washing linens, towels, and clothing in hot water. Pesticide sprays should not be used. Prognosis is good with adequate treatment. Itching may persist for several weeks after treatment. Reinfestation is possible if the home and personal belongings are not cleaned adequately.

Scabies
ICD-9-CM code: 133.0 Scabies is a common, contagious condition in which the skin has been infested with microscopic mites. It is found worldwide and crosses all social classes and races. It

Hypersensitivity and Inammatory Reactions

Hypersensitivity skin disorders are common, especially in people who suffer from other forms of allergies. Among the most common are eczema and psoriasis. In addition, lupus is a serious inammatory disorder that may affect the skin or other body systems.

FIG 25-9 Pediculosis capitis. (From Barankin, Freiman, Derm Notes. FA Davis, Philadelphia, 2006, p. 127, with permission.)

FIG 25-10 Scabies. (From Barankin, Freiman, Derm Notes. FA Davis, Philadelphia, 2006, p. 142, with permission.)

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Eczema
ICD-9-CM code: 690 (general code for seborrheic dermatitis), 691 (general code for atopic dermatitis), 692 (general code for contact dermatitis); refer to diagnosis for specic code Eczema, also known as dermatitis, is a general term for a group of conditions that affect people of all ages. The most common type is atopic eczema, meaning that there is a genetic predisposition for it. It is associated with asthma and hayfever and runs in families. Eczema is fairly common, affecting 10% to 20% of the general population. It is more common among infants and children and may be acute or chronic. Causes are numerous and include allergies, response to chemicals, scratching the skin, emotional stress, illness, or sun exposure. Eczema is not contagious. Rash appearance and symptoms vary with the severity and type of eczema and the causative agent. The skin may be hot, dry, and pruritic. In more severe forms, the skin may be red, swollen, cracked, weeping, scaly, and itchy and may even bleed. There is no specic diagnostic test. Diagnosis is based on medical history, patient symptoms, and physical examination ndings. At present there is no cure for eczema. However, many children will be free of symptoms by the time they are in their teens. There are a number of treatment options, including application of aluminum acetate astringents (Burows solution), which is used in dermatology as a drying agent, for weeping skin lesions. Other medications include corticosteroids, emollients, antihistamines, or injections. Known allergens, which are any substance that causes a hypersensitivity reaction or abnormal immune response, should be avoided. Clothing made from soft-textured cotton is recommended and should be laundered in mild detergent. Keeping room temperatures below 72F (22.2C) and use of room humidiers may help. Sensitivity to specic allergens may never disappear entirely. However are-ups can be minimized and symptoms controlled.

FIG 25-11 Psoriasis. (From Barankin, Freiman, Derm Notes. FA Davis, Philadelphia, 2006, p. 133, with permission.)

crack and bleed. They are commonly found on the knees, shins, elbows, buttocks, lower back, ears, and along the hairline; however, the total body surface may be involved in some cases. Age of onset is usually between 15 and 35 years, although it can develop at any age. There is a pattern of exacerbations and remissions but are-ups can last for years. Many patients report that psoriasis has a signicant impact on their quality of life and affects clothing choice (to cover lesions), quality of sleep, and self-esteem. Symptoms include itching and pain. Diagnosis of psoriasis is based on history, physical examination ndings and the patients description of symptoms. Biopsy may be done when typical lesions and scales are not obvious. There are a number of treatments for psoriasis, including topical corticosteroids, vitamin D, coal tar derivatives, retinoids, and ultraviolet light exposure. Relatively new drugs on the market, known as biologics, have been approved for the treatment of psoriasis. The term biologics refers to a variety of medicinal products derived from natural sources or produced by biotechnology. Drugs created to treat psoriasis include alefacept (Amevive), efalizumab (Raptiva), and etanercept (Enbrel). Other drugs are still undergoing research. In addition to using prescribed medications, patients are encouraged to maintain self-care, which includes preventing skin trauma and avoiding known triggers. There is no cure for psoriasis. However the disorder can be managed by avoiding triggers and using approved treatments and medications. Approximately 10% to 30% of individuals develop a related form of arthritis known as psoriatic arthritis.

Psoriasis
ICD-9-CM code: 696 (general code; refer to diagnosis for specic code) Psoriasis is a chronic, inammatory skin disorder characterized by the development of red, scaly plaques. Appearance varies with the specic type. Psoriasis affects 1% to 3% of the worlds population and approximately 4.5 million people in the United States. It affects men and women equally but is more common in Caucasians. The specic cause of psoriasis is unknown, although it may be autoimmune in nature. Contributing factors include stress, family history, skin trauma, cold weather, infections, and some medications. It is not contagious. The typical presentation of psoriasis includes silvery-white scaly plaques or patches with reddened skin beneath and sharply dened borders. (See Figure 25-11.) Lesions may

Systemic Lupus Erythematosus

ICD-9-CM code: 710.0 Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder, meaning that the body produces antibodies that targets self tissues. These antibodies cause inammation and degeneration of various connective tissues in the body. The exact cause of the autoimmune response is not fully understood. There is some thought that genetics, viruses, some drugs, female hormones, stress, and ultraviolet light in the form of sunlight, uorescent lights, and tanning beds may play a role. Lupus that affects only the skin is called discoid lupus. However SLE is considered systemic because it can target any number of tissues or organs within the body, including the skin, lungs, heart, joints, kidneys, blood, and nervous system.

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SLE affects up to 1.5 million Americans and is eight times more common in women than men. It can occur at any age but is most common in women of childbearing age between the ages of 15 and 45. It is also more common in African Americans, Latinos, Native Americans, and those of Japanese and Chinese descent. Lupus is marked by exacerbations (periods of illness) and remission (periods of wellness). One of the most prominent features of discoid lupus and SLE is the skin rash that may develop anywhere on the body but is most obvious on the face and scalp. It is generally red and at but may have raised borders and is painless and does not itch. Other symptoms of SLE depend on the body system affected. General, wholebody symptoms include mild fever, fatigue, anorexia, and weight loss. Other symptoms include myalgias (muscle aches); arthralgias (aching joints); photosensitivity; splenomegaly (spleen enlargement); enlarged, tender lymph nodes; and Raynauds phenomenon (a circulatory disorder of the ngers and toes). Arthritic changes develop in 90% of those with SLE and cause symptoms of joint pain, stiffness, edema, and possible joint deformity. There is no single test that denitively diagnoses SLE. Instead, 11 criteria are used to conrm diagnosis. Identication of four or more suggests a diagnosis of SLE. These criteria include: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. classic buttery rash across the cheeks and nose discoid skin rash photosensitivity ulcerations in the mouth, nose or throat arthritis pleuritis (inammation in the lining of the lungs) or pericarditis (inammation in the lining of the heart) kidney abnormalities brain irritation abnormal blood count positive antinuclear antibody (ANA) test immunologic disorder characterized by abnormal immune tests, including anti-DNA or anti-Sm (Smith) antibodies, false-positive blood test for syphilis, anticardiolipin antibodies, lupus anticoagulant, or elevated lipoprotein electrophoresis test.

and fatigue. Those with severe kidney or brain disease may benet from plasmapheresis, which is a procedure used to remove autoantibodies from the blood. Other immunosuppressive medications may be used as well. General recommendations also include rest and regular, moderate exercise. Complications from SLE include some forms of cancer, pleuritis, pericarditis, cardiovascular disease, heart attack, kidney failure, stroke, Raynauds phenomenon, and brain involvement. Some patients go into remission for up to a year and require no treatment during that time. Survival and longevity is variable, depending on how many of the 11 diagnostic criteria are present and which organs are affected. Those with SLE limited to skin and joints have the best prognosis. Those with CNS or kidney disease have a poor prognosis.

Neoplasms
An area of abnormal tissue growth may be identied as a neoplasm or dysplasia. Such tissue must be evaluated by a pathologist to determine whether it is malignant (cancerous) or benign (noncancerous). The most common way to determine if a neoplasm is cancerous is to surgically remove a piece of the tissue via biopsy and examine it under a microscope. If the tissue is malignant, the next step is to determine whether it is carcinoma in situ (conned to the original site), has spread regionally, or has metastasized (spread to distant sites). Detection of cancer in regional lymph nodes indicates that it has spread into the lymphatic system and may have spread to other, more distant sites. Cancer is classied according to a system of grading and staging in order to determine the patients overall prognosis and treatment plan. Grading refers to a standardized process of describing cancer cell differentiation, from stage I to stage IV, where stage IV has the least resemblance to normal tissue. Staging refers to the extent of dissemination of the cancer, including tumor size as well as regional and distant metastasis. Treatment of cancer is determined by an oncologist and depends on the type, stage, and grade of the cancer. Treatment options usually include surgery, chemotherapy, radiation therapy, hormone therapy, cryosurgery (surgery with cold probes to destroy cancerous tissue), electrodesiccation (destructive drying of cells by application of electrical energy), application of chemotherapeutic agents, and administration of medications to boost the immune system. These treatments may be used alone or in combination. Benign neoplasms of the skin are common and include birthmarks, such as strawberry hemangiomas and nevi (moles). Cancerous neoplasms of the skin are classied as basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. Together, they make up the most common form of cancer. Areas of the body most commonly affected are

Other testing that may be helpful includes the erythrocyte sedimentation rate (ESR), blood chemistry testing, tissue biopsies, and uid specimen analysis. There is no cure for SLE. Treatment goals aim to relieve symptoms and prevent or minimize complications. A variety of medications may be used to prevent or treat inammation, including nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin), aspirin, naproxen (Aleve), and sulindac. Severe exacerbations may be treated with corticosteroids. Hydroxychloroquine is helpful for treating SLE patients suffering from skin and joint disease

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those frequently exposed to the sun, such as the face and ears.

tissue has been surgically removed. (See Warning signs of malignant melanoma: The ABCD system.)

Basal Cell Carcinoma

ICD-9-CM code: M8090/3 (/3 means malignant, primary site) Basal cell carcinoma is the most common type of skin cancer and, fortunately, grows slowly and rarely metastasizes. It usually begins as a small, shiny papule and eventually enlarges to form a whitish border around a central depression or ulcer that may bleed.

Dermatology Procedures
Dermatology is a medical specialty that focuses on the study and treatment of disorders of the integumentary system. While many physicians, including pediatricians and family practice specialists, diagnose and treat minor skin disorders, those who specialize in this area of medicine are dermatologists. The dermatologist is responsible for identifying skin changes and their possible signicance. Some skin changes occur as a natural part of the aging process, including loss of elasticity (causing lines and wrinkles on the skin), increased numbers of benign growths and lesions (such as age spots and moles), and scars and other changes due to sun exposure and minor trauma. Other skin changes may reect poor nutritional status, circulatory problems, or systemic disease. Some disorders treated by the dermatologist, such as acne, arent considered serious medical disorders. However, because they have an impact on self-image, these disorders deserve as much attention as more serious medical disorders such as cancer.

Squamous Cell Carcinoma

ICD-9-CM code: M8070/3 (/3 means malignant, primary site) Squamous cell carcinoma grows more rapidly than basal cell carcinoma and spreads more easily. It develops in squamous tissue found on the skin or in the mouth, esophagus, bronchi, lungs, or cervix. It may appear as a rm, red nodule, have a scaly appearance, and ulcerate. (See Seven warning signs of cancer.)

Malignant Melanoma
ICD-9-CM code: 172 (use 4th digit for specic site) Malignant melanoma commonly arises from a brown or black mole and has a tendency to spread aggressively to distant sites, making it the most lethal form of skin cancer. Risk factors include sunlight exposure, especially the number of childhood sunburns, as well as fair skin color, red hair, and family history. The initial appearance of malignant melanoma lesions is variable but includes pigmented color (tan, brown, blue, red, black, or white), asymmetry, and irregular borders. Lesions are generally larger than 6 mm in size, often metastasize, and can recur. Therefore, patients should be reevaluated on a regular basis after the malignant

Assisting with Examination

To reach an accurate diagnosis, the physician must obtain a medical history, including a description of symptoms. A physical examination of the skin and skin structures is also important. A thorough examination includes the entire body, from head to toes, including the genital area. While performing inspection, the dermatologist must have good lighting and a magnifying lens in order to closely examine any suspicious lesions or growths. Hell pay attention to changes in skin color as well as the presence of any lesions, ulcers, bruises, or rashes. When performing palpation, the dermatologist notes changes in elasticity and texture as well

Patient Education

Seven Warning Signs of Cancer

Skin cancer is among the most common forms of cancer, is one of the most preventable, and can be one of the most deadly. Teach your patients about the seven warning signs of cancer so they can detect changes early. The seven warning signs of cancer are: Change in bowel or bladder habits A sore throat that does not heal Unusual bleeding or discharge Thickening or a lump in the breast or other area Indigestion or difculty swallowing Obvious change in a mole or wart Nagging cough or hoarseness.

Warning signs of malignant melanoma: The ABCD system

A helpful way to remember and identify the warning signs of malignant melanoma is the ABCD system: AssymetryOne half of the mole does not match the other half. BorderThe edges of the mole are irregular or blurred. ColorVarying shades of color throughout include tan, brown, black, blue, red, or white. DiameterThe mole is larger than 6 mm.

CHAP TER 25

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as the presence of lumps, masses, or areas of rmness. The dermatologist may conduct diascopy, which is a procedure that allows the dermatologist to observe changes in response to pressure. In some cases, the dermatologist may obtain tissue samples via biopsy for microscopic analysis. In an examination, the medical assistant must prepare the patient by checking vital signs and obtaining health history, which should include data regarding outdoor activities, family history of skin problems, and use of sunscreen. She should then assist him as needed with undressing and positioning. She must also assist the dermatologist as needed with any procedures. For example, if the dermatologist notices a lesion, he may ask the medical assistant to apply a dressing or obtain a drainage specimen for culture.

Allergy Skin Testing

Allergy skin testing is done to identify what substance or allergen is responsible for triggering an allergic response in a person. This testing evaluates the persons sensitivity to numerous substances, including those common in trees, shrubs, weeds, and grasses; fungus; dust and dust mites; feathers; pet dander; foods; medications; and insect venom. Symptoms of allergies include sneezing; runny nose; and itchy, watery eyes. Allergies can also trigger asthma attacks. When allergies are identied, individuals may be able to avoid or minimize exposure to the offensive substance or take allergy shots to decrease the severity of their reaction. Allergies are diagnosed through skin or blood testing. Both testing methods expose a person to suspected allergens to see if a reaction occurs. Skin tests are generally preferable due to their reliability, quick results, and low expense.

FIG 25-12 Scratch test.

FIG 25-13 Multiheaded testing device.

Scratch Test
A scratch test, also called a skin prick test, is done by placing a drop of a solution containing a potential allergen on the skin and then pricking the skin with a needle to expose it to the allergen. (See Figure 25-12.) Any smooth surface of the body may be used, including the back, which is a popular site. The locations of scratch tests are documented in some form of a pattern so that any positive reactions can be associated with the correct allergen. A multiheaded testing device is commonly used to allow application of multiple allergen solutions at once. (See Figure 25-13.) They are commonly placed in rows 1 1/2'' to 2'' apart with as many as 50 tests done at once. A positive reaction is indicated by the development of a wheal, which is a rounded temporary elevation in the skin that is white in the center with a pale red periphery and is accompanied by itching, commonly seen with insect bites and allergic reactions. Wheals usually develop within 30 minutes and indicate that the person is allergic to that allergen. More severe reactions may include itching. Positive reactions are graded on a scale from 2 (least severe) to 4 (most severe). In cases of severe reactions, the solution should be wiped off. (See Procedure 25-1: Performing allergy skin testing, page 430.)

Intradermal Test
The intradermal test involves the injection of a tiny dose (0.1 to 0.2 ml) of an allergen solution deeper into the skin. As many as 15 different allergens may be tested on each arm. This test may be done when there is no reaction to the scratch test, yet there is still reason to suspect the individual may be allergic. This test is more sensitive than the scratch test and provides more consistent and reliable results. However, a positive reaction to it does not necessarily conrm the allergen is a severe problem for the individual, but does indicate the presence of antibodies. Other information, including the persons history and description of symptoms, is required to determine whether treatment is needed. (See Figure 25-14.)

Patch Test
A patch test is used to detect contact dermatitis, a form of skin allergy. In this test a pad soaked in an allergen solution is placed on the skin, covered with cellophane, and left in place for up to 2 days. (See Figure 25-15.) As many as 30 such tests may be done at one time and the reaction is checked within 4 days. (See Skin testing guidelines, page 432.)

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FIG 25-14 Intradermal test with injection of 0.1 to 0.2 ml of solution containing an allergen.

FIG 25-15 Patch test pad soaked in an allergen solution and placed on the skin.

PROCEDURE 25-1

Performing allergy skin testing

Task Perform an allergy skin prick test. Conditions Allergen solution Control solution Multiheaded skin-testing device Biohazard container Marking pen Ruler or measuring device Tissues Nonsterile examination gloves Medical record or chart Waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform an allergy skin prick test. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify your patient and introduce yourself. Explain the procedure and ask the patient if he has taken any medications in the past 2 weeks that might interfere with the test. Also ask if the patient has applied any creams, ointments, or moisturizers to his skin today. Substances applied to the skin may cause solution from one test site to run onto another test site. 3. Assist the patient onto the examination table into a position that is comfortable for the patient and convenient for testing. (The test site will be the surface of the inner forearm, the outer upper arm, or the back, depending on the number of test sites needed.) 4. Clean the skin site with water or alcohol (per ofce protocol). 5. Hold the multiheaded skin-testing device next to the patients skin. Use the marking pen to mark the patients skin next to each testing site, according to ofce protocol, to ensure an accurate reading of results.

Mark the patients skin while holding the testing device next to it.

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PROCEDURE 25-1contd

9. Set the timer for 15 minutes. Give the patient some reading material if desired to help the patient pass the time and provide a distraction from skin discomfort or itching. 10. Note the results and measure any positive reactions in millimeters. If wheals are not round in shape, measure the diameter in both directions and record the average of the two (or according to ofce policy) to ensure the most accurate measurement.

Patients skin with marks

6. Press the testing device gently against the patients skin so that the allergen solution enters the top layer of skin.

Measure positive reactions in millimeters.

Press the testing device gently against the patients skin.

7. Repeat steps 6 and 7 with different prepared testing devices until all tests have been completed. 8. Carefully blot (do not wipe) any excess solution with tissue to prevent solution from running between test sites.

11. Remove markings from the skin with an alcohol solution or water. 12. Reassure the patient that any itching should resolve within 20 minutes or so. Apply a cool compress or cortisone cream for itching (per ofce protocol) to increase patient comfort. 13. Instruct the patient with positive reactions to remain in the ofce for at least 20 minutes after completion of the test to provide time for the physician to counsel the patient regarding the test results and to observe the patient for asthma or anaphylaxis. 14. Document results in the medical record according to ofce policy to ensure accuracy of the medical record.
Date 07/23/08; 3:12 p.m. Allergy skin testing completed; Pt. tolerated procedure well; results reviewed by Dr. Lee. ------------------ S. Gonzales, CMA

Apply tissue to the patients skin, without wiping, to blot excess solution.

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Skin testing guidelines

Below are the most common guidelines for allergy skin testing. Medical assistants who assist with allergy testing should be familiar with these guidelines as well as any other related policies established by the medical ofce: Antihistamines or allergy medications should be discontinued a minimum of 3 days prior to testing. Recommended testing sites include the anterior forearm and the back. Sites must be carefully labeled and spaced 1 1/2'' to 2'' apart. Notify the physician immediately if the patient demonstrates signs of anaphylaxis (hives, edema, redness, difculty breathing, nausea, vomiting, anxiety). Keep emergency supplies on hand, such as epinephrine and diphenhydramine hydrochloride (Benadryl).

and less risky. Common procedures include dermabrasion and dermaplaning, microdermabrasion, chemical peels, and laser resurfacing. Patients interested in these procedures should seek the care of a qualied dermatologist. The physician should caution patients that results vary, depending on individual anatomy, physical reactions, and healing abilities and, therefore, the outcome is never completely predictable. These treatments may be expensive and usually are not covered by medical insurance. In some cases, they may be used for scar modication or the removal of precancerous skin growths. Such conditions might meet the criteria of medical necessity required by insurance companies. Individuals should contact their insurance carriers to determine whether coverage will apply in their individual case.

Dermabrasion and Dermaplaning

Dermabrasion is a process in which a surgeon scrapes away the outermost layer of skin using a wire brush or burr impregnated with diamond particles. Dermaplaning is a procedure in which the surgeon uses an instrument called a dermatome, which resembles an electric razor, to skim off surface layers of the skin. Both procedures renish the top layers of the skin and can remove acne scars, scars from previous surgery or accidents, nevi (moles), tattoos, or ne wrinkles and leave a smoother surface. Both procedures can be performed on small areas of skin or the entire face and may be used alone or with other enhancement procedures. Both procedures are usually done under local anesthesia, which numbs the area being treated. Medication may also be administered to help patients feel relaxed yet still awake. In severe cases, general anesthesia may be used. Dermabrasion and dermaplaning usually last from a few minutes up to 90 minutes, depending on the area of skin involved. Cases involving deep scarring may require multiple treatments. Potential complications include infection, skin pigment changes, and scarring.

Radioallergosorbent Test
The radioallergosorbent test (RAST) checks blood for the presence of specic allergy antibodies. It may be done instead of or in addition to skin testing and is useful for people who are on medications that suppress the results of skin tests and for those who cannot discontinue antihistamine medication. It is also more specic than skin testing and is helpful in the diagnosis of asthma, allergies, and other lung disorders.

Culture and Sensitivity Testing

A wound culture involves obtaining secretions from the wound using a sterile, cotton-tipped applicator and securing it in a transport medium. It is then transported to the laboratory for microscopic examination and culturing. Culturing is a process in which the sample is applied to a growth medium and placed in a supportive environment to grow for 24 to 72 hours. Aerobic cultures identify organisms that grow and thrive in environments with oxygen. Such organisms are usually found on or near the surface of wounds. Anaerobic cultures identify organisms that grow and thrive in environments with little or no oxygen. Such organisms are usually found in the deeper layers of wounds and ulcers. When the organisms are identied, a sensitivity test exposes the microorganisms to various anti-infective agents to determine which one is most effective in killing them. This testing helps the dermatologist determine the best antimicrobial agent to prescribe for the patient.

Microdermabrasion
Microdermabrasion is similar to dermabrasion but is less aggressive and less invasive. It stimulates growth of skin cells and collagen and has become a popular nonsurgical procedure. It involves gentle abrasion or polishing, which is useful in reducing ne lines, nevi, age spots, and acne scars. Each treatment takes 30 to 60 minutes. About 5 to 12 treatments are recommended, scheduled 2 to 3 weeks apart. It is effective on all skin types and colors and does not require an anesthetic. It may be used along with a light chemical peel for increased effect. Periodic repeat treatments are needed to maintain the effect.

Image Enhancement Procedures

Procedures to repair disgurement and enhance appearance are becoming more and more popular, due in part to medical advances that are making such procedures more affordable

Chemical Peel
A chemical peel, also called chemabrasion or chemexfoliation, is an alternative to dermabrasion. In this procedure, a chemical

CHAP TER 25

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solution is applied to the skin to improve appearance by removing blemishes, ne wrinkles, and uneven pigmentation. It may also be used to treat scars and tattoos. A chemical peel involves the use of different chemical solutions, depending on the extent of the peel desired; thus, the terms light, medium, and deep are used to describe the level of chemical peel. Most peels may be safely done in the medical ofce or outpatient surgical center. The procedure usually doesnt require anesthesia because the chemical solution acts as an anesthetic. (See Aftercare for the patient undergoing a chemical peel.)

Laser Resurfacing
Laser resurfacing, also called photothermolysis, involves the use of short pulses of light to treat skin conditions. Sometimes called a laser peel, this fairly new procedure involves using a carbon dioxide laser to remove ne lines and damaged skin around the eyes and mouth. It is also used to minimize scars and even out areas of uneven pigmentation. During the procedure, a laser is carefully passed over the skin until the appropriate depth is affected to achieve the desired results. This treatment may be done on specic areas or the whole face and takes anywhere from a few minutes to 90 minutes. Recovery includes application of a dressing for several days. Skin crusts may form temporarily but should not be picked off, as scarring may result. Redness is common and may last for several weeks. Repeated treatments may be necessary to achieve desired results. Final results may not be fully apparent for several months.

was approved by the FDA over 10 years ago for the treatment of certain problems with eye muscles. Physicians and patients noticed that it also improved the appearance of wrinkles around the eyes. It has since been approved for use in lessening the appearance of wrinkles between the eyebrows. It acts by interfering with contraction of the treated muscles, thereby reducing the appearance of wrinkles. In this procedure, the dermatologist injects a small amount of BotoxTM. Results occur within 7 days and may last up to 4 months. Common adverse effects are ulike symptoms of headache, upset stomach, and temporary eyelid droop. Cases of botulism are extremely rare but have been reported. (See Teaching about Botox.)

Patient Education

Teaching About BotoxTM

Patients are becoming more curious about Botox treatments as a means to temporarily reduce ne lines and wrinkles, and unregulated Botox parties are even becoming popular. However, there are potential risks and adverse effects associated with this medical treatment. Therefore, be sure your patients are well informed by providing them with the following information: BotoxTM is only approved to treat wrinkles between the eyebrows. BotoxTM is only approved for those between the ages of 18 and 65. Consult with your physician for appropriate evaluation and treatment. Seek treatment only from qualied medical providers in a physicians ofce or medical clinic. Avoid BotoxTM parties because the person administering the injection may be unlicensed and not properly trained. Never share BotoxTM solution or needles with others. Avoid BotoxTM use if your are pregnant or breastfeeding. Tell the physician if you are taking antibiotics. Tell the physician about nervous or muscular disorders you have.

BotoxTM
BotoxTM treatments have gained increasing popularity in recent years. BotoxTM comes from the botulinim toxin and

Patient Education

Aftercare for the Patient Undergoing a Chemical Peel

The medical assistant should provide these guidelines to the patient undergoing a chemical peel: You may experience some temporary aking, scaling, redness, or dryness. You may experience some swelling. The physician may prescribe a mild analgesic to relieve discomfort. Arrange to have someone help you out at home for a day or two so that you can rest. Avoid sun exposure. Follow any other instructions given to you by the physician.

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Chapter Summary

2. Using medical word elements in Tables 23-1, 23-2, and 25-1, create as many terms related to dermatology as you can think of. List the denition of each term next to it. The team with the most terms wins.

The integumentary system includes the skin, which is the largest organ of the body. It is made up of the epidermis, the dermis, the subcutaneous layer, and other structures. It plays vital roles in protection, temperature regulation, and insulation. Medical assistants must be well versed in language and vocabulary that pertains to the integumentary system. In addition to knowing common combining forms, they should be familiar with common abbreviations and pathological terms. Some of the most common disorders of the integumentary system include impetigo, acne, cellulitis, folliculitis, warts, herpes simplex types 1 and 2, herpes zoster, fungal infections, pediculosis, scabies, eczema, psoriasis, SLE, and neoplasms. Dermatology is a medical specialty that focuses on the study and treatment of diseases and disorders of the integumentary system. To reach an accurate diagnosis, the dermatologist must complete a physical examination of the skin and skin structures. Examination techniques employed include inspection and palpation. Diascopy may also be used. The medical assistant prepares the patient by assisting him as needed with undressing and positioning. She also assists the physician with examinations and procedures. Allergy skin testing is done to identify a substance or allergen that is responsible for triggering an allergic response in a person. Tests include the scratch (skin prick) test, intradermal test, patch test, and RAST. Culture and sensitivity testing may be used to determine what organisms are growing in a wound and the antimicrobial agents that will be most effective in killing them. Procedures to repair disgurement and enhance appearance are becoming more and more popular. Common procedures include dermabrasion and dermaplaning, microdermabrasion, chemical peel, laser resurfacing, and BotoxTM.

Case Studies
1. Shirley Washington is a 54-year-old woman who has come to the dermatology clinic seeking information about image enhancement. She has a history of acne as a teenager that left some scarring. In recent years, she has developed ne lines and wrinkles around her eyes and mouth. She doesnt want to undergo invasive plastic surgery, but is interested in nding out what other options might be available to her. What will you tell her? 2. Wendy and Angela, two high school girls, visit the dermatology clinic together. They tell you that they are gathering information for a school health project about cancer. They are interested in learning about risk factors for cancer and especially want to know about the various types of skin cancer. What will you tell them?

Resources

About.Coms Dermatology Site: http://www.dermatology .about.com American Society of Plastic Surgeons (wide variety of information about plastic surgery and image enhancement): http://www.plasticsurgery.org Centers for Disease Control and Prevention: http://www .cdc.gov E-medicine: http://www.emedicine.com/derm/index.shtml Headlice.org from the National Pediculosis Association: http://www.headlice.org Medline Plus: http://www.nlm.nih.gov/medlineplus/ skinhairandnails.html National Eczema Society: http://www.eczema.org. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS): http://www.niams.nih.gov National Psoriasis Foundation: http://www.psoriasis.org Nemours FoundationKids Health: http://www .kidshealth.org Skin Care Physicians.com: http://www.skincarephysicians.com

Team Work Exercises

1. Create poster illustrations or three-dimensional models of the skin, including the epidermis, dermis, and subcutaneous layers and key structures. Include appropriate labels. Classmates or the instructor may evaluate creations and choose a winner based on accuracy, use of humor, creativity, or other criteria.

C H A P T E R

Neurology
Learning Objectives
Upon completion of this chapter, the student will be able to: define and spell terms related to neurology identify key structures of the neurological system discuss the roles played by the neurological system describe the role of the medical assistant in the neurologists office identify common neurological diseases and disorders list commonly used word elements related to the neurological system give at least 10 examples of how new neurological related terms may be created by combining prefixes, suffixes, and combining forms describe the medical assistants role in assisting with neurological procedures describe physical examination techniques used to evaluate the neurological system. Patient Instruction
Instruct individuals according to their needs

26
Common Nervous System Diseases and Disorders
Disorders of the Central Nervous System Stroke Transient ischemic attack Migraine headache Epilepsy Encephalitis Meningitis Traumatic brain injury Spinal cord injury Parkinson disease Multiple sclerosis Brain tumor Disorders of the peripheral Nervous System Amyotrophic lateral sclerosis Bell palsy Peripheral neuropathy Carpal tunnel syndrome Spinal stenosis

ABHES Competencies
Communication
Use appropriate medical terminology

Administrative Duties
Perform diagnostic coding

Clinical Duties
Prepare patients for procedures Prepare patient for and assist physician with routine and specialty examinations and treatments and minor office surgeries Collect and process specimens

Instruction
Teach patients methods of health promotion and disease prevention

Procedures
Assisting with a neurological examination Assisting with lumbar puncture

Neurology Procedures
Assisting with Examination Nervous System Tests Electroencephalography Lumbar puncture Computed tomography Magnetic resonance imaging

Chapter Outline
Structures and Functions of the Nervous System
Structures of the Nervous System Neuron Central nervous system Peripheral nervous system Functions of the Nervous System Neuron Central nervous system Peripheral nervous system

CAAHEP Competencies
Clinical Competencies Patient Care
Prepare patients for and assist with routine and specialty examination Prepare patients for and assist with procedures, treatments, and minor office surgery

Chapter Summary Team Work Exercises Case Studies Resources

General Competencies Legal Concepts

Document appropriately

Medical Terminology Related to the Neurological System

435

Key Terms
affect

Emotional state or mood

aura

Structures and Functions of the Nervous System

The nervous system plays a key role in maintaining homeostasis, the state of dynamic equilibrium in the internal environment of the body. More complex than the most advanced computer, the nervous system is capable of storing vast amounts of data as well as receiving and sending thousands of messages throughout the body instantly and simultaneously.

Subjective sensation that occurs prior to and signals the onset of a migraine headache or a seizure
bradykinesia

Extreme slowness in movement

Brudzinski sign

Patient response in which neck flexion causes flexion of the hips when the patient is lying in a supine position
central nervous system

Nerve tissue that comprises the brain and spinal cord

cerebral concussion

Structures of the Nervous System

An understanding of the nervous system must begin with its most essential element, the neuron. While the nervous system functions as an integrated system, it is more easily understood when divided into its two major parts: the central nervous system (CNS) and the peripheral nervous system (PNS).

Brief loss of consciousness or brief episode of disorientation or confusion following a head injury
cerebral contusion

Injury involving bruising of brain tissue

contrecoup

Rapid acceleration-deceleration injury of the brain that bruises the front and back of the brain
corpuscallosotomy

Neuron
A neuron includes a cell body, dendrites, and axons. The cell body houses the nucleus and organelles, which are a variety of specialized structures within the cell. Dendrites resemble branches coming off of the cell body, much like the branches of a tree. The axons of a neuron are as short as a few millimeters or as long as a meter. They are cordlike projections that are sometimes covered in a myelin sheath made up of a specialized layer of cells. (See Figure 26-1.) Neuron cell bodies grouped together form gray matter. Axons bundled together form white matter, named for the whitish hue of

Surgical procedure in which the central part of the brain is partially divided in two
embolic

Caused by a moving mass in a blood vessel (embolus)

fasciculation

Visible involuntary muscle twitching

fibrillation

Spontaneous muscle contraction or quivering

homeostasis

State of equilibrium in the body

Kernig sign

Reflexive hamstring contraction and pain when attempting to extend the leg after flexing the hip
motor nerves Dendrite

Nerves involved in movement

myelin

Layer of phospholipids and protein that forms the myelin sheath of neurons and acts as electrical insulation
neuron

Nerve cell
neurotransmitter

Cell body

Chemical that plays an important role in nerve impulse transmission

nuchal rigidity

Nucleus Myelin sheath Axon Schwann cell Axon

Condition that involves pain and stiffness of the neck and a resulting reluctance to flex the head forward
paresthesia

Abnormal sensation
peripheral nervous system

Portion of the nervous system outside the central nervous system that conveys sensory and motor impulses
sensory nerves

Nerves that convey sensory information

spinal fusion

Surgical immobilization of adjacent vertebrae

thrombotic

Myelin sheath FIG 26-1 Neuron.

Caused by a blood clot

transection

Cutting

CHAP TER 26

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the myelin sheaths. Within the PNS, bundles of axons are called nerves.

Central Nervous System

The Central nervous system (CNS) includes the brain and spinal cord. The brain weighs about 3 lb (1.4 kg) and is made up of three major divisions: the cerebrum, cerebellum, and brainstem. The cerebrum is the largest portion of the brain and lies within the forebrain. Its surface, called the cortex, is made up of gray matter and is characterized by deep folds and shallow grooves, which increase its surface area. The cerebral cortex, along with other areas of gray matter, is full of neurons as well as specialized support cells called glia. The cerebrum also contains white matter, which makes up the bulk of the tissue of the cerebral hemispheres. This white matter is made up of the axons of the neuron. Buried in the white matter are special nuclei, called basal ganglia. The cerebrum is divided into two hemispheres, which are mostly separated by a deep, longitudinal fissure but are joined by the corpus callosum. The cerebellum is located in the inferior posterior portion of the head. It is about the size of a fist and shaped like a walnut. It is sometimes called the little brain, and, like the cerebrum, has convolutions (although smaller), an

outer cortex, inner white matter, and nuclei below the white matter. The brainstem runs from the forebrain to the spinal cord. It includes the medulla oblongata, pons, and midbrain. The brain is enclosed and protected by the hard bones of the skull, known as the cranium. The spinal cord extends from the base of the brain down to the second lumbar vertebra and is surrounded by the vertebral column. It is divided into sections that correspond to the vertebra and paired spinal nerves. A cross-section of the spinal cord reveals a butterfly-shaped inner core of gray matter, which contains nerve cell bodies. The gray matter is surrounded by white matter that forms ascending and descending pathways called spinal tracts. The brain and the spinal cord are covered by three membranes called the meninges, which continue beyond the end of the spinal cord to the distal end of the sacrum. Cerebrospinal fluid is contained between layers of the meninges and circulates around the brain and spinal cord. It is a colorless, clear fluid similar to blood plasma. (See Figure 26-2.)

Peripheral Nervous System

The Peripheral nervous system (PNS) includes 31 pairs of spinal nerves, 12 cranial nerves, and nerves in the arms and

Corpus callosum Meninges

Cranium

Cerebrum

Midbrain Brainstem Pons Medulla oblongata Spinal cord FIG 26-2 Brain. Cerebellum

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Central nervous system Peripheral nervous system Autonomic nervous system Parasympathetic system Sympathetic system

Cerebrum Cerebellum Brainstem Spinal cord To arm and head To eye To glands in head To trachea and lung

To heart To stomach To liver and spleen To kidney To intestines To thigh To knee, lower leg, and foot To colon and rectum To bladder To external genitalia

FIG 26-3 Central and peripheral nervous systems, along with the autonomic nervous system.

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legs. The cranial nerves are considered peripheral nerves. Most are called mixed nerves because they are made up of sensory and motor neurons. However, some are only sensory or motor. The spinal nerves branch off from either side of the spinal cord between the vertebra. Each spinal nerve is named for and corresponds to the vertebra above it. Spinal nerves are all mixed nerves. An important part of the PNS is the autonomic nervous system (ANS), which controls involuntary functions. It consists of motor nerves to smooth muscle, cardiac muscle, glands such as sweat glands, and salivary glands. It is further divided into the sympathetic and parasympathetic nervous systems. (See Figure 26-3.)

Functions of the Nervous System

The brain is a complex organ that allows humans to think, reason, express personality, and learn. It is an amazing organ capable of an incredible amount of multitasking. In simple terms, it stores a vast amount of data, processes a wealth of information, controls conscious thought, and keeps all autonomic (automatic) functions workingall at the same time. The spinal cord acts as a messenger, sending information to the brain from the body and from the brain to the body. The functions of the nervous system are organized according to their location in the CNS or the PNS.

involved in sensory perception, emotions, and muscle control. The basal ganglia in the white matter of the cerebrum organize motor function. The cerebellum is responsible for posture, balance, and coordination. The brainstem is an essential pathway that conducts impulses between the brain and spinal cord. The cranium provides a strong, hard enclosure that protects the brain from injury. The spinal cord is the pathway for sensory impulses to the brain from the rest of the body and motor impulses from the brain to the rest of the body. It also mediates stretch reflexes and the defecation and urination reflexes. The vertebral column provides a bony structure to surround and protect the spinal cord. In conjunction with surrounding muscles, it also allows movement of the torso and provides an upright framework for the rest of the skeleton. The meninges provide a supportive structure for many small blood vessels on the brains surface. They also provide protection to the brain and spinal cord by housing the cerebrospinal fluid, which continuously circulates and provides a cushion to protect against injury from impact and sudden movement.

Peripheral Nervous System

In the PNS, the 12 cranial nerves originate in the brain and brainstem and innervate such structures as the eyes, ears, nose, face, tongue, and some muscles in the throat and neck. (See Figure 26-4.) A key function of the 31 pairs of spinal nerves is the innervation of the skin and muscles of the limbs. Specific areas of the skin associated with specific spinal nerves are called dermatomes. (See Figure 26-5.) In some disorders, pain or other sensations caused by spinal nerve injury are felt along the associated dermatome, rather than the actual site of injury. Thus, a patient suffering from spinal nerve root compression sometimes feels pain or other symptoms in his arms or legs, rather than his back. The autonomic nervous system (ANS) within the PNS controls involuntary functions. Its motor nerves control smooth muscle, cardiac muscle, and glands such as sweat glands and salivary glands. Within the ANS, the sympathetic nervous system is responsible for the survival response known as the fight or flight response. This response prepares a person for action, whether it is to run from danger or to respond in some other way. The corresponding physical changes within the body include increased heart rate and force, increased blood pressure, increased blood glucose levels, bronchodilation, and decreased peristalsis. These changes provide the body with increased energy and oxygen while slowing some functions (such as digestion) that are less important at the time. The parasympathetic nervous system essentially creates an opposite response and dominates during nonstressful times. Some of its effects include decreased heart rate, bronchoconstriction, and increased peristalsis.

Neuron
A neuron works alone or in groups to sense internal and external environmental changes, transmit messages between the brain and body, initiate responses to help maintain the bodys state of equilibrium, and facilitate voluntary movement. Dendrites of the neuron, which resemble tree branches, are actually extensions of the cell body and act to sense changes in the bodys internal environment by receiving information from other neurons or from sensory receptors and send impulses to the main cell body. Axons are long, cordlike structures that transmit nerve impulses away from the cell body to other neurons, target organs, or muscles. The myelin sheath wrapped around each axon is composed of specialized cells made of a largely lipid substance that provides insulation to the axon, similar to the rubber covering on an electrical cord. The myelin sheath and the interspersed junctions, called nodes of Ranvier, allow the axon to function efficiently so that it can conduct impulses at an amazingly rapid rate.

Central Nervous System

The corpus collosum of the cerebrum serves to coordinate activity between the two hemispheres of the cerebrum. The convolutions of the cerebrum increase the surface area where nerve cell bodies are located, thus maximizing their function. The cerebral cortex, or gray matter, of the cerebrum is

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III, Oculomotor nerve II, Optic nerve VI, Abducent nerve

IV, Trochlear

V, Trigeminal

I, Olfactory nerve

XII, Hypoglossal nerve VII, Facial

X, Vagus nerve XI, Accessory nerve

VIII, Vestibulocochlear nerve

IX, Glossopharyngeal nerve

FIG 26-4 Cranial nerve locations and functions.

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C2

C2 C3 C3 C4 T2 T3 Cervical C5 C5 T1
C4 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4

C5 C6 C7 C8
C4

C5

C5

T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L2 Thoracic T1 C6 T1 C6

T1

C6

C6 T1

Lumbar

C8 C7

C8 C7 C7

C8

S5

C8 C7

L3 S2,3 L4

L3 L4

Sacral

L5

L5

S1

S2

S2

S1

S1

S1 L4 L5 FIG 26-5 Dermatomes.

Medical Terminology Related to the Neurological System

Neurological disorders cause symptoms that are distressing and uncomfortable to the individuals experiencing them, thus leading them to seek help from their health care providers. Whether medical assistants work in family practice offices, urgent care centers, neurology departments, or other areas, they play an important role in the provision of health care to these patients. To be effective in their role, medical assistants

must become well versed in the language and vocabulary that pertain to the nervous system. The following tables list common medical terminology related to the nervous system.

Common Nervous System Diseases and Disorders

There are many diseases and disorders affecting the nervous system. Here are some of the most common with

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Table 26.1 |

Word Elements

This table contains combining forms, prefixes, and suffixes that pertain to the nervous system, along with their meanings, and examples with a pronunciation guide and definition. Word Element
Combining Forms cerebr/o encephal/o gli/o mening/o meningi/o myel/o spinal cord; bone marrow neur/o spin/o Prefixes aandyshemimicropolyparaquadriSuffixes -al -algia -cele pertaining to pain hernia spinal (SPI-nal) neuralgia (nu-RAL-je-a) meningomyelocele (me-nng-go-MI-e-lo-sel) -eal -esthesia -logist pertaining to sensation specialist in the study of -logy -paresis -pathy -phagia -phasia -plegia -ptosis -trophy study of slight or partial paralysis disease swallowing speech paralysis drooping nourishment or growth neurology (nu-ROL-o-je) hemiparesis (hem-e-par-E-ss) neuropathy (nu-ROP-a-the) dysphagia (ds-FA-je-a) dysphasia (ds-FA-ze-a) blepharoplegia (blef-a-ro-PLE-je-a) blepharoptosis (blef-a-ro-TO-ss) atrophy (AT-ro-fe) meningeal (men-IN-je-al) hyperesthesia (h-per-es-THE-ze-a) neurologist (nu-ROL-o-jst) pertaining to the spine nerve pain herniation of the meninges and spinal cord (spina bifida) pertaining to the meninges increased sensation specialist in the study of nerves (nervous system disorders) study of nerves (nervous system disorders) slight or partial paralysis of half (of the body) disease of the nerves painful or difficult swallowing difficult speech paralysis of the eye or eyes drooping of the eyelid absence of growth without, absence of without, absence of painful or difficult half small much, many beside or near; two four aphasia (a-FA-ze-a) anesthesia (an-es-THE-ze-a) dysphagia (ds-FA-je-a) hemiplegia (hem-e-PLE-je-a) microcephaly (m-kro-SEF-a-le) polyneuritis (pol-e-nu-RI-ts) paraplegia (par-a-PLE-je-a) quadriplegia (kwod-r-PLE-je-a) absence of speech absence of sensation painful or difficult swallowing paralysis of half (of the body) small head inflammation of many nerves paralysis of two (legs) paralysis of four (extremities) nerve spine neurocytoma (nu-ro-s-TO-ma) spinal (SPI-nal) glue or gluelike meninges brain cerebrovascular (ser-e-bro-VAS-ku-lar) encephalocele (en-SEF-a-lo-sel) glioma (gl-O-ma) meningitis (men-n-JI-ts) meningioma (men-n-je-O-ma) myelography (m-e-LOG-ra-fe) pertaining to the brain and vessels herniation of the brain gluelike tumor inflammation of the meninges tumor of the meninges process of recording activity in the spinal cord or bone marrow tumor of nerve cells pertaining to the spine

Meaning

Example

Meaning

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Table 26.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to the nervous system with a pronunciation guide and brief definition for each. Term
amyotrophic lateral sclerosis al e-R a-m-o-TRO-fk LAT-er- skl O-ss Bell palsy BEL PAWL-ze carpal tunnel syndrome KAR-p TUN-el SIN-drom al

Definition
Chronically progressive, degenerative neuromuscular disorder that destroys motor neurons of the body; also called Lou Gehrig disease Disorder of the seventh cranial nerve that causes temporary weakness or paralysis of one side of the face Syndrome that is characterized by pain or numbness of the median nerve in the hand and forearm and caused by nerve compression and inflammation due to cumulative trauma from repetitive motion

encephalitis en-sef- I-ts a-L encephalomeningitis en-sef- o-m n-JI-ts a-l en- epilepsy ep-s EP--l e Huntington chorea ko-RE- a meningitis m n-JI-ts en- migraine headache MI-gran HED- ak multiple sclerosis MUL-t-pl skl O-ss e-R Parkinson disease PAR-kn-s d-Z EZ on peripheral neuropathy p IF- al nu-ROP- e er- er- a-th poliomyelitis pol-e-o-m-el-I-ts sciatica s-AT--k a shingles SHING-lz spinal stenosis al SPI-n ste-NO-ss stroke STROK transient ischemic attack TRANS- e- ent s-KE-mk a-TAK

Disorder that involves inflammation of the brain

Disorder that is a combination of encephalitis and meningitis

Chronic disorder of the brain marked by recurrent seizures, which are repetitive, abnormal electrical discharges within the brain Hereditary nervous disorder that leads to bizarre, involuntary movements and dementia Infection of the meninges, the spinal cord, and the cerebrospinal fluid, usually caused by an infectious illness Familial disorder marked by episodes of throbbing, severe headache that is commonly unilateral and, sometimes, disabling Chronic autoimmune disease that affects the central nervous system, causing inflammation and degeneration of the myelin sheath that protects nerve fibers Chronic, degenerative disease of the central nervous system that results in movement disorders and changes in cognition and mood Dysfunction of nerves that transmit information to and from the central nervous system with resulting pain, altered sensation, and muscle weakness Inflammation of the spinal cord caused by a virus, possibly resulting in spinal and muscle deformity and paralysis Severe pain of the sciatic nerve that radiates from the buttocks to the feet

Unilateral, painful vesicles that appear on the upper body and are caused by the herpes zoster virus Disorder that involves narrowing of an area of the spine that puts pressure on the spinal cord and nerve roots Sudden loss of neurological function due to vascular injury to the brain; also called cerebrovascular accident (CVA) and brain attack Temporary impairment of neurological functioning due to a brief interruption in blood supply to a part of the brain

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Table 26.3 |

Abbreviations

In neurology, as with other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed below save time and effort in documentation and written communications. Abbreviation
ALS

Term
amyotrophic lateral sclerosis, also called Lou Gehrigs disease

CNS CSF CT CVA

central nervous system cerebrospinal fluid computed tomography cerebrovascular accident; also called stroke or brain attack

EEG EMG ICP LP MRI MS PNS TIA

electroencephalography electromyogram intracranial pressure lumbar puncture magnetic resonance imaging multiple sclerosis peripheral nervous system transient ischemic attack

a summary of each, along with its corresponding ICD-9 code.

bleeds. Risk factors for hemorrhagic strokes include hypertension and the presence of aneurysms, which are weak, bulging areas in a vessel, or arteriovenous malformations (AVMs), which are abnormal clusters of tiny veins connected directly to tiny arteries without a capillary bed between. The cause of ischemic strokes is thrombotic, meaning caused by a blood clot, or embolic, meaning caused by an embolus, which is a substance in the bloodstream that becomes lodged in a small vessel. (See Figure 26-6.) Risk factors for ischemic stroke include cerebrovascular disease, atrial fibrillation (a type of heart irregularity), tobacco use, alcohol abuse, and clotting disorders. Signs and symptoms of stroke are highly variable depending on the extent of injury and the specific part of the brain affected. The patient usually exhibits symptoms on the opposite side of the body from the side of the brain injured. A left-sided stroke may cause right-sided paralysis or weakness and a right-sided stroke may cause left-sided symptoms. Other symptoms are usually sudden in onset and may include paresthesia (altered sensation, such as numbness, stinging, or burning, that results from injury to nerves) and weakness on one side of the body, vision loss or changes, dysphasia (difficulty speaking or understanding speech), dysphagia (difficulty swallowing), severe headache, dizziness, confusion, altered consciousness, and difficulty with gait (manner of walking) and balance. Diagnosis is usually based on signs and symptoms. Radiological studies, such as computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA), are used to confirm the diagnosis and differentiate hemorrhagic from ischemic strokes. In the case

Disorders of the Central Nervous System

Some of the most common diseases and disorders of the central nervous system include stroke, transient ischemic attack, migraine headache, epilepsy, encephalitis, meningitis, traumatic brain injury, spinal cord injury, Parkinson disease, multiple sclerosis, and tumors.
Area of brain deprived of blood

Blood unable to pass clot

Stroke
ICD-9-CM code: 436 Stroke, also called cerebrovascular accident (CVA) and brain attack, is the sudden loss of neurological function due to vascular injury to the brain. More than 700,000 individuals suffer from strokes annually in the United States. At greatest risk are those over age 65 with a family history of cerebrovascular disease. Cerebrovascular disease is caused by Au: bold atherosclerosis of cerebral arteries, which is the narrowing ok? not in key term and loss of elasticity of vessels due to accumulation of fatty list. cholesterol deposits. Strokes are classified as hemorrhagic or ischemic. Hemorrhagic strokes occur when a vessel in the brain ruptures and

Blood clot

Blood vessel

FIG 26-6 Thrombotic stroke.

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of a hemorrhagic stroke, lumbar puncture (LP) may reveal the presence of blood in the CSF. Treatment of ischemic strokes involves the administration of thrombolytic and anticoagulant medications. Thrombolytics are powerful drugs that dissolve blood clots. Anticoagulants are medications that delay or prevent blood clot formation. Criteria for the use of thrombolytic agents are very strict. The drug must be started within a specific time frame, usually 3 hours or less from the onset of symptoms, and cannot be given to anyone at risk for hemorrhage. Anticoagulant medication protects the individual from another stroke while the body heals itself. Treatment of hemorrhagic stroke includes surgery to remove blood clots from the brain and repair identified aneurysms. Other treatment is highly individualized and depends on the type and severity of the stroke and personal factors, such as age and baseline health status. Extended hospitalization may be required. As the patient recovers and enters the rehabilitation phase, emphasis is placed on reestablishing an optimal level of independence in all activities of daily living (ADLs), such as eating, bathing, toileting, dressing, and mobility. The rehabilitation period commonly takes months. Stroke is the third leading cause of death in the United States. It commonly produces long-term or permanent disability in those who survive. Common deficits include impairment of movement, mobility, and speech. However, many individuals are able to recover significant function with the help of physical, occupational, and speech therapies. (See Caring for stroke victims.)

Transient Ischemic Attack

ICD-9-CM code: 435 (use 4th digit to code specific site) Transient ischemic attack (TIA) is the temporary impairment of neurological functioning due to a brief interruption in blood supply to a part of the brain. Unlike stroke,

the impairment is temporary in nature and neurological function is fully restored within minutes or hours. An estimated quarter of a million Americans experience a TIA each year. Rates are higher in Hispanic and African American populations. TIAs are commonly caused by tiny particles of atherosclerotic plaque or tiny blood clots that dislodge from a heart valve or artery wall and travel in the bloodstream to the brain. Because of their tiny size, they are quickly dissolved by the bodys protective mechanisms before permanent damage results. Vascular spasm can also cause TIAs. Risk factors for TIA include cerebrovascular disease, tobacco use, alcohol abuse, hypertension, and clotting disorders. Signs and symptoms of TIA are variable and temporary. They include one-sided weakness, paresthesias, visual changes or vision loss, dysphasia, dysphagia, dizziness, confusion, altered consciousness, and difficulty with gait and balance. Deficits usually resolve within minutes or hours and signs and symptoms may resolve by the time the patient is evaluated. Therefore, a careful history and description from the patient and any witnesses is essential. Because a TIA is viewed as a possible warning sign of a future stroke, it must be taken seriously. Diagnostic testing is done to try to determine the cause and may include MRI and CT scans to examine cerebral arteries. Carotid Doppler studies may identify carotid artery narrowing. Treatment of the TIA is not necessary. However, measures to prevent stroke are critical and may include anticoagulant medication, management of hypertension, and surgery to remove carotid artery plaque. Patients are advised to reduce or eliminate modifiable risk factors, such as tobacco and alcohol abuse, as well as lose weight and include regular exercise in their daily routine.

Migraine Headache
ICD-9-CM code: 346.9 (unspecified) Migraine headaches are a familial disorder marked by episodes of severe throbbing headache that is commonly unilateral and sometimes disabling. They affect more than 28 million Americans and are three times more common in women than in men. The cause of migraine headaches is not fully understood, although they tend to run in families, are worse early in life, and generally improve in later years. Current theories about causes include involvement of the trigeminal nerve, imbalances in such chemicals as serotonin, and vascular dilation and inflammation. Many risk factors and potential triggers have also been identified, including hormonal changes and such foods as red wine, beer, aged cheese, chocolate, aspartame, and monosodium glutamate. Other triggers include stress, bright lights, fumes, perfumes, smoke, exertion, fatigue, environmental changes, and some medications.

Front officeBack office connection

Caring for Stroke Victims

Patients who suffer from stroke and other neurological injuries receive their early care in the hospital. However, those who recover will return to the medical office for follow-up care. Many of them may be struggling with some residual neurological deficit that impacts their ability to move, process information, respond, and speak. Therefore, medical assistants must remember to be patient, speak clearly, and allow such patients ample time to respond.

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Some individuals experience an aura, which is a type of sensory warning prior to the onset of the migraine. Auras may include flashes of light, visual changes, or tingling in the arms or legs. Signs and symptoms of migraine headache vary somewhat with the individual but commonly include throbbing pain on one or both sides of the head, nausea with or without vomiting, photophobia (sensitivity to light), and phonophobia (sensitivity to sound). Untreated migraines usually last between 4 and 72 hours. They may occur once a year or as often as every week. Diagnosis is nearly always based on the patients description of symptoms and a physical examination. However, if the headaches have a sudden, severe onset or have changed significantly in frequency or character, a more thorough neurological evaluation and diagnostic testing may be warranted. Such tests might include a CT or MRI scan and an LP so that cerebrospinal fluid can be evaluated. Treatment of migraine headaches has improved dramatically in recent years and numerous medications are now available, including ibuprofen (Motrin), a nonsteroidal antiinflammatory drug (NSAID), and acetaminophen (Tylenol) and other analgesics. In addition, one of the newer triptans, rizatriptan (Maxalt), helps abort the headache. People who experience more than two migraines per month commonly benefit from preventive medications, such as the antihypertensive lisinopril (Zestril), the antidepressant nortriptyline (Pamelor), and the antiseizure medication valproic acid (Depakote). In most cases, migraines cannot be totally eliminated. However, the prognosis for most individuals is good. Effective management for each person depends on identifying and eliminating or minimizing exposure to triggers and determining the most effective medication regimen. (See Caring for patients with migraine.)

from antiseizure medication, head trauma, illness, emotional or physical stress, fatigue, specific foods and chemicals, and flickering or flashing lights. Signs and symptoms of epilepsy depend on the type of seizures involved. (See Types of seizures.) Diagnosis is based on a history and description of symptoms and a description of the seizure activity. A thorough neurological evaluation is required. A number of diagnostic studies may be done, including electroencephalogram (EEG), CT scan, MRI scan, and LP. Treatment of epilepsy is aimed at reducing the number and severity of seizures. A variety of medications are available, including phenytoin (Dilantin), phenobarbital (Luminal), carbamazepine (Tegretol), valproic acid (Depakene), and gabapentin (Neurontin). For patients whose epilepsy does not respond to medication, surgical options may be considered, including implanting a vagal nerve stimulator, excision of the brain tissue responsible for triggering the seizures, and corpuscallosotomy, in which the central part of the brain, the corpus callosum, is partially divided in two. These surgical procedures effectively reduce the severity and frequency of seizure activity and make the individual more responsive to antiseizure medication. Treatment during an actual seizure should focus on protecting the individual from injury by removing nearby objects and providing privacy (when possible). Nothing should be inserted in the individuals mouth. The prognosis for epilepsy is generally good depending on the severity of the disorder and how responsive the patient is to treatment. In some cases, the seizures cannot be totally eliminated. However, in most cases, the severity and frequency can be reduced, resulting in an improved quality

Epilepsy
ICD-9-CM code: 345.90 (unspecified) Epilepsy is a chronic disorder of the brain marked by recurrent seizures, which are repetitive abnormal electrical discharges within the brain. Epilepsy seizure types have been categorized as partial, generalized, or unclassified. With generalized seizures, the excessive nervous activity affects both sides of the brain. With partial seizures, also called focal or local seizures, activity begins in one part of the brain but may occasionally evolve into a generalized seizure. As many as 2% to 3% or 2.3 million Americans have epilepsy and 125,000 new cases are diagnosed each year. Those most commonly affected are children and those over age 70. The cause of epilepsy is not clear but is thought to result from congenital or acquired brain disease. Various types of stimuli may trigger a seizure, including withdrawal

Front officeBack office connection

Caring for Patients with Migraine

The misery of migraine headaches is difficult to describe and is generally incomprehensible to those who have never had them. A sensitive response by administrative and clinical medical assistants will be greatly appreciated by such patients. Simple but thoughtful measures include: quickly escorting the patient to an examination room if one is available dimming the lights in the examination room offering an ice pack keeping noise to a minimum asking about nausea offering an emesis basin and a cool, wet washcloth.

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Types of seizures
The following table lists the most common types of seizures and the defining characteristics of each.

of life for the patient. A life-threatening complication of epilepsy is status epilepticus, which is characterized by continuous or recurrent seizure activity.

Encephalitis
Seizure Type
tonic-clonic (formerly called grand mal)

Characteristics
Duration: 2 to 5 minutes Intense muscle tension followed by jerking movements Loss of consciousness Bowel and bladder incontinence Postictal state for up to an hour, characterized by fatigue, lethargy, and confusion

GENERALIZED SEIZURES

tonic

Duration: 30 seconds to several minutes Intense muscle tension Loss of consciousness

clonic

Duration: several minutes Muscle contraction alternating with relaxation

absence (formerly called petit mal)

Duration: several seconds Patient appearing to be conscious but is not No postictal state More common in children Familial tendency

myoclonic

Duration: several seconds Brief jerking or stiffening of extremities

atonic

Sudden loss of muscle tone that may cause the patient to fall Postictal state characterized by confusion

ICD-9-CM code: 323.9 (unspecified) Encephalitis is inflammation of the brain and is usually associated with meningitis, which is the inflammation of the meninges. The two combined are known as encephalomeningitis. Encephalitis, which affects approximately 20,000 Americans each year, is usually caused by a virus. Those most commonly involved viruses are the arboviruses (group of viruses carried by insects, such as mosquitoes and ticks), herpes virus, AIDS, influenza, measles, chickenpox, and rabies. Some types of fungi and protozoa may also be involved. Patients with encephalitis may exhibit a wide variety of neurological symptoms, including seizures, fever, abnormal reflexes, muscle weakness, paralysis, and confusion. The individual may eventually lapse into a comatose state. Diagnosis is based on a history and description of signs and symptoms. Cerebrospinal fluid (CSF) is obtained via LP and examined to determine the causative organism. Other diagnostic tests include CT and MRI scans. Treatment of encephalitis is aimed at the underlying cause. Acyclovir is given for herpesvirus infections and rabies is treated with rabies immune globulin and vaccine. In all cases, treatment is supportive and focuses on managing increased intracranial pressure (ICP) with diuretics and corticosteroids. The prognosis for encephalitis depends on the timeliness of diagnosis and treatment. In many cases, rehabilitation and therapy is needed for the treatment of residual neurological deficits.

PARTIAL SEIZURES complex partial (also called psychomotor or temporal lobe) Duration: 1 to 3 minutes Loss of consciousness that involves odd behaviors, such as lip smacking, patting, and picking at clothing or other items No recollection of the event by the patient simple partial Patient remaining conscious Patient possibly experiencing an aura prior to the seizure, which might include a feeling of dj vu, an offensive smell, or a painful sensation Unilateral extremity movement Unusual sensations Autonomic symptoms that may include a change in heart rate, flushing, and epigastric discomfort

Meningitis
ICD-9-CM code: 322.9 (unspecified) Meningitis is an infection of the meninges, the spinal cord, and CSF and is usually caused by an infectious illness. The incidence worldwide ranges from 0.5 to 5 per 100,000 individuals. Those at greatest risk include infants and children and those in the military or living in dormitories. Other risk factors include a history of splenectomy, exposure to active and passive tobacco smoke, and exposure to those who are ill with meningitis. The cause of meningitis is usually viral or bacterial, although fungi, amoebas, or chemical irritation may also be causative factors. The most common infecting organisms include Streptococcus pneumoniae and Niesseria meningitides. Fortunately, the practice of including the Hib vaccine with childhood immunizations has drastically reduced the incidence of the Haemophilus influenzae meningitis. Some types of bacterial and viral meningitis are contagious and may be

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transmitted through exposure to large-droplet respiratory or oral secretions by coughing or kissing. Those at greatest risk are those who live in the same household or have close physical contact with infected persons. Common signs and symptoms of meningitis include headache; high fever; stiff, painful neck; nausea; vomiting; photophobia; confusion and fatigue; and seizures. Many of these symptoms may not be obvious in infants, who may exhibit loss of appetite, vomiting, irritability, or lethargy. Definitive diagnosis is based on examination of CSF, which may appear slightly cloudy due to increased white blood cells, protein, glucose, and bacteria. Most importantly, it will reveal the causative organism in the case of bacterial meningitis. Physical examination findings may include nuchal rigidity, which is pain and stiffness of the neck with a resulting reluctance to flex the head forward, a positive Kernig sign, which is the reflex contraction and pain in the hamstring muscles when attempting to extend the leg after flexing the hip, and Brudzinski sign, in which neck flexion causes flexion of the hips when the patient is lying in a supine position. Deep tendon reflexes are also increased. Treatment for meningitis must be aggressive to reduce the risk of death and disability. Differentiating bacterial from viral meningitis is important to determine the appropriate treatment and prevent transmission. Furthermore, identifying the specific causative organism in cases of bacterial meningitis is crucial in determining the appropriate antibiotic. Intravenous steroids reduce the risk of death and disability. Other medications may be given to reduce pain, fever, and seizure activity. The patients room should be kept dark and quiet to reduce environmental stimuli. In the case of bacterial meningitis, family members and those with

close direct contact may be treated with antibiotics as a preventive measure. Viral meningitis is usually less severe than bacterial meningitis with a better prognosis. Bacterial meningitis has a greater risk of causing brain damage, disability, or even death. Mortality rates are between 10% and 40%, with the highest rates in the elderly. Between 11% and 19% of those who survive meningitis will suffer permanent deficits, such as hearing loss, mental retardation, and limb loss.

Traumatic Brain Injury

Cerebral concussionICD-9-CM code: 850.9 (unspecified) Cerebral contusionICD-9-CM code: 851 More than 1.5 million Americans suffer from traumatic brain injury each year. Fortunately, approximately 75% of these cases involve only mild concussion. The incidence of head injury is greatest in adolescents, elderly patients, men, and African Americans. Cerebral concussion is a vague term that refers to a brief loss of consciousness or brief episode of disorientation or confusion following a head injury. Cerebral contusion refers to bruising of brain tissue and is, therefore, the more severe of the two injuries. The most common cause of cerebral concussion and contusion is a blow to the head, or a contrecoup type of injury, in which there is a rapid acceleration followed by deceleration that throws the brain forward and backward within the skull. As a result, delicate brain tissue and small vessels may be torn by the force or cut by sharp protrusions within the bony cranium. (See Figure 26-7.) Cerebral concussion usually results in a brief episode of loss of consciousness, confusion, or disorientation. Other temporary symptoms may include headache, drowsiness,

Cerebral contusion

Cerebral contusion

Contrecoup FIG 26-7 Brain injury. (A) Contrecoup. (B) Coup.

Coup

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and visual changes. The symptoms of contusion are generally more severe due to tiny cerebral hemorrhages and edema and include more prolonged loss of consciousness, memory problems, and vomiting. Diagnosis is based on neurological evaluation as well patient signs and symptoms. A CT scan is recommended for those with loss of consciousness lasting more than 1 minute or those with deteriorating neurological status. A CT scan revealing a salt and pepper appearance caused by tiny hemorrhages confirms the diagnosis of cerebral contusion. Spinal films should also be done to rule out spinal injury. Treatment of mild concussion is conservative and usually involves rest and analgesics. Treatment of severe concussion and cerebral contusions is more aggressive and hospitalization is usually required. The focus of care is on reducing and managing intracranial pressure (ICP), which can contribute to further brain injury if it rises too high. Prognosis is good with mild concussion. Those with more severe concussion may develop post-concussion syndrome, which includes memory problems, depression, and dizziness. The prognosis for cerebral contusion is more guarded, with a risk of escalating ICP and microhemorrhages progressing to hematoma. In either case, compression of the brain increases the risk of further injury with a higher likelihood of permanent neurological deficit.

Spinal Cord Injury

ICD-9-CM code: 344.1 (paraplegia), 344.0 (quadriplegia) Spinal cord injury involves traumatic bruising, crushing, or tearing of the spinal cord. Transection (cutting) of the spinal cord may be partial or complete, depending on the mechanism of injury (means by which injury occurred). Approximately 14,000 individuals in the United States suffer from acute spinal cord injury each year and another 300,000 to 400,000 are living with some degree of chronic disability as a result of spinal cord injury. More than 80% of acute spinal cord injury patients are young adult white males. Alcohol or mood altering drugs are a factor in more than half of all spinal cord injuries. The cause of spinal cord injury is some type of traumatic force, most commonly a motor vehicle accident. Other causes include violence in the form of shootings and stabbings, falls, and injuries from sports, such as diving and football. Initial signs and symptoms of spinal cord injury include loss of function, sensation, and reflexes below the site of the injury. However, with time and medical care, some return of function may occur. The degree of permanent deficit is widely variable and depends on the location, extent, and nature of the injury. Some individuals with relatively minor injury may regain full function, while others may be left permanently paralyzed from the neck down.

Diagnosis of spinal cord injury is based on a thorough neurological evaluation and radiological studies, including x-rays of the spine, CT scan, and MRI. Treatment involves stabilization of the patient in the emergency department, followed by transfer to the critical care unit. The spinal cord and vertebrae may be stabilized by application of Gardener-Wells tongs and traction. (See Figure 26-8.) This stabilization protects the spinal cord from further damage until the patient is deemed stable enough for surgery. During surgery, bone fragments and hematomas are removed and the spine is stabilized through spinal fusion, which is the surgical immobilization of adjacent vertebrae by grafting bone or insertion of hardware. Subsequently, application of a halo traction brace may enable increased mobility. (See Figure 26-9.) Victims of spinal cord injury suffer from profound, lifealtering injury as well as severe emotional trauma. The longterm prognosis varies and depends on the location, type, and severity of injury. In general, the higher the injury occurs on the spinal cord, the more severe the consequences and the more grim the prognosis. As the patient moves into the rehabilitation phase, emphasis is placed on restoration of optimal function and independence. Rehabilitation takes many months. Many patients require special medical care and must pay careful attention to self-care for the remainder of their lives in order to avoid such complications as pressure ulcers and autonomic dysreflexia. The eventual causes of death for those who survive the initial injury include pneumonia, pulmonary embolism, and kidney failure. (See Autonomic dysreflexia, page 450.)

Parkinson Disease
ICD-9-CM code: 32.0 Parkinson disease is a chronic degenerative disease of the central nervous system that results in movement disorders

FIG 26-8 Patient with Gardener-Wells tongs and traction.

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Autonomic dysreflexia
Autonomic dysreflexia is a potentially life-threatening complication for patients with spinal cord injury. The most common triggers are bowel distention, caused by constipation, or bladder distention, caused by urinary retention. The effects of autonomic dysreflexia are immediate and profound. Unless the patient gets immediate attention, autonomic dysreflexia may progress to a stroke. The best way for individuals to avoid this life-threatening complication is to maintain regular and effective bowel and bladder elimination patterns. The most common symptoms of autonomic dysreflexia are: hypertension profuse sweating above the spinal cord lesion severe, throbbing headache blurred vision apprehension nausea.

FIG 26-9 Patient with halo brace.

and changes in cognition and mood. It affects 1.5 million Americans, is most common in patients over age 65, and is more common in men than women. The cause of Parkinson disease is not fully understood; however, it does tend to cluster in families. The symptoms are caused by a deficiency of dopamine. Dopamine is a type of neurotransmitter, which is a chemical released by an axon terminal to inhibit or excite a target cell. Neurotransmitters play an important role in nerve impulse transmission. With a deficiency in these neurotransmitters, nerve impulse transmission becomes dysfunctional. Early symptoms of Parkinson disease include gradual onset of aching and fatigue in the extremities followed by resting hand tremor. Muscle rigidity develops and the classic, pillrolling tremor of the hands becomes prominent. The face develops a masklike, nonexpressive appearance and the voice becomes softer and quieter. Bradykinesia, a slow, hesitating pattern of movement, develops. In addition, the individual develops a shuffling gait that tends to speed out of control with walking. The posture becomes stooped with the neck bent forward. The individual develops difficulty initiating movements, such as standing up or turning over in bed. Swallowing difficulty is common and difficulty in managing oral secretions may eventually cause drooling. In some cases, mental slowing also occurs.

Diagnosis is based on presenting signs and symptoms and a thorough neurological evaluation. Dopamine levels in urine may be decreased. There is no known cure for Parkinson disease. Medical treatment includes levodopa-carbidopa (Sinemet) and other dopamine agonists. Other medications may be given to reduce oral secretions, tremor, and muscle rigidity. A multidisciplinary team approach is required to help the patient and family cope with this disabling disease. Because Parkinson disease is a progressive, degenerative disorder with no known cure, the outlook may be disheartening for those affected. Average life expectancy from the time of diagnosis is 10 years. However, many individuals live much longer and, with supportive care, are able to maintain a good quality of life.

Multiple Sclerosis
ICD-9-CM code: 340 Multiple sclerosis (MS) is thought to be a chronic autoimmune disease. Autoimmune diseases occur when the bodys immune system loses the ability to distinguish its own self cells from foreign or non-self cells. As a result, the immune system attacks the cells and tissues that it has misidentified. In the case of multiple sclerosis, the autoimmune disorder affects the central nervous system and causes inflammation and degeneration of the myelin sheath that protects nerve fibers. Attacks are usually episodic, resulting in repetitive episodes of disrupted nerve impulse conduction. There are several different types of MS; however, the

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most common is the relapsing-remitting type, which affects 85% of patients with MS. It is characterized by increasingly frequent attacks in which the individual experiences worsening symptoms alternating with periods of remission. Approximately 500,000 people in the United States have been diagnosed with MS. It is twice as common in women than men, with typical onset between the ages of 20 and 40. It is also more common in cold climates. The cause of MS is not fully understood, although it is thought to have an autoimmune basis. The immune system mistakenly recognizes the myelin sheath of nerve fibers as foreign and attacks it. Degeneration and malfunction occurs as a result. Triggers for MS include infections, viruses, and pregnancy. There is a familial component; children of patients with MS are 15 times more likely to develop MS than the average person. Symptoms of MS vary widely and may include weakness, fatigue, muscle spasms, altered gait, tremors, bowel and bladder dysfunction, sexual dysfunction, vertigo, tinnitus (ringing, buzzing, tinkling, or hissing sound in the ear), hearing loss, visual changes, altered sensation, dysphasia, dysphagia, anxiety, mood fluctuations, short-term memory deficits, inattentiveness, and impaired judgment. Diagnosing MS commonly takes time because the symptoms are intermittent and variable and other disorders must be ruled out. This process can be frustrating to patients. Diagnostic studies include MRI and CT scans, which indicate the presence of MS plaques. There is currently no cure for MS. Acute exacerbations may be treated with corticosteroids. Some medications may reduce the frequency and severity of relapses for some types of MS. However, they are expensive and not effective in every case. Therefore, therapy must be individualized. Patients with MS must develop a plan of self-care in which the focus is protection of the immune system. Regular, moderate exercise; good nutrition; adequate rest; and minimizing stress are all key components of such a plan. Prognosis for patients with MS varies and depends on the type of MS involved. In general, life expectancy is less than that of the general population.

cysts, abscesses, and a variety of benign and cancerous growths. Most are named for the tissue from which they originate and approximately half result from cancer that has spread from another site in the body. The specific cause of many types of brain tumors is unknown. Signs and symptoms of brain tumors are usually related to the pressure exerted on surrounding structures and increased ICP. Such signs and symptoms include headaches, seizures, nausea, vomiting, loss of consciousness, memory problems, personality changes, muscle weakness, sensory loss, aphasia, alterations in gait and balance, and visual disturbances. Diagnosis of brain tumor is based on a description of signs and symptoms, a thorough neurological evaluation, a medical history, and results of an MRI or CT scan. Examination of CSF may reveal cancerous cells, indicating spread of the cancer to the spinal cord. Edema of the optic nerve may be apparent on ophthalmic examination. Study of tissues obtained through surgery or biopsy determine whether the growth is cancerous or benign. Treatment for brain tumors depends on the type and location of the tumor. When possible, a tumor may be surgically removed. In any case, measures are taken to relieve ICP and associated symptoms. Antiseizure medication is given to treat or prevent seizures and corticosteroids may be given to decrease inflammation, thereby decreasing ICP. When the tumor is cancerous, surgery is usually followed with chemotherapy or radiation therapy. Prognosis depends on the type and location of the tumor. The general 5-year survival rate is just over 30%. However, the outcome is generally more favorable for younger patients, those with small tumor size, those with absence of mental changes at the time of diagnosis, and those in which the entire tumor is successfully removed. Survival rate is nearly 70% in children; however, many of them live with some degree of permanent neurological deficit caused by the tumor or adverse effects of treatment.

Disorders of the Peripheral Nervous System

Some of the most common diseases and disorders of the peripheral nervous system include amyotrophic lateral sclerosis, Bell palsy, peripheral neuropathy, carpal tunnel syndrome, and spinal stenosis.

Brain Tumor
ICD-9-CM code: 239.6 Tumor is a vague term used to describe any type of abnormal mass or growth of tissue that is different from neighboring tissue. A brain tumor is any type of abnormal mass growing within the cranium. Approximately 190,000 Americans are diagnosed with brain tumors each year. They are more common among populations of industrialized countries and among Whites. The composition of brain tumors varies with the type and there are more than 120 different types. Examples include

Amyotrophic Lateral Sclerosis

ICD-9-CM code: 335.20 Amyotrophic lateral sclerosis (ALS), also called Lou Gehrigs disease, is a chronic, progressive, degenerative neuromuscular disorder that destroys motor neurons of the body. It affects approximately 30,000 Americans with 5,600 new cases diagnosed each year. Men are affected more than women,

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and Whites are more commonly affected. Typical onset is between the ages of 40 and 70. The cause of ALS is unclear, although one form that affects approximately 10% of ALS patients is hereditary. ALS affects the motor nerves of the body and usually leaves sensory nerves and cognitive function intact. The typical course involves muscle weakness and fatigue that begins in the extremities and progresses to the trunk and head. It eventually affects respiratory muscles and muscles of the head, neck, and face. As a result, individuals become progressively paralyzed and eventually experience difficulty with breathing, speech, and swallowing. Life expectancy is only about 5 years from the time of diagnosis. Death is usually due to respiratory complications. There is no specific diagnostic test for ALS. Therefore, the diagnosis is achieved by ruling out other disorders. A thorough neurological evaluation and medical history are required. EMG and nerve conduction velocity (NCV) may reveal muscle fasciculations (visible, involuntary twitching of muscle fibers) and fibrillations (quivering or spontaneous contraction of muscle fibers). Muscle biopsy reveals atrophy. There is currently no cure for ALS. Survival time may be extended by use of riluzole (Rilutek), a medication approved for the treatment of ALS. The focus of care is on supportive, palliative care with the goal of helping the individual to maintain an optimal level of independent function. Palliative care is care that attempts to relieve pain and suffering but does not provide a cure. Priority must be given to protecting respiratory function. Medications may be used to decrease muscle spasticity and pain and to reduce oral secretions. A multidisciplinary approach to care is essential and should involve the patient, patients family, physician, nurses, medical assistants, therapists, case managers, and hospice workers. The patient and family should be given information about community resources, support groups, and advance directives.

Symptoms of Bell palsy vary somewhat. In most cases, there is some degree of paralysis that causes drooping of the facial features on the affected side. (See Figure 26-10.) Other symptoms may include twitching, weakness, drooling, eye dryness, impaired taste, excessive tearing, headache, ringing in the ears, and difficulty eating or drinking. Diagnosis is based on the patients signs and symptoms. A neurological examination is required. An EMG test will detect nerve damage. CT scan, MRI, and skull x-rays may be done to rule out other disorders. There is no cure for Bell palsy. However corticosteroids may be given to decrease inflammation and swelling. Antiviral medications may be given if a viral cause is suspected. Analgesics and warm, moist compresses may help relieve pain. Because the individual may be unable to effectively blink or close the eye, measures must be taken to protect the eye and keep it moist, including use of artificial tears and an eye patch. The prognosis for those with Bell palsy is very good. Recovery is complete in most cases but may take as long as 6 months. In some cases, the symptoms may never fully resolve and, in a very small number of cases, the paralysis may be permanent. Recurrences are rare.

Peripheral Neuropathy
ICD-9-CM code: 356.9 Peripheral neuropathy is a dysfunction of nerves that transmit information to and from the brain and spinal cord.

Bell Palsy
ICD-9-CM code: 351.0 Bell palsy is a disorder of the seventh cranial nerve that causes temporary weakness or paralysis of one side of the face. It usually comes on suddenly and takes months to resolve. It affects approximately 40,000 individuals each year in the United States. It is equally common in men and women and is most common between the ages of 15 and 60. It is more common among pregnant women and patients with diabetes or upper respiratory infections. Bell palsy occurs when the seventh cranial nerve becomes inflamed, swollen, and compressed. The underlying cause is unknown; however, it is believed that a virus may serve as the triggering event.
Facial drooping

FIG 26-10 Bell palsy.

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The disorder is characterized by pain, altered sensation, and muscle weakness. It may affect a single nerve or nerve group or may affect multiple nerves. Experts do not agree about the definition of peripheral neuropathy, which makes its incidence difficult to estimate. However, they all agree that it is extremely common. The cause of peripheral neuropathy is not clear. However, a number of disorders are associated with it, including diabetes, alcoholism, AIDS, rheumatoid arthritis, systemic lupus erythematosus (SLE), ingestion of toxic substances and some drugs, and nerve injury from prolonged immobility or compression. The symptoms of peripheral neuropathy may be motor, sensory, or both and vary widely depending on the nerve or nerves affected. The most common sensory symptoms are nerve pain and numbness. Motor symptoms include weakness, muscle twitching, atrophy, muscle cramps, loss of movement, and loss of coordination. Damage to autonomic nerves that impact involuntary or semivoluntary functions may result in such signs and symptoms as blurred vision, dizziness, diarrhea, constipation, urinary incontinence, and impotence, among others. Diagnosis is based on a detailed history and neurological examination. Tests may include an EMG, nerve conduction tests, and nerve biopsy. Blood tests may be done to identify or rule out underlying medical disorders, such as diabetes or nutritional deficits. Therapy is individualized depending on the symptoms. Goals include treating underlying disorders or nutritional deficiencies. Physical and occupational therapy may help build muscle strength and coordination. Braces, splints, or mobility aids may improve independence. Emphasis is placed on safety with a goal of preventing falls or injuries to extremities with decreased sensation. Such medications as analgesics, anticonvulsants, and antidepressants may help alleviate pain. The prognosis for peripheral neuropathy is variable, depending on the specific cause. In cases where an underlying disorder can be cured or treated, the outlook is positive. However, in some cases, nerve damage is permanent.

Transverse carpal ligament

Median nerve

Tendons

Tunnel

FIG 26-11 Carpal tunnel syndrome.

Carpal Tunnel Syndrome

ICD-9-CM code: 354.0 Carpal tunnel syndrome is a common type of entrapment neuropathy that occurs when the median nerve in the forearm and hand becomes compressed or irritated as a result of inflammation. It is three times more common in women than men. Also at risk are persons with diabetes or other metabolic disorders that affect the peripheral nerves. Carpal tunnel syndrome occurs as a result of increased pressure on the median nerve, which runs down the forearm into the wrist. (See Figure 26-11.) In some cases, the problem has a congenital cause, meaning the carpal tunnel,

through which the median nerve travels, is smaller in some people. Contributing factors include injury to the wrist, rheumatoid arthritis, and work stress in which the wrist is subjected to vibrations or repetitive movements. Carpal tunnel syndrome is especially common in individuals who perform assembly-line work, such as sewing, manufacturing, cleaning, or packing meat. Symptoms of carpal tunnel syndrome begin gradually, increase over time, and are commonly worse at night. They include tingling, itching, weakness, numbness, and pain that radiates up the arm. Diagnosis is usually based on signs and symptoms and physical examination. The wrist may be tender, warm, red, and swollen. Diagnosis can be confirmed with a nerve conduction study and ultrasound. Treatment for carpal tunnel syndrome begins with treating an underlying cause such as arthritis. Initial treatment is usually conservative and includes resting the wrist by splinting or avoidance of exacerbating activities. In addition, cool packs and NSAIDs may help relieve inflammation and pain. Corticosteroids may be taken orally or injected directly into the wrist to relieve inflammation. Some individuals find that chiropractic and acupuncture treatments are helpful. Yoga has been found useful in decreasing pain and increasing grip strength. The carpal tunnel release surgical procedure is recommended for those whose symptoms last longer than 6 months and who have not found relief with other measures. The surgery does not require hospitalization and can be done under local anesthesia. Recovery is usually complete but can take several months. Recurrence is uncommon.

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Spinal Stenosis
ICD-9-CM code: 956.0 (sciatic nerve injury), 724.00 (spinal stenosis) Spinal stenosis is the narrowing of an area of the spine. It most typically affects the upper or lower back and puts pressure on the spinal cord and spinal nerve roots. (See Figure 26-12.) It currently affects an estimated half a million Americans and is most common in those over age 50. In some cases, patients are born with spinal stenosis. However, it usually develops later in life, secondary to degenerative changes associated with aging. Primary contributors include osteoarthritis, disk herniation, ligament changes, misalignment of the vertebra, spinal tumors, traumatic injuries, and disorders of bone tissue formation. Any of these conditions can result in compression of spinal cord or spinal nerve roots, causing the associated symptoms.

Signs and symptoms of spinal stenosis vary, depending on the severity and the specific location. Patients commonly experience pain, numbness, or cramping in the legs, back, neck, shoulders, or arms. Patients may also complain of decreased sensation in the extremities, balance problems, and bowel and bladder dysfunction. Diagnosis of spinal stenosis is based on medical history, description of signs and symptoms, and a thorough examination of the spine. Radiologic studies help confirm the diagnosis and may include spinal x-rays, MRI, CT scan, CT myelogram, and bone scan. Nonsurgical interventions for spinal stenosis include NSAIDs (such as ibuprofen) and analgesics (such as acetaminophen) for pain as well as rest; moderate exercise; physical therapy; wearing a back brace or corset; epidural steroid injection; and an anesthetic injection known as nerve block. Surgical options, which usually provide long-term relief, include decompressive laminectomy, laminotomy, and spinal fusion.

Spinal cord Cauda equina Cauda equina

Spinal ganglion Spinal canal

Normal vertebra

Compressed nerves

Spinal stenosis of the lumbar vertebrae Stenosis

FIG 26-12 Spinal stenosis.

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Neurology Procedures
Neurology is a medical specialty that focuses on the study and treatment of diseases and disorders of the nervous system. A physician who specializes in this area of medicine is a neurologist.

Electrodes

Assisting with Examination

The medical assistant must prepare the patient for neurological evaluation by first checking vital signs and updating health history, including data regarding medications, allergies, family history, and recent symptoms of concern to the patient. In addition, the medical assistant should pay special attention to subtle clues about neurological functioning and possible deficits. While it is the neurologists role to conduct a thorough neurological evaluation, any significant observations made by the medical assistant might help the physician identify issues of special concern. Thus, the medical assistant should note the patients general appearance, hygiene, dress, and affect, which is the emotional reaction associated with an experience (also called mood). She should note whether the patient understands and responds appropriately to questions and commands, as well as any difficulty with shortterm memory and disturbances in gait, movement, strength, coordination, or speech. She should then assist the patient as needed with undressing and positioning and also assist the neurologist as needed with the examination and any procedures. (See Procedure 26-1: Assisting with a neurological examination, page 456.)

Brain waves monitored

FIG 26-13 Patient undergoing EEG testing.

Nervous System Tests

The medical assistant working in the neurology department may help with patient evaluations by conducting or assisting with a variety of diagnostic procedures. Each of these procedures helps to evaluate the patients condition and to gather data necessary for the diagnosing and treatment of neurological disorders.

cause waveform changes. For example, delta waves are slow, irregular waves normally found only in infants, small children, and sleeping adults. They are an abnormal finding in wakeful adults. Theta waves are slow, regular waves that indicate a decline in brain function. A flatline EEG indicates an absence of brain activity and is part of the criteria for determining brain death. (See Figure 26-14.) EEG has

Alpha: Relaxed

Electroencephalography
Electroencephalography is the process of amplifying, recording, and analyzing the electrical activity of the brain. The printed record obtained is called an electroencephalogram (EEG). A variety of electrodes are placed at specific locations on the patients scalp. (See Figure 26-13.) The machine then records the electrical activity at each site and measures the difference in activity between various sites. In resting adults the most common waveform is called the alpha rhythm and it includes 812 to 12 waves per second. Characteristic waveform changes occur depending on whether the individual is sleeping, awake and restful, or concentrating. In some cases, neurological diseases may
Beta: Alert

Theta: Drowsy

Delta: Sleeping 1 sec FIG 26-14 EEG wave patterns.

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PROCEDURE 26-1

Assisting with a neurological examination

Task Prepare the patient for and assist the physician with a complete neurological examination. Conditions Examination table Drape Patient examination gown Specific supplies and equipment including but not limited to: neurology reflex hammer safety pin otoscope ophthalmoscope penlight tongue blade tuning fork pinwheel cotton ball items for testing heat and cold sensation per physicians instructions small containers of sweet and salty solutions per physicians instructions items for odor identification per physicians instructions. Standards In the time specified and within the scoring parameters determined by the instructor, the student will successfully assist with a neurological examination. Performance Standards 1. Complete preliminary steps as for any general physical examination. Assist the patient into positions as instructed by the physician. Arrange the drape for warmth and privacy. 2. As the physician examines the patient, be prepared to hand him items as needed, such as the otoscope, ophthalmoscope, penlight, and tongue depressor.
Date 04/23/09; 11:55 a.m. Neurological examination completed by Dr. Lee, EEG scheduled for 4/24/09 at 8:10 a.m. -------------------------------------------------------------------------------------- S. Gonzales, CMA

3. Dim the lights if directed when the physician examines the patients eyes to help the patients eyes dilate. 4. Throughout the remainder of the examination, continue to assist the patient in assuming the positions directed by the physician and continue to hand needed items to the physician. 5. Follow standard precautions and take care when receiving any potentially contaminated items from the physician (such as the tongue depressor, speculum, or swabs) and handle them in a manner that prevents exposure to you. 6. Dispose of all waste in appropriate containers. 7. Place any obtained specimens in appropriately labeled containers. 8. Upon completion of the examination, assist the patient down from the table and instruct her to get dressed. Leave the room for a few minutes so the patient may change in privacy unless she requires your assistance to protect and respect the patients safety and privacy. 9. Schedule any ordered follow-up tests or appointments. 10. Direct the patient back to the reception area. Assist her if needed. 11. Document patient education, instructions, or scheduled tests in the medical record to ensure that the medical record is thorough and accurate. 12. Clean, sanitize, and restock the examination room as needed so that the room will be ready for the next patient.

been especially useful in the evaluation of seizure disorders and locating lesions within the brain.

Lumbar Puncture
Lumbar puncture (LP) is a procedure in which a hollow needle is inserted into the subarachnoid space below the end of the spinal cord, usually at the L3 to L4 intervertebral space. (See Figure 26-15.) The needle is used to withdraw CSF for analysis, inject dye, or drain fluid in order to relieve

pressure. Presence of blood in the CSF might indicate a stroke. Presence of bacteria might indicate bacterial meningitis. Elevated levels of protein or other substances might indicate a variety of other neuromuscular disorders. Lumbar punctures are performed on hospitalized patients at the bedside, in surgical centers, and in clinics in special procedure rooms. Therefore, the medical assistant must be prepared to assist with this procedure and to monitor the patient afterward. (See Procedure 26-2: Assisting with lumbar

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Spinal cord Subarachnoid space

L3 vertebra

Spinal needle is usually inserted between the 3rd and 4th lumbar vertebrae
01 1 2 3 4 5 6 7 8 9

L4 vertebra

FIG 26-15 Lumbar puncture.

puncture, page 458.) Facility policy must be followed regarding observing the patient for adverse effects, treating discomfort, and monitoring fluid intake and vital signs. (See Teaching about lumbar puncture, page 459.)

Computed Tomography
Computed tomography (CT) scanning is a radiographic technique that uses a computer to create a clear x-ray image of selected sections of anatomy. The images can be created in slices as thin as 1 mm. The procedure may be done with or without a contrast medium, which is injected before the scan. When used, the contrast medium enhances the images of certain structures. (See Figure 26-16.)

images of soft tissues and organ structures in the body. MRI is especially useful for imaging structures in the musculoskeletal and central nervous systems. The precise location of tumors or lesions within the brain can be detected, allowing a surgeon a clear three-dimensional picture of what might be encountered before performing surgery. (See Figure 26-17.) While contrast agents may be used with MRI, they are not required to create clear images of most structures. This type of procedure should not be used on a patient who has a cardiac pacemaker or other type of metal in the body. (See Teaching about MRI, page 459.)

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is a type of diagnostic radiography that uses powerful magnetic fields to create

FIG 26-16 Patient undergoing a CT scan.

FIG 26-17 Patient undergoing an MRI scan.

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PROCEDURE 26-2

Assisting with lumbar puncture

Task Prepare an individual for and assist with lumbar puncture to collect a specimen for CSF analysis. Conditions Local anesthetic Disposable lumbar puncture tray Mayo-type of supply stand Marker to label specimen tubes Sterile gloves Syringe and needle Patient examination gown Drape Standards In the time specified and within the scoring parameters determined by the instructor, the student will successfully assist with lumbar puncture. Performance Standards 1. Greet and identify your patient and introduce yourself to prevent errors and ease patient anxiety. 2. Review the nature of the procedure and determine whether the patient has any questions. 3. Check to make sure a consent form has been signed to ensure that the patient understands the procedure and possible effects and to reinforce information already given by the physician. 4. Instruct the patient to empty his bladder to increase patient comfort during the procedure. 5. Give the patient an examination gown. Instruct him to put it on with the opening in the back and then lie down on the examination table on his left side. 6. Provide the patient with a pillow for his head and a second pillow to place between his knees if desired to allow the physician the best access to the patients lumbar spine, while ensuring optimal patient comfort. 7. Position the patient in a fetal position and cover him with a drape to provide warmth and privacy for the patient and to maximize the spread of the L4-to-L5 space, making correct needle insertion easier and safer. 8. Wash your hands, assemble the supplies, and set up a sterile field, including needed sterile supplies. 9. Perform sterile skin preparation on the patients lumbar area to decrease microorganisms in critical areas and reduce the risk of infection at the puncture site. 10. Assist the physician as needed with the procedure, including: a. Hold the anesthetic vial upside down at an angle so the physician can aspirate fluid from it or pour it into a sterile cup on the sterile field. b. Provide reassurance to the patient and assist him in holding still in the fetal position to make the procedure easier for the physician and reduce the risk of injury to the patient. c. Hold the top of the manometer if requested by the physician. d. If pressure readings are taken, instruct the patient to refrain from talking or holding his breath. e. If directed by the physician, assist the patient in straightening his legs to increase the accuracy of the pressure readings. f. Mark the specimens sequentially according to the order in which they are collected (for example, #1, #2, and #3). g. Complete the laboratory requisition form and package the specimens for transport to ensure that results are accurately reported and accurately documented. 11. After the physician has completed the procedure and applied an adhesive bandage to the site, position the patient in a prone or supine position as directed by the physician. 12. Instruct the patient to lie flat for the required number of hours because lying flat, especially in the prone position, reduces likelihood of CSF leakage at the puncture site. It also reduces the risk of postprocedure headache for the patient. 13. Measure and record the patients vital signs, provide liquids, and evaluate the patient for discomfort according to facility policy. Through careful monitoring, the medical assistant becomes aware of any changes in the patients status. Promoting fluid intake helps the body replace the lost CSF fluid, reducing risk of headache. 14. Dispose of supplies, taking care to place sharps and contaminated items in appropriate biohazard waste containers. 15. Clean the room per facility protocol and sanitize your hands to maintain infection control. 16. Document data in the patients chart to ensure that the medical record is complete and accurate.
Date 02/19/09; 11:15a.m. LP performed by Dr. Greer. Specimen sent to lab, Pt lying prone, denies pain, VSS ---------------------------------------------------------------------------------------------- S. Gonzales, CMA

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Patient Education

Teaching About Lumbar Puncture

The medical assistant may share the following information with the patient preparing to undergo a lumbar puncture: The physician will explain the exact nature and purpose of the procedure. You will be asked to read and sign an informed consent form. This is your opportunity to ask the physician any questions you may have. Proper positioning is very important. You will be asked to lay on your left side or sit on the side of the examination table and lean forward on a pillow. In either case, you will flex your thighs and bend your head and chest as far forward as possible to assume the fetal position. Holding very still is extremely important. Someone will help you to do so. The physician will give you a local anesthetic to numb the area. The most common adverse effect is headache. You can minimize this and other potential complications by drinking fluids and laying down after the procedure as instructed.

Chapter Summary

Patient Education

Teaching About MRI

The medical assistant may share the following information with the patient preparing to undergo a magnetic resonance imaging (MRI) scan: You must remove any metal objects from your body, such as earrings, body jewelry, and watches. You should not undergo this procedure if you have metal inside your bodyfor example, a pacemaker or metal clip, pin, or rod. You will be asked to lay very still on a flat surface for the duration of the procedure, which usually takes between 30 and 90 minutes. The test itself is not painful. You may hear sounds coming from the pulsing of the magnetic field; this sound is normal. You will be able to talk with staff by microphone during the procedure. Please let the technicians know ahead of time if you suffer from claustrophobia.

The nervous system is made up of the central and peripheral nervous systems. It plays a key role in maintaining homeostasis in the body and is capable of storing and processing vast amounts of data. Medical assistants must be well versed in the language and vocabulary that pertain to the nervous system. In addition to knowing common combining forms, prefixes, and suffixes, they should be familiar with common abbreviations and pathological terms. Some of the most common disorders of the neurological system include stroke, transient ischemic attack, migraine headaches, epilepsy, encephalitis, meningitis, cerebral concussion, cerebral contusion, spinal cord injury, Parkinson disease, multiple sclerosis, brain tumor, amyotrophic lateral sclerosis, Bell palsy, peripheral neuropathy, carpal tunnel syndrome, and spinal stenosis. Neurology is a medical specialty that focuses on the study and treatment of diseases and disorders of the nervous system. To reach an accurate diagnosis, the neurologist must complete a thorough evaluation of the nervous system. The medical assistant prepares the patient by assisting him as needed with undressing and positioning. She also assists the physician with examinations and procedures. Procedures commonly used to diagnose neurological disorders include electroencephalogram, lumbar puncture, computed tomography, and magnetic resonance imaging.

Team Work Exercises

1. Teams will select or be assigned one of the following assignments. Research about the Mini Mental State Examination. Return to class with the following information prepared: a. purpose of the tool b. type of clients most commonly evaluated with this tool c. how the results are scored d. implications of low scores e. a role-play scenario in which the medical assistant evaluates the patient using the tool. Research about the Glasgow Coma Scale. Return to class with the following information prepared: a. purpose of the tool b. type of clients most commonly evaluated with this tool c. how the results are scored

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d. implications of low scores e. a role-play scenario in which the medical assistant evaluates the patient using the tool. A chart or poster that reflects the following information: a. name and function of each of the 12 cranial nerves b. method that might be used by the physician to evaluate each of the nerves c. a role-play scenario where the physician evaluates at least 4 of the cranial nerves A chart, illustration, or poster that reflects the following information: a. dermatomes of the body b. description of how the information in this chart might be useful in understanding a patients sensory symptoms c. a list and description of some of the tools that might be used to evaluate sensory function in a client without causing harm (heat, cold, sharp, dull, etc.). 2. Using medical word elements in the tables in this chapter, create as many terms related to neurology as you can think of. List the definition of each term next to it. The team with the most terms wins.

2. Hector Gonzalez is a 49-year-old Hispanic patient who woke up this morning and found the left side of his face paralyzed and drooping. He was extremely upset when he arrived and was sure that he had suffered from a stroke. He shares that his father died of a stroke and he is afraid this means he is going to die. He has a wife and several children depending upon him for support and he is worried about them. After a neurological evaluation, Mr. Gonzalez was diagnosed with Bell palsy. After the examination, the physician asked the medical assistant to provide more information about Bell palsy to Mr. Gonzalez. What information will you share?

Resources

Case Studies
1. Mr. and Mrs. Sommersby have an appointment today. Mr. Sommersby recently suffered from a stroke and now walks with the aid of a walker. They both convey their concerns about his risks of falling and injuring himself. What are some of the questions that the medical assistant might ask to learn more about the Sommersbys home environment? What are some suggestions that the medical assistant might offer to help reduce Mr. Sommersbys risk of injury in and around the home?

ALS Association: www.alsa.org Centers for Disease Control and Prevention: www .cdc.gov E-medicine: www.emedicine.com Hyman-Newman Institute for Neurology and Neurosurgery: www.nyneurosurgery.org Mayo Clinic: Generalwww.mayoclinic.org; Tools for Healthier Liveswww.mayoclinic.com Medline Plus: www.nlm.nih.gov/medlineplus The Michael J. Fox Foundation for Parkinsons Research: www.michaeljfox.org National Brain Tumor Foundation: www.braintumor.org National Institute of Neurological Disorders and Stroke: www.ninds.nih.gov National Parkinson Foundation: www.parkinson.org/ NETCOMMUNITY/Page.aspx?&pid=201&srcid=-2

CHAPTER

Cardiology and Lymphatics

Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell terms related to the cardiovascular and lymphatic systems identify key structures of the cardiovascular and lymphatic systems describe the electrical conduction system of the heart discuss the roles played by the cardiovascular and lymphatic systems describe the role of the medical assistant in the cardiology ofce identify common cardiovascular and lymphatic disorders list commonly used word elements related to the cardiovascular and lymphatic systems give at least 10 examples of how new cardiology-related terms may be created by combining prexes, sufxes, and combining forms describe physical examination techniques used to evaluate the cardiovascular and lymphatic systems list and describe types of cardiovascular testing done in or out of the cardiology ofce demonstrate the performance of an electrocardiogram (ECG). General Competencies Patient Instruction
Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention

27
Common Cardiovascular and Lymphatic System Diseases and Disorders
Cardiovascular System Hypertension Coronary artery disease Myocardial infarction Heart failure Aneurysm Atrial brillation Varicose veins Deep vein thrombosis Shock Anemia Leukemia Lymphatic System Hodgkin disease Non-Hodgkin lymphoma Acquired immune deciency syndrome

ABHES Competencies
Clinical Duties
Prepare patients for procedures Prepare patient for and assist physician with routine and specialty examinations, treatments, and minor ofce surgeries Perform electrocardiograms

Instruction
Teach patients methods of health promotion and disease prevention

Procedure
Performing a 12-lead ECG

Cardiology and Lymphatics Procedures

Assisting with Examination Electrocardiography Preparing the electrocardiograph machine Electrocardiograph paper Standardization Leads and electrodes Preparing the patient Recording the ECG Rhythm interpretation Artifacts Articial Cardiac Pacemaker Implantable Cardioverter Debrillator Cardiac Stress Test Holter Monitoring Event Recorder

Chapter Outline
Structures and Functions of the Cardiovascular System
Structures of the Cardiovascular System Heart Circulatory system Functions of the Cardiovascular System Heart Circulatory system

Structures and Functions of the Lymphatic System

Structures of the Lymphatic System Thymus Spleen Functions of the Lymphatic System Thymus Spleen

CAAHEP Competencies
Clinical Competencies Diagnostic Testing
Perform electrocardiography

Patient Care
Prepare and maintain examination and treatment areas Prepare patients for and assist with routine and specialty examinations

Medical Terminology Related to the Cardiovascular and Lymphatic Systems

Chapter Summary Team Work Exercises Case Studies Resources

461

Key Terms
ablation

Therapeutic destruction of a body part, pathway, or function using surgery, chemicals, electrocautery, or radiofrequency
angioplasty

Structures and Functions of the Cardiovascular System

The cardiovascular system is made up of the heart and the circulatory system, including arteries, veins, and capillaries. The cardiovascular system provides oxygen and nutrients to the entire body.

Endovascular procedure that reopens narrowed blood vessels

apical pulse

Pulse felt or heard over the apex of the heart

artifact

Signal interference on an ECG caused by patient movement, faulty equipment, or other factors
blood pressure

Structures of the Cardiovascular System

The structures of the cardiovascular system include the heart, located in the center of the chest, and the complex system of arteries, veins, and capillaries that are distributed throughout the entire body.

Tension exerted by blood against the arterial walls during ventricular contraction and relaxation
cardiac cycle

One complete contraction and relaxation cycle of the heart

cardioversion

Restoration of normal sinus rhythm by chemical or electrical means

depolarization

Heart
The heart is a muscular organ about the size of a closed st. (See Figure 27-1.) It is located in the center of the chest and slightly to the left in an area called the mediastinum. The heart has three layers: the outer lining, called the epicardium, the middle muscular layer, called the myocardium, and the inner lining, called the endocardium. The heart is enclosed in a brous membrane called the pericardium or pericardial sac, which also contains a small amount of uid called pericardial uid. The heart has two upper chambers, the right and left atria, and two larger, lower chambers, the right and left ventricles. The left ventricle is larger and more muscular than the right because of its greater workload. The right and left sides of the heart are divided by a thick layer of muscle tissue called the septum. There are four valves in the heart. The tricuspid valve exits the right atrium into the right ventricle, and the mitral, or bicuspid, valve exits the left atrium into the left ventricle. The pulmonary valve exits the right ventricle into the pulmonary artery, and the aortic valve exits the left ventricle into the aorta. The largest part of the heart, the lower left, is known as the apex. This site is best for auscultating sounds from the mitral valve and is where the apical pulse is best heard. Auscultating the apical pulse for one full minute is considered the most accurate method of measuring heart rate and is the preferred method in situations where accuracy is critically important.

Electrical change in cells in which the inside becomes positive in relation to the outside
diastole

Period of cardiac muscle relaxation when blood is lling the chambers of the heart and blood pressure is lowest
electrocardiogram

Record or tracing of electrical activity of the heart

electrocardiograph

Instrument used to record an electrocardiogram

electrocardiography

Process of recording the electrical activity of the heart

ligation

Application of a band, thread, or wire to tie a blood vessel or other structure in order to constrict or fasten it
lumen

Space within a vessel or other tubelike structure

lymph

Clear, colorless, alkaline uid found within lymph vessels made up of water, protein, salts, urea, fats, and white blood cells
palpitation

Sensation of rapid or irregular beating of the heart sometimes described as a thudding or uttering sensation
perfusion

Circulation of blood, nutrients, and oxygen through tissues and organs

phagocytosis

Process in which specialized white blood cells (phagocytes) engulf and destroy microorganisms, foreign antigens, and cellular debris
pressure point

Point at which an artery may be compressed to decrease blood ow in the event of hemorrhage
systemic circulation

Circulatory System
The circulatory system is composed of all the vessels of the body. (See Figure 27-2.) Major vessels entering and exiting the heart include the aorta, which is the largest artery in the body; right and left pulmonary arteries, which connect the right ventricle to the lungs; the superior and inferior vena cava, which are the largest veins in the body; and the right and left pulmonary veins, which connect the lungs to the left

Circulation throughout the entire body

systole

Period during contraction of chambers of the heart when blood pressure is the highest
systolic pressure

Tension exerted against arterial walls during ventricular contraction and represented by the top number in a blood pressure reading
troponin

Protein that is released into the blood by damaged heart muscle and, therefore, a highly sensitive and specic indicator of recent myocardial infarction

CHAP TER 27

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463

Superior vena cava Pulmonary artery

Aorta Pulmonary artery

Pulmonary veins

Pulmonary veins Pulmonary valve Left atrium Aortic valve Mitral valve

Right atrium Tricuspid valve

Right ventricle

Left ventricle

Inferior vena cava

Apex Interventricular septum FIG 27-1 Structures of the heart.

atrium. Blood ows from the heart to the body through smaller and smaller arteries, eventually ending in capillary beds. Capillaries are the tiniest blood vessels in the body. Capillaries also connect arteries and veins. Blood leaves capillary beds and is returned to the heart by way of larger and larger veins.

Functions of the Cardiovascular System

The heart serves as a pump that propels blood throughout the entire circulatory system. The heart and the circulatory system deliver much-needed oxygen and nutrients to all parts of the body.

Heart
The heart is a hollow, muscular organ that generates its own contractions approximately 60 to 100 times per minute throughout a persons entire life span. At an average rate of 72 beats per minute, the heart beats 104,000 times per day, and 38,000,000 times per year. The heart is enclosed within the pericardial sac, which contains a very small amount of pericardial uid. This uid acts as a type of lubricant and serves to reduce friction as the heart repeatedly contracts and relaxes.

Blood ows through both sides of the heart simultaneously and each side pumps blood to different parts of the body. (See Figure 27-3.) Blood that is low in oxygen but high in carbon dioxide (CO2) returns from the body to the right atrium via the inferior and superior vena cava. The atria are smaller than the ventricles and do approximately 30% of the workload of the heart, while the larger, more muscular ventricles do the other 70% of the work. Both atria contract at the same time, each pumping blood to a different area. As the right atrium contracts, blood is forced downward through the tricuspid valve into the right ventricle. As the right ventricle contracts, it forces blood up and out through the pulmonary valve into pulmonary arteries. The pulmonary arteries lead to the lungs, where CO2 is exchanged for oxygen (O2). The pulmonary arteries are the only arteries in the body that transport deoxygenated blood. Oxygen-enriched blood then returns through the pulmonary veins to the left atrium. The pulmonary veins are the only veins in the body that transport oxygenated blood. As the left atrium contracts, it forces blood downward through the mitral valve into the left ventricle. As the left ventricle contracts, it forces blood upward and out through

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the aortic valve into the aorta and out to various parts of the body. Branching off the base of the aorta are the right and left coronary arteries, which provide the heart with its own

blood supply and ensure that the heart always receives a generous share of richly oxygenated blood.

Conduction System
A cluster of specialized cells in the right atrium called the sinoatrial (SA) node serves as a natural pacemaker for the heart and initiates an electrical impulse about 60 to 100 times

Aorta

Pulmonary artery Superior vena cava Pulmonary vein

To head and arms

Inferior vena cava Lungs

Pulmonary artery Superior vena cava Right atrium Right ventricle

Pulmonary vein Aorta Left atrium Left ventricle

To organs

To trunk and legs

FIG 27-2 Structures of the circulatory system.

FIG 27-3 Cardiopulmonary circulation.

CHAP TER 27

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465

per minute. Each of these impulses is transmitted throughout all muscle cells of the heart, resulting in electrical depolarization. Depolarization is an electrical change in cardiac muscle cells in which the inside of the cells become positive in relation to the outside. This depolarization causes individual cardiac muscle cells in the atria to contract in unison. Within the oor of the right atrium is a backup pacemaker, the atrioventricular (AV) node. It receives the impulse from the SA node and transmits it onward to both ventricles via the bundle of His, located within the septum and the Purkinje bers, distributed through the septum and throughout the ventricles. As the electrical impulse is transmitted throughout the ventricles, all ventricular muscle bers contract in unison. This contraction occurs just slightly after the contraction of the atria and the combination of the two results in one complete heartbeat. This entire process is repeated with each heartbeat. (See Figure 27-4.)

pressure created by pumping blood, known as blood pressure, is written as two numbers, one written over the other, such as 120/80. The upper number, called the systolic pressure, is a measurement of the highest pressure exerted against artery walls during ventricular contraction, or systole. The lower number, called the diastolic pressure, measures the lowest pressure exerted against artery walls during ventricular relaxation, or diastole. Large arteries in the body that have a strong pulse and are easily palpated are known as pulse points. These points, sometimes called pressure points, may be compressed to slow bleeding in the case of hemorrhage. (Common pulse points are illustrated in Chapter 21, Vital Signs, on page 319.)

Circulatory System
The aorta, the largest artery of the body, delivers oxygenrich blood from the heart to various parts of the body via systemic circulation. As blood leaves the aorta, it moves through smaller and smaller arteries, all of which have thick, muscular walls because they carry blood under high pressure. The tiniest arteries, called arterioles, terminate in capillary beds. Capillaries are the tiniest blood vessels in the body and

Cardiac Cycle
The contraction and relaxation of the four heart chambers creates each heartbeat and is known as the cardiac cycle. Each cardiac cycle takes approximately 0.8 second. The

Sinoatrial (SA) node Right atrium Atrioventricular (AV) node Bundle of His Right ventricle Left atrium

Left ventricle Left bundle branch

Right bundle branch FIG 27-4 Electrical conduction system of the heart.

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are where the exchange of gases and nutrients occurs. Capillaries have walls that are only one cell thick, making them semipermeable. This permeability facilitates the delivery of oxygen and nutrients to tissue cells and the retrieval of carbon dioxide. Blood that is low in oxygen and high in carbon dioxide leaves the capillaries and enters tiny veins called venules. Venous blood continues owing through larger and larger veins until it returns to the heart via the superior and inferior vena cava. It then returns to the lungs, which facilitate the release of carbon dioxide. Venous blood travels under much less pressure than arterial blood. Because of this lack of pressure, venous blood cannot easily ow against gravity to ascend the legs and return to the heart. Fortunately, veins contain one-way valves that facilitate circulation by preventing the backow of blood. The pumping action created by the contraction and relaxation of leg muscles also helps to propel the blood forward.

veins, and capillaries. While blood vessels rely on the pumping action of the heart, there is no pump for the lymphatic vessels. Instead, lymph ow is facilitated by the pumping action of skeletal muscle contraction. The lymphatic system includes lymph nodes, commonly called glands, which serve as lters to clean debris from lymph and also to produce some white blood cells. Because of these functions, the lymphatic system is also considered part of the immune system.

Structures of the Lymphatic System

Lymph is excess uid from tissues that is eventually returned to the circulatory system via lymphatic vessels. While located in tissue spaces, it is called interstitial uid or intercellular uid. When located within lymphatic vessels, it is called lymph. Lymphatic vessels are located throughout the body and are connected to the superior vena cava, which is where lymph enters the circulatory system and is combined with blood. Lymph nodes are distributed along lymphatic vessels, with higher concentrations in the neck, axilla, groin, and the mesentery of the abdomen. (See Figure 27-5.) There are two sets of lymph nodes in the oropharynx, commonly known as the tonsils and adenoids. These nodes can become tender and swollen when the individual has a cold or sore throat. This occurs when lymph nodes that have been working to lter bacteria, virus, or other substances from lymph become overwhelmed and inamed. An inamed gland may be referred

Structures and Functions of the Lymphatic System

Lymph is tissue uid that has entered lymph capillaries and made its way into larger lymph vessels. It is a clear, colorless, alkaline uid made up mostly of water along with some protein, salts, urea, fats, and white blood cells. Lymphatic vessels are found throughout the body alongside arteries,
Blood capillary

Tissue cells Lymph capillary Interstitial fluid enters

Interstitial spaces

Arteriole

Venule

Lymph

Lymphatic vessel FIG 27-5 Lymphatic vessels.

CHAP TER 27

Cardiology and Lymphatics

467

to as adenitis or adenopathy. Other organs of the lymphatic system include the thymus gland and spleen.

Thymus
The thymus gland is located in the mediastinum above the heart. It consists of two fused lobes and is divided into an outer cortex mostly composed of immature T lymphocytes (a type of white blood cell) and an inner medulla. The thymus grows until puberty and then gradually shrinks in size as individuals age.

Adenoids Tonsils Cervical lymph nodes

Spleen
The spleen is a dark red, oval-shaped, lymphoid organ located in the left upper quadrant of the abdomen just under the ribs. It is surrounded by an outer capsule of connective tissue and is divided into compartments. (See Figure 27-6.)

Thymus gland

Axillary lymph nodes

Spleen

Functions of the Lymphatic System

The lymphatic system includes an intricate network of lymph vessels that collect and lter excess tissue uid and return it to circulation. This system plays a major role in the immune system because lymph nodes are rich in white blood cells (WBCs), which engulf bacteria and cellular debris through a process known as phagocytosis. The body responds to infection and inammation by increasing production of phagocytes.
Peyer's patches (small intestine) Appendix Bone marrow

Inguinal lymph nodes

Thymus
The thymus is most active during the prenatal period and early years of life. It plays a role in cellular immunity and is believed to play a role in protecting the body against cancer. T-lymphocytes, also known as killer T cells, mature in the thymus and then circulate to the spleen, lymph nodes, and other lymphoid tissue, where they are involved in cellmediated immune responses.

Lymphatic vessels

Spleen
The spleen contains a supply of 100 to 300 ml of blood and 30% of the bodys total platelets, most of which can be returned to circulation in the event of hemorrhage. Because of its location and rich blood supply, the spleen may be injured if the individual sustains a blow to the abdomen. Such an injury may require a splenectomy (surgical removal of the spleen) to stop internal bleeding. Fortunately, most people can survive without their spleen, although their immune system will be slightly weakened, leaving them more vulnerable to infection. During prenatal development, the spleen forms red and white blood cells. After birth, RBCs are produced by the spleen only in cases of severe need. However, the spleen continues creating WBCs as well as antibodies as part of its role in the immune system. Phagocytosis occurs to remove microorganisms, cell debris, and blood cells that are damaged, old, abnormal, or marked by antibodies.

FIG 27-6 Lymphatic system.

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Medical Terminology Related to the Cardiovascular and Lymphatic Systems

Cardiovascular disorders are among some of the most common and most serious problems treated in health care today. Lymphatic disorders, though slightly less common, can be

equally devastating to those affected by them. Medical assistants who work in family practice ofces, urgent care centers, cardiology clinics, or other areas play an important role in the provision of health care to these patients. To be effective in this role, the medical assistant must become well versed in the language and vocabulary that pertain to these body systems. The following tables list common medical terminology related to the cardiovascular and lymphatic systems.

Table 27.1 |

Word Elements

This table contains combining forms, prexes, and sufxes related to the cardiovascular and lymphatic systems along with examples of terms that use the word element and a pronunciation guide. Word Element
Combining Forms aden/o angi/o vas/o aort/o arteri/o ather/o atri/o cardi/o electr/o hem/o hemat/o lymph/o phleb/o ven/o splen/o thromb/o ventricul/o Prexes bradymicrosupratachySufxes -cyte -centesis cell surgical puncture thrombocyte (THROM-bo-st) phlebocentesis (eb-o-sen-TE-ss) clotting cell (term sometimes used for platelets) surgical puncture of a vein (more commonly, but less accurately, called phlebotomy) slow small above rapid bradycardia (brad-e-KAR-de-a) microcardia (m-kro-KAR-de-a) supraventricular (soo-pra-ven-TRIK-u-lar) tachycardia (tak-e-KAR-de-a) condition of a slow heart (beat) condition of a small heart pertaining to above the ventricles condition of a rapid heart (beat) spleen thrombus (clot) ventricle lymph vein aorta artery thick, fatty atria heart electric blood gland vessel adenoma (ad-e-NO-ma) angioedema (an-je-o-e-DE-ma) vasorrhaphy (vas-OR-a-fe) aortostenosis (a-or-to-ste-NO-ss) arteriosclerosis (ar-te-re-o-skle-RO-ss) atheroma (ath-er-O-ma) atrioventricular (a-tre-o-ven-TRIK-u-lar) tachycardia (tak-e-KAR-de-a) electrocardiogram (e-lek-tro-KAR-de-o-gram) hemolytic (he-mo-LIT-k) hematemesis (hem-at-EM-e-ss) lymphoma (lm-FO-m a) phleborrhexis (eb-o-REK-ss) venostasis (ve-no-STA-ss) splenomegaly (sple-no-MEG-a-le) thrombophlebitis (throm-bo-e-BI-ts) ventriculostomy (ven-trk-u-LOS-to-me) tumor of a gland swelling of a vessel suture of a vessel narrowing or stricture of the aorta hardening of the artery thick, fatty tumor pertaining to the atria and the ventricles condition of a rapid heart (beat) electrical recording of the heart pertaining to destruction of the blood vomiting of blood lymph tumor rupture of a vein stopping of a vein (refers to slowed blood ow) enlargement of the spleen inammation of a vein in the presence of a clot mouthlike opening in the ventricle

Meaning

Example

Meaning

CHAP TER 27

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469

Table 27.1 |

Word Elementscontd
Meaning
swelling condition of the blood

Word Element
-edema -emia

Example
lymphedema (lmf-e-DE-ma) leukemia (loo-KE-me-a)

Meaning
swelling caused by lymph uid a condition of white blood cells (refers to malignancy of the blood)

-genesis -gram -graphy -logist -lysis -megaly -ole -ule -pathy -penia -rrhage -rrhexis -rrhaphy -stenosis

creating, producing record process of recording specialist in the study of destruction enlargement small

hemogenesis (hem-o-JEN-e-ss) electrocardiogram (e-lek-tro-KAR-de-o-gram) angiography (an-je-OG-ra-fe) hematologist (hem-a-TOL-o-jst) hemolysis (he-MOL--ss) cardiomegaly (kar-de-o-MEG-a-le) arteriole (ar-TE-re-ol) venule (VEN-ul) adenopathy (ad-e-NOP-a-the) erythrocytopenia (e-rth-ro-s-to-PE-ne-a) hemorrhage (HEM-e-rj) phleborrhexis (eb-o-REK-ss) vasorrhaphy (vas-OR-a-fe) aortostenosis (a-or-to-ste-NO-ss)

creating or producing blood record of heart electricity (cardiac rhythm) recording of a vessel (radiological picture) specialist in the study of blood destruction of blood enlargement of the heart small artery small vein diseased gland deciency of red blood cells bursting forth of blood (severe bleeding) rupture of a vein suturing of a vessel narrowing or stricture of the aorta

disease deciency bursting forth rupture suture, suturing narrowing, stricture

Table 27.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to the cardiovascular and lymphatic systems with a brief denition of each. Term
Cardiovascular anemia a-NE-me-a aneurysm AN-u-rzm angina an-JI-na arrhythmia a-RITH-me-a arterial occlusion ar-TE-re-al o-KLOO-zhun arteriosclerosis ar-te-re-o-skle-RO-ss Reduction in the mass of circulating red blood cells

Denition

Dilation in the wall of a blood vessel due to weakness or a congenital defect

Chest pain or pressure caused by insufcient oxygen supply to the heart muscle

Irregular heart rhythm

Blockage of blood ow through an artery

Thickening and loss of elasticity and contractility in artery walls

Continued

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Table 27.2 | Term

Pathologic Termscontd
Denition
Condition in which fatty plaque deposits accumulate on the inner walls of arteries

atherosclerosis ath-er-o-skle-RO-ss bruit brwe cardiomyopathy kar-de-o-m-OP-a-the crackles KRA-kels deep vein thrombosis DEP VAN throm-BO-ss embolus EM-bo-lus endocarditis en-do-kar-DI-ts heart failure HART FAL-yer hypertension h-per-TEN-shun ischemia s-KE-me-a leukemia loo-KE-me-a murmur MUR-mur myocardial infarction m-o-KAR-de-al n-FARK-shun orthopnea or-THOP-ne-a paroxysmal nocturnal dyspnea par-ok-SIZ-mal nok-TUR-nal DISP-ne-a petechiae pe-TE-ke-e postphlebitic syndrome post-e-BI-tc SIN-drom prehypertension pre-h-per-TEN-shun premature atrial contraction pre-ma-CHUR A-tre-al kon-TRAK-shun premature ventricular contraction pre-ma-CHUR ven-TRIK-u-lar kon-TRAK-shun

Abnormal arterial or venous swishing sound heard on auscultation

Any of several diseases that affects the heart muscle

Abnormal lung sound heard on auscultation that is produced by air passing over retained airway secretions or the sudden opening of collapsed alveoli Blood clot within a vein deep in the legs

Mass of undissolved solid, liquid, or gaseous matter oating in the blood

Infection or inammation of the valves and inner lining of the heart

Inability of the heart to circulate blood effectively enough to meet the bodys needs

Condition in which blood pressure is higher than 140/90 on three separate readings that are several weeks apart Temporary reduction in blood supply to a localized area of tissue

Malignancy of the blood in which immature blood cells multiply at the expense of other cells Blowing or swishing sound in the heart due to turbulent blood ow or backow through a leaky valve Loss of living heart muscle as a result of coronary artery occlusion; also called a heart attack Labored breathing that occurs when lying at and is relieved by sitting upright

Episodic dyspnea at night that occurs repeatedly and without warning

Small, purplish, hemorrhagic spots on the skin that appear in patients with platelet deciencies and in many febrile illnesses Condition sometimes following deep vein thrombosis in which the individual experiences chronic edema and aching Condition in which systolic blood pressure measures between 120 and 140, diastolic blood pressure measures between 80 and 90, or both Heartbeat stimulated by a group of irritable cells in the atria other than the SA node

Heartbeat stimulated by a group of irritable cells in the ventricles

CHAP TER 27

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471

Table 27.2 | Term

Pathologic Termscontd
Denition
Hypertension that has no identiable cause; also called essential hypertension

primary hypertension PRI-ma-re h-per-TEN-shun pulmonary edema PUL-mo-ne-re e-DE-ma pulmonary embolism PUL-mo-ne-re EM-bo-lzm rhonchi RONG-k secondary hypertension SE-kun-dar-e h-per-TEN-shun shock SHOK venous stasis VE-nus STA-ss varicose vein VAR--kos VAN Lymphatic acquired immunedeciency syndrome a-KWIRD m-un de-FISH-en-se SIN-drom Hodgkin disease HOJ-kn d-ZEZ lymphadenopathy lm-fad-e-NOP-a-the lymphosarcoma lm-fo-sar-KO-ma mononucleosis mon-o-nu-kle-O-ss non-Hodgkin lymphoma non-HOJ-kn lm-FO-ma

Accumulation of uid in the interstitium and alveoli of the lungs

Obstruction of a pulmonary artery from an embolus

Low-pitched snoring, squeaking, or gurgling sound heard during auscultation of the lungs and caused by partial airway obstruction from mucus Hypertension caused by an identiable factor

Syndrome marked by inadequate perfusion and oxygenation of cells, tissues, and organs due to low blood pressure Sluggish blood ow caused by venous congestion

Enlarged, dilated vein

Late-stage infection with the human immunodeciency virus

Malignant lymphoma characterized by giant Reed-Sternberg cells

Enlargement and tenderness of lymph nodes due to local or regional infection or tumor growth Cancer of the lymphatic tissue not related to Hodgkin disease

Acute infection with the Epstein-Barr virus, which causes sore throat, fever, fatigue, and enlarged lymph nodes Group of malignant tumors of B or T lymphocytes

Table 27.3 |

Abbreviations

In cardiology and lymphatics, as in other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed below save time and effort in documentation and written communications. Abbreviation
Cardiovascular System AIDS ASHD acquired immune deciency syndrome arteriosclerotic heart disease

Term

Abbreviation
Cardiovascular System BP CABG

Term

blood pressure coronary artery bypass graft

Continued

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Table 27.3 |

Abbreviationscontd
Term
deep vein thrombosis hypertension (high blood pressure) International Normalized Ratio left atrium left ventricle myocardial infarction premature atrial contraction paroxysmal nocturnal dyspnea percutaneous transluminal coronary angioplasty

Abbreviation
DVT HTN INR LA LV MI PAC PND PTCA

Abbreviation
PVC RBC PTT RA RV WBC Lymphatic System AIDS HIV PCP

Term
premature ventricular contraction red blood cell partial thromboplastin time right atrium right ventricle white blood cell

acquired immune deciency syndrome human immunodeciency virus Pneumocystis pneumonia

PT

prothrombin time

Common Cardiovascular and Lymphatic System Diseases and Disorders

There are innumerable diseases and disorders of the cardiovascular and lymphatic systems. Some of the most common include hypertension, coronary artery disease (CAD), myocardial infarction (MI), heart failure, and acquired immune deciency syndrome (AIDS).

Cardiovascular System
Disorders of the cardiovascular system include hypertension, coronary artery disease, myocardial infarction, heart failure, aneurysm, atrial brillation, varicose veins, deep vein thrombosis, shock, anemia, and leukemia.

Hypertension
ICD-9-CM code: 401 Hypertension, commonly known as high blood pressure, is a condition in which three separate blood pressure readings over several weeks time measure the systolic pressure above 140, the diastolic pressure above 90, or both. It is further categorized as stage 1 (systolic of 140 to 159 or diastolic of 90 to 99) and stage 2 (systolic 160 or above or diastolic 100 or above). With the goal of identifying and treating hypertension earlier, experts have now dened prehypertension as systolic readings between 120 and 140 and/or diastolic readings between 80 and 90. One-third of American adults over age 35 have hypertension and a third of those do not know it. Incidence of hypertension increases with age

and is higher in the African American population than other ethnic groups. Hypertension is classied as secondary, which means that it is caused by an underlying disorder, or primary (also called essential), which means that the specic cause is unclear. Secondary hypertension makes up 5% to 10% of all cases, and primary hypertension makes up the other 90% to 95% of cases. Causes of secondary hypertension include kidney disease, congenital abnormalities of the aorta, and narrowing of certain arteries. Risk factors for primary hypertension include pregnancy, obesity, tobacco use, a family history of hypertension, and endocrine disorders such as diabetes. Hypertension is known as a silent killer because most people are asymptomatic until complications arise due to advanced disease. In some cases, individuals may complain of headache. However, unless high blood pressure is noted through the course of routine health screening or when individuals seek care for other problems, the rst indicator may be a complication such as stroke or heart attack. Diagnosis is easily made based on repeated high blood pressure readings over several weeks time. Treatment of hypertension depends on the severity. In most cases, health care providers try to employ conservative measures rst. Such measures include modication of identied risk factors, such as weight loss, elimination of tobacco use, dietary changes, alcohol intake restriction (1 to 2 drinks per day), and regular aerobic exercise. If these measures fail to achieve the desired result or the hypertension is extreme, the provider will prescribe medication. The most commonly used medications include diuretics and antihypertensives. Because of the large list of medications to choose from and

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the variation in individual response, the provider must personalize each treatment plan for the individual patient. Hypertension is a major contributor to the development of several serious conditions, including coronary artery disease, heart failure, heart attack, kidney failure, stroke, and vision loss. Therefore, health care providers should take the condition seriously and treat it aggressively whether the patient is symptomatic or not.

Lumen (space within artery)

Coronary Artery Disease

ICD-9-CM code: 414.0 Coronary artery disease (CAD) is dened as a narrowing of the lumen (the space within a vessel or other tubelike structure) of the arteries of the heart due to atherosclerosis, which is a condition marked by cholesterol-lipid-calcium deposits on the inner walls of arteries. It is the most common type of heart disease and is the leading cause of death of men and women in industrialized nations. Approximately 13 million Americans currently suffer from CAD and nearly half a million people die from the disease each year. CAD results from the development of atherosclerosis and arteriosclerosis (changes in arterial walls caused by thickening, hardening, and loss of elasticity), which impedes blood ow to heart muscle. (See Figure 27-7.) Risk factors include hypertension, tobacco use, sedentary lifestyle, obesity, diabetes, advanced age, and family history of CAD. Individuals with CAD are asymptomatic until the disease has advanced enough to cause angina (chest pain or pressure caused by insufcient blood ow and oxygen delivery to heart muscle) or heart attack. Symptoms of angina include chest pain and pressure or burning that may radiate to the neck, jaw, back, shoulders, or arms. Other symptoms of angina include nausea, vomiting, and diaphoresis (profuse sweating). Symptoms are brought on by physical exertion, emotional stress, eating large meals, or being in a cold environment. Symptoms of angina are temporary (usually lasting less than 30 minutes) and relieved by rest and nitroglycerine. Diagnosis of CAD is based on presenting signs and symptoms (if any) and the results of diagnostic tests. Tests may include a 12-lead electrocardiogram (ECG), cardiac catheterization, echocardiogram, chest x-ray, cardiac stress test, and blood lipid studies. Treatment of CAD depends on the severity of the disease and whether or not symptoms are present. In most cases, health care providers will employ conservative measures rst. These measures include lifestyle modication, such as weight loss, elimination of tobacco use, low-fat diet, alcohol restriction, and regular aerobic exercise. If these measures fail to achieve desired results or lipid levels are extreme, the provider will prescribe medication to reduce cholesterol and triglyceride levels. If the disease is limited to one or two areas within cardiac arteries, the patient may undergo

Blood flow

Narrowed lumen

Plaque

Artery wall

FIG 27-7 Coronary artery disease.

coronary angioplasty. In this procedure, the surgeon will place a stent or inate a tiny balloon to open narrowed vessels. When disease is more extensive, the patient may undergo open heart surgery to place coronary artery bypass grafts (CABGs) to divert blood around areas of narrowing or blockage. Prognosis for CAD varies, depending on the extent and severity of disease and the individuals underlying health status. Health care providers must take the condition seriously, because disease progression increases the risk of death from heart attack or other complications. However, early diagnosis and aggressive management usually results in signicantly increased length and quality of life. (See Reducing heart disease risk, page 474.)

Myocardial Infarction
ICD-9-CM code: 427.5 Myocardial infarction (MI), commonly called heart attack, is dened as the death of heart muscle related to coronary artery occlusion (blockage), which cuts off the supply of oxygen and nutrients. Over 1 million individuals in the United States suffer from an MI each year and about half of them die. Risk factors for MI are the same as for CAD and include atherosclerosis and arteriosclerosis, hypertension, tobacco use, sedentary lifestyle, obesity, diabetes, advanced age, and family history of heart disease. Symptoms of MI include pain, pressure, fullness, heaviness or squeezing sensation in the chest, arms, neck, jaw, back or epigastric

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Patient Education

Reducing Heart Disease Risk

Modiable risk factors for heart disease include hypertension; tobacco use; alcohol abuse; sedentary lifestyle; poorly controlled diabetes; obesity; low levels of high-density lipoprotein (HDL); and high levels of cholesterol, triglycerides, low-density lipoprotein (LDL), and very low-density lipoprotein (VLDL). Medical assistants working in the cardiology clinic as well as general family practice areas should be familiar with the following patient education guidelines: Stop or reduce the use of tobacco products. Keep alcohol intake to 2 drinks per day or less. Participate in aerobic exercise several times per week. Maintain blood pressure within recommended ranges. Diabetics should maintain blood glucose level within the recommended range. Keep cholesterol, LDL, VLDL, HDL, and triglycerides within the recommended ranges. Schedule a screening examination to nd out what cholesterol levels are. Eat a diet low in cholesterol and saturated fat. Attain and maintain a healthy weight.
Healthy muscle FIG 27-8 Myocardial infarction. Cholesterol plaque Coronary artery Dying muscle Occlusion Artery

area; dyspnea; nausea; diaphoresis; and lightheadedness. MI commonly causes heart arrhythmias (irregularity or loss of rhythm of the heartbeat, also called dysrhythmias). Half of those who suffer from an MI die within the rst hour of symptom onset. (See Figure 27-8.) Diagnosis of MI is based on presenting signs and symptoms and results of diagnostic testing. Immediate tests include a 12-lead ECG and blood tests to check cardiac enzymes. The blood test that is considered most reliable is the troponin level, which determines how much heart muscle damage has occurred. When the patients condition is stable, testing may be done to determine the extent of CAD and whether surgical intervention is needed. Such tests may include a nuclear heart scan, cardiac catheterization, and coronary angiography. These tests allow close inspection of heart chambers, valves, and coronary arteries. A MI is a life-threatening emergency and the effectiveness of treatment depends on early, aggressive treatment. Unfortunately, many individuals delay seeking medical attention for 2 to 12 hours. (See MI warning signs.) Initial medications include aspirin, nitroglycerine, thrombolytics, beta-blockers, and morphine. These drugs are usually followed by anticoagulants and, if needed, medication to manage hypertension and lower triglycerides and cholesterol levels. Other supportive care includes treatment of arrhythmias, administration of

IV uids, and respiratory support. In some cases, emergency angioplasty is done to treat severely narrowed coronary arteries. Rehabilitation focuses on two areas: exercise and education. Each patient follows an individualized exercise plan that supports him in gaining strength and endurance. The plan is designed around the patients abilities, energy level, and personal interests. Education addresses risk reduction through lifestyle modication and newly prescribed medications. A MI is a signicant event that destroys some heart muscle. For those who survive the rst post-MI hour and receive timely diagnosis and treatment, prognosis is good, with a 95% survival rate. Recovery and rehabilitation may take several weeks or months. (See Patient with chest pain.)

Heart Failure
ICD-9-CM code: 427.5 Heart failure, formerly called congestive heart failure, is the inability of the heart to pump enough blood to meet the needs of the body. The left ventricle is the part of the heart most affected in this condition. When the left ventricle is affected, the condition is referred to as left-sided heart failure and results in decreased effectiveness in pumping oxygenrich blood to all parts of the body. Failure of the right ventricle, called right-sided heart failure, is less common. This condition impedes effective pumping of blood that returns

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Patient Education

MI Warning Signs
Unlike in the movies, the fact that someone is having a heart attack is not always immediately apparent. Consequently, a person sometimes waits too long to summon help. The medical assistant should provide the following guidelines to patients at risk for a myocardial infarction (MI).

Different in women
A womans symptoms may vary from the major symptoms above and may include: nausea shortness of breath back or jaw pain chest discomfort (not as common).

Major signs of MI
Major signs of an MI include: mild or severe chest pain, pressure, fullness, heaviness, or squeezing that is constant and lasts for more than a few minutes or goes away and then returns discomfort in other areas of the upper body, such as one or both arms or the back, neck, jaw, or upper stomach shortness of breath with or without chest discomfort nausea breaking out in a cold sweat dizziness or lightheadedness.

What to do?
If you suspect that you or a companion may be experiencing an MI, take these measures: Call 911. If you are the person experiencing symptoms, do NOT drive yourself to the hospital. While waiting for an ambulance, rest in a position of comfort to decrease oxygen demands on your heart. Take one aspirin. Take nitroglycerine if it has been prescribed.

Front ofceBack ofce connection

Patient with Chest Pain

When a patient enters the medical ofce with complaints of pain, pressure, heaviness, or a squeezing sensation in the chest that may be accompanied by dyspnea, he must be treated as if he could be having a myocardial infarction (MI). An immediate and cooperative effort from administrative and clinical medical assistants and other staff is required to: Notify the physician. Assist the patient to an examination room and onto an examination table. Bring the code cart or supply cart that contains cardiac monitoring equipment, emergency cardiac medications, intubation equipment, and oxygen delivery equipment. Prepare for a STAT electrocardiogram (ECG). Prepare to draw blood for STAT laboratory tests. Prepare to start an IV. Call 911 if directed by the physician so the patient can be transported to a hospital. Minutes saved can mean lives saved. Therefore, the ofce staff should develop and follow a clear protocol for such situations and all members of the health care team should be familiar with their roles so that everything is handled efciently without duplication of effort.

to the lungs via the right side of the heart. Even so, as heart failure progresses, both sides of the heart become affected. Approximately 5 million Americans suffer from heart failure, and the incidence is increasing. More than half a million individuals are newly diagnosed each year, and about 300,000 people die annually from heart-failure-related causes. Those at greatest risk for developing heart failure include African Americans and the elderly. Heart failure is caused by ineffective pumping of the ventricles. The ventricles may lose effectiveness after heart muscle is lost due to MI or the heart is weakened by cardiomyopathy or other disorders, such as diseased heart valves, congenital heart defects, heart arrhythmias, CAD, diabetes, and hypertension. Damage from disorders such as kidney failure, sepsis (systemic response to massive infection), and other illnesses also contributes to heart failure. Because left-sided heart failure results in uid buildup in the lungs, the most common signs and symptoms are related to respiratory problems. Individuals commonly complain of shortness of breath, especially with exertion, and general fatigue. Some individuals may experience orthopnea (dyspnea when lying at that is relieved by sitting up) or paroxysmal nocturnal dyspnea (PND) (episodes of dyspnea at night that occur repeatedly and without warning). Other symptoms include lower extremity edema, decreased oxygen saturation, and the presence of crackles (uid in alveoli) heard on auscultation.

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Diagnosis of heart failure is based on signs and symptoms, medical history, and diagnostic testing. An echocardiogram, which creates a moving picture of the heart using sound waves, is one of the most useful tests. It reveals data about the hearts size, shape, and valve function. It also reveals areas of poor blood flow and whether all parts of the heart are contracting normally. Chest x-ray reveals pulmonary edema (fluid in the interstitium and alveoli of the lungs) and cardiomegaly (enlarged heart). A blood test of B-type natriuretic peptide (BNP) will be elevated. Treatment of heart failure includes the administration of diuretics, antihypertensives, and digoxin (Lanoxin). Diuretics stimulate ltration and excretion of urine. Excretion of urine reduces intravascular uid and allows uid to shift from the lungs back into blood vessels, thereby relieving dyspnea. Antihypertensives decrease the workload of the heart. Digoxin increases cardiac muscle contractility, thereby strengthening the pumping force of the heart. In cases of valvular disease, heart valve replacement may be considered. Heart transplantation is considered only in extreme cases. Of those with heart failure, approximately 10% to 20% die each year. However, early diagnosis and medical management can prolong life and increase its quality for most people.

Brain aneurysm

Brain Artery

Aneurysm
ICD-9-CM code: 442.9 An aneurysm is an abnormal dilation in the wall of a blood vessel (usually an artery) by more than 50% due to weakness in the vessel wall. Brain aneurysm is the most common type, and abdominal aortic aneurysm (AAA) is the second most common type. (See Figure 27-9.) One in fteen Americans has a brain aneurysm, although most will not realize it unless they become symptomatic. Every year, approximately 30,000 will suffer from bleeding. Brain aneurysms are most common in adult women between the ages of 35 and 60. However, AAA is most common among White males over the age of 60, and approximately 15,000 Americans die from a ruptured AAA each year. Atherosclerosis and weakness in the vessel wall is the cause of AAA. Brain aneurysms are usually congenital. General risk factors that compound vessel injury and increase aneurysm expansion and risk of rupture include diabetes, hypertension, tobacco use, alcohol abuse, and insomnia. A patient with a brain aneurysm or an AAA is usually asymptomatic unless the aneurysm ruptures. Rupture of a brain aneurysm causes sudden severe headache and hemorrhagic stroke. Rupture of an AAA causes pain in the abdomen or back that may radiate into the groin or ank. The patient may also complain of a feeling of fullness. Without immediate medical attention, severe hypotension, shock, and death quickly follow.

Aneurysm

Aorta

Heart

FIG 27-9 Aneurysm. (A) Brain aneurysm. (B) Aortic aneurysm.

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Diagnosis of an abdominal aneurysm may be discovered on examination when a pulsating mass is noted in the midabdomen. A bruit (abnormal swishing sound) may be heard upon auscultation. Radiological studies, such as MRI, CT scan, and ultrasound, conrm the diagnosis for all types of aneurysms. In some cases, aneurysm is noted when patients undergo examination or radiological testing for other purposes. When an aneurysm is found, it is usually examined repeatedly over time to determine whether it is increasing in size. This approach is sometimes called watchful waiting. Traditional treatment of unstable aneurysms includes surgery to insert a graft or clip to stabilize the area. In the late 1990s, a treatment method known as coil embolization was developed to treat brain aneurysms. In this procedure, a microcatheter is inserted through a large vessel near the groin and threaded to the aneurysm. Coils are inserted into the aneurysm, filling it from within and thus plugging it and preventing blood from entering. When a patient is identified as having a dissecting (tearing) or ruptured aneurysm, emergency measures are initiated, including surgery, blood and fluid replacement, and respiratory support. Prognosis depends on the type and location of the aneurysm and whether or not it is identied prior to rupture. When intervention occurs prior to rupture, chances of survival are good. However, once an aneurysm ruptures, the survival rate is low. Among those who suffer a ruptured brain aneurysm, 10% to 15% will die before reaching a hospital. Of those who survive the initial event, 50% will die within 30 days. Of those who survive long-term, approximately 50% will have some type of permanent neurological decit.

Atrial Fibrillation
ICD-9-CM code: 427 There are many types of heart arrhythmias. By far, the most common is atrial brillation. It occurs when irritable myocardial cells in the atrium, other than the SA node, re chaotically. As a result, the atria quiver uncontrollably rather than contracting normally. The ventricles, in turn, contract irregularly at a faster rate than normal, which results in a rapid, irregular heartbeat. Because of their chaotic quivering, the atria are ineffective in emptying and some blood may pool there and form a clot. Atrial brillation affects as many as 10% of all individuals over the age of 70, or about 2.2 million Americans. The underlying cause of atrial brillation is not always clear. Known triggers are many and include stress, exercise, alcohol withdrawal, cardiac surgery, cocaine intoxication, hypoxia, MI, pulmonary embolism (PE), and others. Chronic atrial brillation also occurs in those with chronic forms of heart disease.

Individuals with atrial brillation are sometimes asymptomatic. However, most experience rapid, irregular heart beat; hypotension; and chest palpitations (sensation of rapid or irregular beating of the heart). Other symptoms include shortness of breath, dizziness, and exercise intolerance. Atrial brillation is diagnosed using a 12-lead ECG. However, atrial brillation is sometimes intermittent in nature and may be missed by an ECG, which only detects arrhythmias occurring at the moment the ECG is performed. Therefore, accurate diagnosis may require the patient to wear a Holter monitor or an event recorder. These devices allow the detection of abnormal heart beats as the individual goes about her daily routine. Other diagnostic techniques may include echocardiography and transesophageal echocardiography. Conservative treatment of atrial fibrillation includes medication, such as digoxin, that slows the heart rate and may restore normal sinus rhythm (NSR). If medication is not successful, the patient will undergo cardioversion, which is a synchronized shock of electrical current delivered to the chest wall while the patient is under sedation and analgesia. If these measures are unsuccessful, the patient may undergo ablation (destruction of electrical conduction pathways) of the AV node. Subsequent placement of a pacemaker may prevent the chaotic atrial impulses from affecting the ventricles and ensure a stable heart rate. Prognosis for those with atrial brillation is good with accurate diagnosis and treatment. Even when restoration of NRS is not achieved, people commonly lead productive lives for many years with atrial brillation at a controlled rate. Potential complications include blood clot formation in the atria that may embolize to the brain and other vital organs and cause life-threatening complications, such as stroke or pulmonary embolism.

Varicose Veins
ICD-9-CM code: 454 Varicose veins are enlarged, dilated supercial veins that most commonly develop in the legs. An estimated 12 million Americans suffer from varicose veins. Women suffer from varicose veins more than men, with over 40% of all women over age 50 affected. Varicosities develop in veins rather than arteries because venous blood travels under low pressure and must ght against gravity to return to the heart. Blood ow is helped along by the presence of one-way valves in veins as well as the pumping action of surrounding leg muscles. However, when valves become incompetent and fail to close properly, blood movement becomes sluggish. This sluggishness results in vein engorgement, which further exacerbates valvular incompetence. It is unclear why this problem develops in some individuals and not in others; however, family history of varicose veins is a known risk factor. Others

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risk factors include obesity, pregnancy, and prolonged sitting or standing. Signs and symptoms of varicose veins include the appearance of distended, knotted-appearing supercial veins of the legs and feelings in the legs of pain, aching, and fatigue. Symptoms worsen with prolonged standing and are temporarily relieved by elevating the legs. Diagnosis is based on appearance of the veins and a description of symptoms from the patient. Conservative treatment aims at relieving symptoms and promoting venous blood return to the heart. It includes rest periods during which legs are elevated above the heart, wearing support hose, and ambulation or leg exercises every hour throughout the day. Patients should avoid activities that impede circulation, including wearing hose with tight leg bands, wearing girdles, crossing the legs, and sitting or standing for a prolonged time. Weight loss is encouraged if obesity is a factor. More aggressive treatment includes ligation and stripping (surgical procedures to remove the affected veins) or injection of a sclerosing solution that causes the vein to collapse, harden, and, eventually, atrophy. In most cases, varicose veins pose no signicant health risk other than discomfort and embarrassment related to their appearance. However, severe varicose veins do contribute to the development of deep vein thrombosis, which can be serious.

health care provider may also advise the patient to elevate the limb and apply warm compresses. A potential complication of DVT is embolization of the clot to the lungs, resulting in pulmonary embolism (blood clot in the lungs), which may be a life-threatening event. However, with timely diagnosis and intervention, most individuals recover without incident. In some cases, postphlebitic syndrome, a chronic condition marked by edema and aching, may develop.

Shock
ICD-9-CM code: 785.50 (unspecied; failure of peripheral circulation), 785.51 (cardiogenic), 785.59 (other) Shock is a syndrome of inadequate perfusion and oxygenation of cells, tissues, and organs as a result of low blood pressure. It is classied according to the underlying cause. Types of shock include cardiogenic (cardiac failure), hemorrhagic (blood loss), septic (massive infection), and anaphylactic (allergic). Incidence varies with the type of shock involved. Regardless of the cause, all forms of shock, if severe enough, ultimately lead to severe hypotension. As a result, vital organs of the body are not adequately perfused, resulting in organ system dysfunction and possible death. Early symptoms of shock are variable, depending on the underlying cause; however, they always include anxiety and a decreased level of consciousness. Late signs of shock include tachycardia, profound hypotension, diaphoresis, confusion, pallor, a dramatic drop in oxygen saturation levels, a dramatic decrease in urinary output, and, eventually, death. Diagnosis is based on recent medical history, the patients presenting signs and symptoms, and physical examination ndings. Because shock may be life-threatening, timely diagnosis is important, as is aggressive treatment tailored to the specic cause. Hypotension is treated by blood transfusion or administration of IV uids and vasoactive medications. The patient may be admitted to an intensive care unit, placed on cardiac monitors, and provided with respiratory support. Prognosis for the individual experiencing shock depends on the underlying cause and how quickly diagnosis and treatment begin. The outcome for a patient suffering from mild shock is good if appropriate treatment is initiated. However, survival for those suffering from severe, late-stage shock is poor.

Deep Vein Thrombosis

ICD-9-CM code: 451 Deep vein thrombosis (DVT), also known as thrombophlebitis, occurs when a blood clot develops in a deep vein, usually in the legs. The condition most commonly develops in adults over the age of 60 and those with impaired mobility, such as those with paralysis. DVT usually occurs secondary to vessel injury and blood stasis (sluggish blood ow) caused by poor circulation and immobility. Platelets begin to gather and brin formation occurs in areas of injury, creating a blood clot, and then inammation ensues. Other contributing factors include clotting disorders, heart failure, estrogen use, malignancy, obesity, and pregnancy. Common symptoms of DVT include a dull ache in the area of the clot, a feeling of heaviness, and localized edema, redness, and heat. A tentative diagnosis is based on physical examination ndings, description of symptoms, and tenderness on palpation. Diagnosis is conrmed with compression ultrasonography, which reveals the failure of a vein to compress where a clot is located. Radiographic venography may also help conrm the diagnosis. Treatment of DVT includes administration of an anticoagulant medication, such as heparin or enoxaprin (Lovenox), followed by warfarin (Coumadin). The patient should rest and refrain from exercise until the condition resolves. The

Anemia
ICD-9-CM code:280 to 289 (depends on specic type) Anemia is not a disease, but rather a symptom of disease. It is dened as a reduction in the mass of circulating red blood cells. An individual is considered anemic when her hemoglobin level drops below a specied point. However, normal

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values vary depending on gender, pregnancy status, age, the altitude at which a person lives, and race. Approximately 3.4 million Americans suffer from some form of anemia. Those most commonly affected include women and those with chronic disease. Some of the numerous causes of anemia include blood loss, vitamin or mineral deciencies, drop in red blood cell production as a result of kidney or bone marrow failure, or disorders that cause excessive red blood cell destruction. Signs and symptoms of acute anemia include weakness, fatigue, light-headedness, tachycardia, tachypnea, dyspnea, heart palpitations, angina, and headache. Chronic anemia may cause pallor and ssures at the corners of the mouth. In general, an individual has symptomatic anemia when the hemoglobin content of the blood is less than that required to meet the oxygen-carrying demands of the body. Diagnosis of a specic type of anemia is usually done by examining red blood cells (RBCs) and other blood components under the microscope to determine their shape, size, and color characteristics. Treatment of anemia depends on the underlying cause. For example, iron deciency anemia is treated with iron and vitamin C supplements. Pernicious anemia is treated with vitamin B12 supplements, and sickle cell anemia is treated with supplemental iron and blood transfusions. Prognosis for individuals suffering from anemia depends on the specic type, the underlying cause, and the individuals response to therapy.

Signs and symptoms of leukemia include fatigue, fever, frequent infections, pallor, petechiae (tiny purple-red hemorrhagic spots under the skin), and easy bruising or bleeding. Individuals may also experience hepatomegaly, splenomegaly, enlarged axillary or cervical lymph nodes, tenderness over bony areas, headache, weight loss, and bone and joint pain. Diagnosis is based on signs and symptoms, physical examination ndings, and examination of the blood and bone marrow. CBC with differential may reveal anemia as well as an abnormal count of the different types of WBCs, platelets, and RBCs. A lumbar puncture may be done to obtain spinal uid for examination. Treatment of leukemia varies with the specic type and usually involves chemotherapy, bone marrow transplantation, or both. Prognosis for individuals suffering from leukemia depends on the specic type and timeliness of diagnosis and treatment as well as other factors, such as whether a suitable bone marrow donor is identied. Survival rates vary dramatically, from 20% to 75%, depending on the type of leukemia and other factors.

Lymphatic System
Hodgkin Disease
ICD-9-CM code: 201.90 Hodgkin disease, also known as lymphoma, is a malignancy of the lymph system. It initially affects lymph nodes and eventually spreads throughout the lymphatic system, involving the spleen, liver, and bone marrow. About 7900 new cases of Hodgkin disease are diagnosed each year in the United States. Those most commonly affected include young adults between the ages of 15 and 40 and those over age 55. The cause of Hodgkin disease is not fully understood. However, the Epstein-Barr virus has been found in approximately 50% of those with the disease. Therefore, a link between the two is suspected. Other risk factors include a weakened immune system from chemotherapy or radiation, from human immunodeciency virus or AIDS, or from immunosuppressive therapy related to organ transplantation. A family history of Hodgkin disease is also a risk factor. In the early stages of Hodgkin disease, patients may be asymptomatic except for a painless lump in the axilla or neck. Other signs and symptoms are similar to inuenza and include fever, anorexia, weight loss, fatigue, itching, and night sweats. Eventually, tumors develop. Diagnosis of Hodgkin disease is conrmed upon nding the giant Reed-Sternberg cells in biopsied lymph node tissue. Staging is done to determine how advanced the disease is and to determine the best course of treatment. There are ve stages, with stage I being early disease involving a single lymph structure through stage V, which involves widespread disease. Chest, abdomen, and pelvic CT scans may be done to determine the extent of disease.

Leukemia
ICD-9-CM code: 204.0, 204.1, 205.0, 205.1 (depends on specic type) Leukemia is a malignancy of the blood and blood-forming tissues, including the bone marrow, spleen, and lymph nodes. There are a number of different types of leukemia, including acute and chronic forms. The chronic forms have a relatively slow course that averages 4 years, while the acute forms are fatal within months or even weeks. In the United States, approximately 29,000 adults and 2,000 children are diagnosed with some form of leukemia each year. Acute lymphocytic leukemia (ALL) is the most common type of leukemia to affect children. The other three typesacute myelogenous leukemia (AML), chronic lymphocytic leukemia (CLL), and chronic myelogenous leukemia (CML)may occasionally affect children but develop mostly in older adults. In all types of leukemia, abnormally rapid proliferation of one type of white blood cell (WBC) results in reduced production of other types of WBCs, RBCs, and platelets. The underlying cause is not always fully understood. Suspected triggers or contributors are thought to include viruses, tobacco use, chemical exposure, some drugs, previous radiation treatment, other types of cancer, and genetic factors.

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Treatment for Hodgkin disease includes chemotherapy alone or in combination with radiation therapy. Combinations of agents known by such acronyms as BEACOPP and others are common. Bone marrow transplantation may also be done. Approximately 1300 Americans die from this disease each year, a 60% drop in mortality since the 1970s. Prognosis depends on the stage of metastasis at the time of diagnosis. Early disease is conned to one or a few nodes, while advanced disease has spread to both sides of the diaphragm or throughout the body. Those with early disease have a 5-year survival rate as high as 90%.

Non-Hodgkin Lymphoma
ICD-9-CM code: 202.8 Non-Hodgkin lymphoma is a group of more than 30 types of malignancies of B or T lymphocytes. These malignancies affect approximately 54,000 Americans each year. The disease is more common in men than women. The cause of non-Hodgkin lymphoma is unclear. However, those who have received previous treatment with immunosuppressive therapies have a risk 100 times greater than others. Other risk factors include infection with AIDS and Epstein-Barr viruses, the Helicobacter pylori bacteria, and exposure to some chemicals used to kill weeds and insects. Early symptoms of non-Hodgkin lymphoma are similar to Hodgkin disease and include painless lymphadenopathy and, sometimes, fever, night sweats, fatigue, abdominal pain or swelling, and weight loss. Diagnosis is determined by identifying malignant cells via lymph node biopsy and bone marrow examination. CT scans and MRI are done to help determine the extent of spread. Treatment of non-Hodgkin lymphoma includes radiation therapy, chemotherapy, and bone marrow transplantation. Prognosis depends on the specic type of non-Hodgkin lymphoma involved and the timeliness of diagnosis and treatment. Some types spread slowly and respond well to treatment; others spread quickly, respond to treatment poorly, and are rapidly fatal.

Acquired Immune Deciency Syndrome

ICD-9-CM code: 042 Acquired immune deciency syndrome (AIDS) is a latestage infection of the human immunodeficiency virus (HIV), which progressively weakens the immune system. This disease was rst reported in the United States in 1981 and has since become a worldwide epidemic. Two human immunodeciency viruses have been identied: HIV-1 and HIV-2. Most HIV infections in West Africa are caused by HIV-2. Most other cases in the world are caused by HIV-1. HIV is a retrovirus, which means that it cannot survive on its own but invades human CD-4 lymphocytes and

uses them as its host cell. As the virus proliferates and destroys CD-4 lymphocytes, it leaves the body vulnerable to infection. Diagnostic criteria for diagnosis of AIDS includes HIV infection with a CD-4 helper T-cell count of less than 200, the presence of an opportunistic infection, the presence of an AIDS-dening malignancy, or a combination of these criteria. AIDS is the fourth most common cause of death worldwide and is the leading cause of death in Africa. While anyone can be infected with the AIDS virus, the most common victims have limited access to health care and are poor, heterosexual, and between the ages of 15 and 44. Approximately 1 million cases of AIDS have been reported in the United States and about half of those individuals have died. It is estimated that only about 10% of those infected with AIDS have been diagnosed. Approximately 40,000 Americans are newly infected each year and more than 40 million individuals are infected with AIDS worldwide. HIV is acquired through direct contact with infected bodily uids, such as blood, blood products, semen, and vaginal secretions of another person. The most common means of AIDS transmission includes unprotected sexual intercourse, injection drug use, and children born to infected mothers. It is not spread through casual contact, such as shaking hands and hugging. Health care workers may contract the disease through needlestick injuries and major exposure to mucus membranes, such as splashing of blood or body uids into the eyes and nose. However, the practice of standard precautions signicantly minimizes this risk. About 1 to 2 weeks after exposure to HIV, individuals commonly experience ulike symptoms of fever, body aches, and sore throat. However, few people recognize this as a warning that they have contracted HIV. For the most part, individuals are asymptomatic in the early stages and may unwittingly transmit the virus to others. As the disease progresses and the immune system weakens, opportunistic infections are frequent. Common examples of opportunistic infection include Pneumocystis pneumonia (PCP), cytomegalovirus, infections with Candida albicans, and malignancies. These infections cause anorexia, weight loss, fatigue, fevers, chills, sweats, breathlessness, pneumonia, diarrhea, lymphadeonopathy (tender, enlarged lymph nodes), and skin rashes. In some cases, dementia develops. Confirmation of HIV infection is based on the detection of HIV antibodies in the blood by the enzyme-linked immunosorbent assay (ELISA) and Western blot test. If the ELISA test is positive, the test is repeated. Confirmation of diagnosis is done with the Western blot test. Trained clinic personnel can employ newer testing methods, which produce results within 60 minutes and involve testing the blood or swabbing the inside of the mouth around the gums. A home test is also available. The test includes instructions for obtaining a drop of blood by pricking the

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finger and applying it to the enclosed card, which must be mailed to a laboratory for testing. Because the individual uses an identification number, this system ensures privacy and confidentiality. As with other HIV testing, the patient must confirm positive results by undergoing a Western blot test. Disease progression is monitored by checking CD-4 lymphocyte counts and viral load. As the disease progresses and the immune system weakens, the CD-4 count decreases and viral load increases. There is currently no cure for HIV or AIDS. Treatment includes the use of highly active antiretroviral therapies (HAART), which include a drug that inhibits HIV-1 protease and drugs that block viral reverse transcriptase. General measures that protect the immune system and protect against other infections are advised. These measures include getting immunized, use of anti-infective medications as needed, avoidance of high-risk behaviors, good nutrition, adequate sleep, moderate exercise as tolerated, and avoidance of others with communicable diseases or infections. AIDS is ultimately a fatal disease. However, individuals with AIDS are living much longer, healthier lives than in the past, due to advances in treatment. Current life expectancy is approximately 10 years from the time of diagnosis. Even so, the prognosis varies widely, depending on the individuals self-care practices and access to health care resources. (See Immunocompromised patients.)

Cardiology and Lymphatics Procedures

Cardiology is a medical specialty that focuses on the study and treatment of disorders of the cardiovascular system. While many physicians diagnose and treat cardiac disorders, those who specialize in this area of medicine are called cardiologists.

Assisting with Examination

To reach an accurate diagnosis, the physician must obtain a medical history, including a description of symptoms, and perform a comprehensive physical examination. The physician inspects the skin for discoloration that might indicate poor circulation as well as distended neck veins or lowerextremity edema that might indicate uid overload related to heart failure. The physician carefully auscultates the heart to detect abnormal sounds. He also auscultates the lungs for abnormal sounds, such as crackles or rhonchi (low-pitched snoring, squeaking, or gurgling sounds), that indicate the presence of uid. The medical assistant must prepare the patient by checking vital signs and obtaining a health history, which may include family history, risk factors for CAD, and new or unusual symptoms the patient has experienced. She should then assist the patient as needed with undressing and positioning and assist the physician as needed with the examination and procedures.

Front ofceBack ofce connection

Immunocompromised Patients
Patients with diseases like leukemia and AIDS are commonly immunocompromised, which means they are especially vulnerable to acquiring other infectious diseases within the medical ofce. Clinical and administrative medical assistants should collaborate with the other health care providers in the ofce to identify steps they can take to ensure the welfare of such patients. Such measures may include: establishing a plan for immunocompromised patients to enter the ofce through a lesser-used entrance immediately escorting the patient to an examination room providing the patient with a mask to wear while in the medical ofce providing a supply of masks for the patient to keep at home for their next trip to the clinic remembering to carefully practice standard precautions ensuring that health care personnel with infectious conditions (such as the common cold) do not come in contact with the patient.

Electrocardiography
Electrocardiography is a common, painless, noninvasive procedure that can be done in the physicians ofce during a routine physical examination. The electrocardiogram (ECG) is the written record that is produced from this procedure and is created by use of an electrocardiograph machine. The electrocardiograph machine is connected to the patient with wires and electrodes that are sensitive to the electrical impulses generated by the patients heart. This electrical activity is represented on electrocardiograph paper through specic waveforms, which are then reviewed and analyzed by the physician. The information obtained aids in the diagnosis and treatment of cardiac problems. ECGs are also commonly done prior to major surgical procedures to establish baseline health information about a patient and to identify potential cardiac disorders. Because this data is so important, the medical assistant must have a good understanding of how to obtain an accurate ECG.

Preparing the Electrocardiograph Machine

To obtain accurate ECG tracings, the medical assistant must be familiar with the ECG machine and equipment in

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the medical ofce and become procient in its use. (See Figure 27-10.)

Electrocardiograph Paper
The paper used in ECG machines is pressure- and heatsensitive. The ECG machine includes a stylus that becomes hot when the machine is turned on. The stylus marks the ECG paper as it moves horizontally past at a specic rate. The paper is also a type of graph paper, with vertical and horizontal lines at 1-mm intervals and bold horizontal and vertical lines at 5-mm intervals. The space between each vertical line represents 0.04 second of time, and the space between bold vertical lines (5 tiny boxes) represents 0.2 second of time. The space between horizontal lines represents amplitude or voltage. When the machine is properly calibrated, 10 mm of amplitude (10 tiny boxes or 2 large boxes) equals 1 millivolt (mV) of electrical activity. (See Figure 27-11.)

or calibration, of the ECG machine each time she conducts an ECG. To check for standardization, the medical assistant must rst make sure that the machine is set at 1 STD. Then she must verify that 1 mV of electricity causes the stylus to move 10 mm vertically by quickly pushing the STANDARDIZATION button. The machine should respond by creating a deection that is 10 mm (10 tiny boxes) high vertically and 2 mm (2 tiny boxes) wide horizontally. (See Figure 27-12.) The manufacturers manual explains the exact method for adjusting the machine to create perfect standardization.

Leads and Electrodes

The medical assistant must place electrodes on the patients arms, legs, and chest to sense cardiac electrical activity. Each of the electrodes is connected to color-coded leadwires (commonly called leads) by a metal clip. The leadwires transmit data about cardiac electrical activity to the ECG machine. The ECG machine amplies the electrical activity and represents it on the ECG paper by characteristic waveforms created by deection of the stylus. Older ECG machines use metal disks, rubber bands, and suction cups to attach the electrodes and keep them in place. Such equipment is cumbersome and difcult to use, especially when time is of the essence. Therefore, most medical ofces now use disposable,

Standardization
All ECG machines are standardized in the same way so that an ECG can be interpreted in the same manner, regardless what part of the world a patient is in. To ensure this consistency, the medical assistant must check for standardization,

FIG 27-10 ECG machine.

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0.2 sec 1 mm 5 mm

0.04 sec

1 sec

1 mV

FIG 27-11 ECG paper.

Standardization mark

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3 FIG 27-12 Standardization mark.

V6

self-adhesive electrodes that are impregnated with the optimal amount of electrolyte gel. Correct leadwire placement enables the ECG machine to record electrical activity of the heart from different viewpoints. Frontal leads include leads I, II, III, aVR, aVL, and aVF. Other leads are on the horizontal plane. These leads include the six precordial leads, or chest leads. Each lead records electrical activity between positive and negative electrodes. When depolarization of heart muscle occurs toward a positive electrode, it creates a positive, or upright, deection. If it occurs toward a negative electrode, it creates a negative, or downward, deection. (See Lead placement, page 484.) Color coding and labels make accurate attachment of leadwires to electrodes easy. The RA lead is attached to the right arm lead, the LA lead is attached to the left arm lead, and so on. In the case of a patient who has had a limb amputated, the medical assistant should place the limb electrodes above the

amputation, making sure to place the electrodes directly across from each other. She should not place electrodes on scars, skin growths, or open wounds. If the patient has excessive hair, the medical assistant may need to clip the hair on the area before placing the electrodes. Shaving should be avoided because shaving commonly causes small nicks in the skin that can put the patient at risk for infection.

Preparing the Patient

Medical assistants and other health care providers who routinely perform ECGs sometimes forget that the procedure does not feel routine to a patient, who may be anxious, embarrassed, confused, or in pain. Therefore, the medical assistant must be sensitive and take care to properly prepare the patient so that an accurate tracing can be obtained and the patient is as comfortable as possible. Although the patient must disrobe above the waist, he should be offered a gown (with the opening in the front). The medical assistant

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Lead placement
Although there are 10 electrodes, heart activity is recorded from 12 different angles, thus the term 12-lead electrocardiogram (ECG). Electrodes are applied to the patient in these specic locations: V1fourth intercostal space at the right sternal border V2fourth intercostal space at the left sternal border V3midway between V2 and V4 V4fth intercostal space, in the left midclavicular line V5lateral to V4, in the left anterior axillary line V6lateral to V5, in the left midaxillary line RA and LAanterior surface of the upper arms near the shoulder RL and LLclean, dry, eshy areas of the lower legs.

should carefully drape a female patient, in particular, during the procedure to protect her privacy to the greatest extent possible without compromising the accuracy of the ECG tracing. The medical assistant should position the patient in a supine position or semi-Fowler position if short of breath. The patient should not cross or dangle his legs. The medical assistant should record in the patients chart his current medications and vital signs. Alternatively, some machines allow the medical assistant to program these details into the machine, which will print them on the ECG tracing. The medical assistant should reassure the patient that the procedure will be painless and should remind him to lie still and breathe normally.

Recording the ECG

There are a variety of ECG machines, so the medical assistant should become familiar with the ECG machine used in her ofce. Most types currently in use perform labeling and standardization automatically. However, the medical assistant may need to enter information about the patients gender, age, and medications. Six-channel ECG machines print and label all 12 leads and include a strip across the bottom of the paper in lead II. This type of machine completes a recording quickly. When the recording is complete, the medical assistant must review it for clarity, the presence of electrical interference, or other problems. If the recording appears satisfactory, the medical assistant must give it to the physician for review and analysis. She should then help the patient get off the examination table and dress, as needed.

V1

V2 V3 V4 V5 V6

RA

LA

Rhythm Interpretation
To be able to accurately examine the ECG waveforms, the medical assistant must understand what each one represents. The rst waveform occurs when the muscle cells of the atria depolarize. This electrical activity causes the stylus to deect upward, creating the P wave. It is usually a slight upward, rounded wave. After a brief pause, the ventricles depolarize. This depolarization generates a greater amount of electrical activity, causing a larger deection of the stylus, creating the Q, R, and S waves, more commonly known as the QRS complex. This complex is followed by a brief period with no electrical activity, causing the ST segment, where the stylus remains at the baseline. Next, ventricular repolarization occurs, creating the T wave. (See Figure 27-13.) The physician is responsible for analyzing and interpreting the ECG tracing. However, because the medical assistant routinely performs ECGs, she must be familiar with the most common rhythmsespecially those that may be lifethreatening. Basic rhythm interpretation involves several simple steps, including:

RL

LL

calculation of the ventricular rate calculation of the atrial rate measurement and examination of the waveforms.

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of breath, or dizziness must receive evaluation and treatment.

Examination of the P Waves

When examining the P waves, the medical assistant should note whether there is consistently a P wave in front of every QRS complex. She should also note whether P waves are upright and rounded and whether all P waves have the same appearance.

Measurement of the PR Interval

T P U

The PR interval represents the time required for the electrical impulse to spread from the SA node through the atrial muscle cells and the AV node. The PR interval should be measured from the beginning of the P wave (where it leaves the baseline) to the beginning of the QRS complex. All PR intervals should be of the same length and should measure between 0.12 and 0.20 second (3 to 5 tiny boxes).

Measurement of the QRS Complex

PR QRS QT

FIG 27-13 ECG waveforms.

Calculation of the Ventricular Rate

The simplest way to calculate the ventricular rate is to count the number of R waves in a 6-second strip (30 large squares) and multiply by 10, or count the number of R waves in a 3-second strip (15 large squares) and multiply by 20. Three-second segments are generally easy to identify on rhythm strips by small marks across the top of the strip. This system is fairly accurate as long as the rhythm is regular. For grossly irregular rhythms, this system is less reliable. The normal adult heart rate is between 60 and 100 beats/minute.

The QRS complex represents the time required for the electrical impulse to spread through the right and left ventricles. The QRS complex is measured from the beginning of the Q wave to the end of the S wave and should be less than 0.12 second in length. All QRS complexes should be of consistent shape and size. Isolated QRS complexes that occur earlier than expected and are wide and oddly shaped represent premature ventricular contractions (PVCs). In PVC, the electrical impulse originates somewhere within the ventricles. Occasional PVCs are generally not of concern. However, patients experiencing frequent PVCs accompanied by symptoms of chest pain, shortness of breath, or dizziness must receive evaluation and treatment.

Examination of the ST Segment

The ST segment should be iso-electric, which means that it should be at the baseline. However, some patient factors may cause variations in the ST segment. For example, ST segment elevation or depression may suggest myocardial ischemia or even myocardial infarction and should be examined by the physician immediately, particularly if the patient is symptomatic.

Calculation of the Atrial Rate

Calculation of the atrial rate is similar to calculating the ventricular rate except that P waves are counted instead of R waves. This step may seem redundant and unnecessary. However, in some abnormal rhythms, the atria and ventricles function out of sync with one another and may have different rates. Counting P waves allows the examiner to identify this abnormality. Isolated QRS complexes that occur earlier than expected are called premature atrial contractions (PACs). In a PAC, the electrical impulse originates somewhere in the atria other than the SA node. Occasional PACs are generally not of concern. However, patients experiencing frequent PACs accompanied by symptoms of chest pain, shortness

Examination of the T Wave

The T wave may be curved upward with a rounded top, more sharply peaked, or even inverted, depending on a number of patient factors. For example, patients with hyperkalemia (elevated blood potassium) usually exhibit tall, peaked T waves.

Examination of the QT Interval

The QT interval is measured from the beginning of the QRS complex to the end of the T wave. It represents the

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time required for the impulse to spread through the muscle cells of the ventricles and for repolarization to occur. The normal QT interval length is between 0.32 and 0.44 second long. (See Common ECG rhythms.)

Cardiac Stress Test

A cardiac stress test is a test performed to evaluate the hearts response to physical exercise. This test has a number of other names, including exercise stress test, exercise treadmill test, exercise tolerance test, stress test, exercise ECG test, and, if radioactive isotopes are used, nuclear stress test. This test may be useful for patients who experience angina caused by stenosis of 75% or more of a coronary artery. In the test, the patient walks on a treadmill or is given IV medication that causes a response similar to the bodys response to exercise. During the procedure, the medical assistant monitors the patients heart rate, blood pressure, and any symptoms. The American Heart Association recommends a cardiac stress test for patients with a medium risk of coronary artery disease based on the risk factors of smoking, hypertension, family history of heart disease, high cholesterol, and diabetes. However, patients who have had an MI within the previous 48 hours and those with unstable angina, uncontrolled arrhythmias, or certain other unstable conditions should not undergo stress testing. Because the cardiac stress test does subject the patient to physical stress, close monitoring is important. Members of the testing team must be familiar with emergency protocols and should be prepared to respond if the patient develops arrhythmias, dyspnea, chest pain, or an actual MI. The medical assistant or other staff member should keep emergency cardiac medications and equipment on hand, and the testing team must be familiar with their use.

Artifacts
Because electrocardiograph machines are sensitive to electrical activity, they sometimes record electrical activity from sources other than the patients heart. Examples include electricity from nearby equipment or even the patients own noncardiac muscle movement. When the ECG stylus moves in response to this interfering electrical activity, it records markings on the ECG strip known as artifacts, which are distracting and irrelevant. (See Common types of artifact, page 490.) The medical assistant must review the ECG tracing for the presence of artifacts or other errors that may require her to perform the test again. (See Procedure 27-1: Performing a 12-lead ECG, page 492.)

Articial Cardiac Pacemaker

An articial pacemaker is a device that delivers electrical impulses to the heart to stimulate a heartbeat. The purpose is to maintain an adequate heart rate in individuals whose natural heart rate is too slow or irregular due to a malfunction of the SA node or a block in the electrical conduction system. The pacemaker is implanted under a patients skin, usually on the left anterior chest wall, and has electrodes that are implanted into the heart muscle. There are numerous makes and models of pacemakers and each can be programmed specically for the needs of the patient. Pacemakers may be programmed to stimulate atrial contraction, ventricular contraction, or both (dual channel). The physician can set the pacemaker to pace the heart all of the time or only as needed when the patients SA node res below a specied rate. Pacemaker spikes may or may not show up on the ECG tracing, depending on the type and setting of pacemaker. If present, pacemaker spikes appear as small vertical lines just before the P wave (if pacing the atria) or just before the QRS complex (if pacing the ventricles) or both. A rate-responsive pacemaker senses the patients physical activity and responds by increasing or decreasing the rate.

Holter Monitoring
The Holter monitor is a portable device that records the patients cardiac rhythm over a 24- or 48-hour period. This type of testing, also known as ambulatory electrocardiography, is useful when the patient complains of an irregular heartbeat or other symptoms that are intermittent and therefore difcult to obtain on a 12-lead ECG in the medical ofce. The medical assistant should apply the Holter monitor electrodes to the patient and show him how to carry the monitor in a small pouch with a shoulder strap. She should instruct him to wear the device while participating in normal daily activities and to record in a journal when he feels any symptoms, such as heart palpitations and dizziness, or if he engages in heavy physical activity. After wearing the monitor for the designated period of time, the patient returns it to the medical ofce, where the data is downloaded. A cardiologist then reviews and interprets it and discusses the results with the patient. The medical assistant may be responsible for applying and removing the monitor as well as providing the patient with instructions. The patient may not shower or bathe while wearing the Holter monitor, but may take a sponge bath. The medical assistant may need to clip chest hair to ensure good electrode adhesion. The patient keeps the

Implantable Cardioverter Debrillator

An implantable cardioverter debrillator (ICD), also called an automated implantable cardioverter debrillator (AICD), is a small device slightly larger than a pacemaker that is implanted in patients at risk for life-threatening arrhythmias, such as ventricular brillation and ventricular tachycardia. Some devices are actually a combination of a pacemaker and a debrillator. ICDs continually monitor the individuals heart rate and rhythm. If a patient develops a potentially lifethreatening arrhythmia, the ICD delivers an electrical shock to the heart with the goal of restoring normal sinus rhythm.

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Common ECG rhythms

This table describes the features of some of the most common electrocardiograph (ECG) rhythms. Some are considered normal while others may be life-threatening.

Rhythm
Sinus Rhythms Normal sinus rhythm (NSR)

Characteristics

Signs and Symptoms

Required Response
No special action is required.

Rate: 60 to 100 beats/minute Rhythm: regular PR interval: 0.12 to 0.20 second QRS complex: <0.12 second

None

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 20, with permission.)
Sinus bradycardia Rate: <60 beats/ minute Rhythm: regular PR interval: 0.12 to 0.20 second QRS complex: <0.12 second Usually none Notify the physician if the patient is symptomatic.

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 21, with permission.)
Sinus tachycardia Rate: >100 beats/minute Rhythm: regular PR interval: 0.12 to 0.20 second QRS complex: <0.12 second Usually none Notify the physician if the patient is symptomatic.

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 21, with permission.)
Sinus arrhythmia Rate: uctuates with respiratory pattern Rhythm: regular PR interval: 0.12 to 0.20 second QRS complex: <0.12 second None No special action is required.

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 22, with permission.)

Continued

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Common ECG rhythmscontd

Rhythm
Atrial Arrhythmias Sinus rhythm with premature atrial contractions (PACs)

Characteristics

Signs and Symptoms

Required Response
No special action is required.

Rate: 60 to 100 beats/minute Rhythm: regular, except when PACs occur PR interval: 0.12 to 0.20 second; may vary in the PACs

Usually none Possible palpitations

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 29, with permission.)
Atrial brillation

QRS complex: <0.12 second Rate: possibly rapid Rhythm: irregular P waves: none PR interval: none QRS complex: <0.12 second Palpitations, dyspnea, and dizziness possible with rapid, uncontrolled rate Possibly no symptoms with controlled rate Notify the physician if the patient is symptomatic.

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 32, with permission.)
Atrial utter Rate: atrial, rapid (250 to 350 beats/minute); ventricular, variable (125 to 175 beats/minute) Rhythm: usually regular Possible palpitations, shortness of breath, and dizziness Notify the physician immediately.

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 31, with permission.)

P waves: none identiable; instead, sawtooth patterned utter waves QRS complex: <0.12 second

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Common ECG rhythmscontd

Rhythm
Ventricular Arrhythmias Sinus rhythm with premature ventricular contractions (PVCs)

Characteristics

Signs and Symptoms

Required Response

Rate: 60 to 100 beats/minute Rhythm: regular except when PVCs occur PR interval: 0.12 to 0.20 second, none when PVCs occur QRS complex: <0.12 second, except PVCs, which show up as bizarrely shaped, wide QRS complexes with no preceding P wave. Rate: rapid, usually 100 to 220 beats/minute Rhythm: usually regular P waves: none QRS complex: wide, oddly

Usually none unless PVCs are frequent Possible palpitations

No special action is required unless the patient is symptomatic.

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 46, with permission.)
Ventricular tachycardia

Dramatic hypotension Loss of consciousness

This is a lifethreatening emergency that requires you to contact the physician immediately. If the patient is pulseless and breathless, initiate cardiopulmonary resuscitation (CPR).

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 54, with permission.)
Ventricular brillation

shaped, and >0.12 second Rate: rapid (350 to 450 beats/minute) Rhythm: irregular; chaotic P waves: none QRS complex: none Loss of consciousness Loss of pulse Imminent death

This is a lifethreatening emergency that requires you to contact the physician immediately. If the patient is pulseless and breathless, initiate cardiopulmonary resuscitation (CPR).

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 57, with permission.)

Continued

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Common ECG rhythmscontd

Rhythm
Asystole

Characteristics
Rate: zero P waves: none QRS complex: none (occasional agonal beats)

Signs and Symptoms

Loss of pulse Imminent death

Required Response
This is a lifethreatening emergency that requires you to contact the physician immediately. If the patient is pulseless and breathless,

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 59, with permission.)

initiate cardiopulmonary resuscitation (CPR).

Common types of artifact

It is important for the medical assistant to become familiar with common types of artifact so she can minimize interference when obtaining electrocardiograms (ECGs). The patient and physician depend on the medical assistant to provide accurate ECGs to aid in accurate diagnosis and create an effective treatment plan. The following table lists the types of artifacts that commonly interfere with accurate ECG recording, along with a description and sample tracing, typical causes, and solutions.

Artifact
Somatic tremorcauses small, irregular, jagged peaks and may give the tracing a fuzzy appearance

Cause
Electrical activity from noncardiac muscle movement caused by: neuromuscular disorder such as Parkinson disease pain shivering due to cold anxiety talking

Solution
Ensure patient comfort by treating pain, providing for warmth and privacy, and placing pillows under patients head and knees. Provide reassurance. Instruct patient to not talk. Instruct patient to place hands, palms down, under buttocks. Place arm electrodes close to

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 72, with permission.)
Wandering baselinecauses the entire ECG tracing to stray away from the baseline in a gentle, curved manner Patient movement Faulty electrode attachment Dirty or corroded electrodes Creams, lotions, or oils on the patients skin Electrodes that are too tight or too loose Tension on the electrode

the shoulders.

Instruct the patient to remain still. Use an equal amount of electrolyte gel for all electrodes. Use disposable, stick-on electrodes. Inspect electrodes for dirt and corrosion. Clean or replace them as needed.

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Common types of artifactcontd

Artifact Cause Solution
Clean the patients skin with alcohol. Clip (do not shave) chest hair if necessary. Tape leadwire 1 to 2 below the clip. Alternating current (AC) interferencecauses a series of short spikes Electrical currents from nearby equipment or wires Plug ECG machine into 3prong, grounded outlet. Avoid crossing leadwires. Unplug nearby electrical equipment. Move the examination table away from the wall. Turn off the overhead uorescent lights. Perform ECGs in the room furthest away from other electrical equipment. Interrupted baselineappears as large, irregular uctuations in which the stylus moves to the margins of the ECG paper Interruption of electrical connection caused by patient movement Broken leadwires Loose cable tips Instruct the patient to remain still. Replace the leadwires. Attach the cable tips rmly to the electrodes.

(From Geiter, E-Z ECG: Basic Step-by-Step Interpretation. FA Davis, Philadelphia, 2007, p. 301, with permission.)

(From Jones, ECG Success: Exercises in ECG Interpretation. FA Davis, Philadelphia, 2008, p. 71, with permission.)

monitor in a pouch that is attached to a belt or slung over the shoulder. (See Figure 27-14.)

Event Recorder
An event recorder, sometimes called a King of Hearts monitor, is a small portable monitor that the patient can wear around the neck like a pendant or place in a shirt pocket. It is attached to two electrodes on the patients chest that may be activated by the patient when he feels such symptoms as chest pain, dizziness, and palpitations. The data is then sent to the cardiology clinic via the telephone for

analysis. This type of device is ideal for patients whose symptoms are intermittent and unpredictable and, therefore, unlikely to manifest during an ECG test. Event recorders may be worn for as long as 30 days to capture events likely to be missed by an ECG or even a Holter monitor. Most event recorders allow telephone transmission of recordings, so the medical assistant should also provide the patient with instructions about how to do this. Lastly, the medical assistant should give the patient contact information in case he has questions or concerns. (See Wearing an event recorder, page 492.)

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PROCEDURE 27-1

Performing a 12-lead ECG

Task Obtain an accurate 12-lead ECG recording. Conditions ECG machine with cable and paper 10 disposable, self-adhesive electrodes Examination gown Drape Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully obtain an accurate 12-lead ECG recording. Performance Standards 1. Wash or sanitize your hands to ensure proper infection control and assemble supplies. 2. Greet and identify your patient, introduce yourself, and explain the procedure to prevent errors and ease patient anxiety. 3. Instruct the patient to remove socks or pantyhose as well as clothing above the waist, including undergarments to facilitate the placement of electrodes. Assist the patient as necessary. 4. Position the patient on the examination table in the supine position. Drape her for warmth and privacy. 5. Turn on the machine. Enter the patients name, date, time, and patients current cardiac medications into the machine or write the information on the tracing paper to ensure proper identication of the tracing and provide relevant data. 6. Clean the patients skin with alcohol at each site where an electrode will be placed and clip hair if 7. necessary to remove skin oils or hair that would interfere with secure sensor adhesion. Apply self-adhesive electrodes to a dry, clean, intact, eshy area on the extremities across from one another and to the cleaned areas on the chest. Connect the leadwires to the electrodes using the alligator clips. Make sure the correct leads are connected to the correct electrodes. Do not cross leadwires to help prevent artifact. Press the AUTO button on the ECG machine. The machine runs automatically once the AUTO button is pressed. Watch for artifacts and make corrections as needed to get an acceptable tracing. Disconnect the leadwires from the electrodes and then remove the electrodes from the patient. Assist the patient off the examination table and with dressing as needed. Clean and return the ECG machine to storage so it will be ready for the next use. Mount the ECG tracing in the patients chart or give it to the physician as directed. Document the procedure in the patients chart to ensure a complete, accurate medical record. Wash or sanitize your hands.

8.

9.

10. 11. 12. 13. 14. 15.

Date 11/22/08; 9:30 a.m. ECG recording obtained and given to physician for review. ------------------------------------------- S. Gonzales, CMA

Leads

Patient Education

Wearing an Event Recorder

The medical assistant should be sure to give the patient who is to wear an event recorder the following instructions: Trigger the event recorder any time you feel symptoms, such as shortness of breath, palpitations, weakness, and dizziness. Remove the event recorder before bathing and reapply it immediately afterward.
Holter monitor

Keep a diary of your daily activities and any symptoms you experience. Change the electrodes and batteries daily as instructed.

FIG 27-14 Holter monitor.

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Patient Educationcontd

Lead

Lead

Event recorder

Chapter Summary

The heart is a muscular organ located in the center of the chest that beats an average of 60 to 100 times per minute and pumps blood throughout the circulatory system. Blood ows from the heart to all parts of the body and, eventually, into capillary beds (where oxygen and carbon dioxide are exchanged in the tissues) and then returns to the heart by way of the veins. The heart contains its own specialized electrical conduction system, which includes the SA node, the AV node, the bundle of His, and the Purkinje bers. The cardiac cycle includes systole, the phase of heart chamber contraction, and diastole, the phase of heart chamber relaxation. Lymphatic vessels are found throughout the body and carry lymph uid from the tissues back into vascular circulation. Lymph nodes are rich in WBCs and help clean bacteria and cell debris from lymph uid.

The thymus, located in the mediastinum above the heart, plays a major role in the immune system. It grows until puberty and then gradually shrinks in size as a person ages. The spleen, located in the left upper quadrant of the abdomen, creates WBCs as well as antibodies as part of its role in the immune system. It also contains a supply of RBCs that can be made available to the cardiovascular system in the event of hemorrhage. Medical assistants must become well versed in the language and vocabulary that pertain to the cardiology and lymphatic systems so they can communicate effectively with other members of the health care team. Medical assistants should become familiar with the more common diseases and disorders of the cardiovascular system, including hypertension, coronary artery disease (CAD), myocardial infarction (MI), heart failure, aneurysm, atrial brillation, varicose veins, deep vein thrombosis (DVT), shock, anemia, leukemia, Hodgkin disease, non-Hodgkin lymphoma, and acquired immune deciency syndrome (AIDS). Cardiology is a medical specialty that focuses on the study and treatment of disorders of the cardiovascular system. Medical assistants help with the provision of care to patients in the cardiology ofce by helping with examinations, procedures, and testing. Medical assistants commonly perform 12-lead ECGs. To effectively carry out their duties, they must understand how to prepare the ECG machine, read the paper, assess for standardization, apply the leads and electrodes, prepare the patient, and record the ECG. The physician is responsible for interpreting the ECG rhythm and diagnosing the patient. However, because medical assistants routinely perform ECGs, they must be familiar with common rhythms, including those that indicate a life-threatening condition. Steps to rhythm interpretation involve calculation of the atrial and ventricular rates and measurement and examination of the waveforms. To obtain accurate and useful ECGs, medical assistants must be familiar with common forms of artifact, including somatic tremor, wandering baseline, AC interference, and interrupted baseline, and take measures to prevent them. Articial pacemakers are devices that deliver electrical impulses to the heart to stimulate a heartbeat and maintain an adequate heart rate in individuals whose natural heart rate is too slow or irregular. An ICD is a small device that is implanted in patients at risk for life-threatening arrhythmias, such as ventricular fibrillation and ventricular tachycardia. Some devices are actually a combination of a pacemaker and a defibrillator.

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Cardiac stress testing is done to evaluate the hearts response to physical exercise. The Holter monitor is a portable device that records the patients cardiac rhythm over a 24- or 48-hour period. This type of testing is useful when the patient complains of an irregular heartbeat or other symptoms that are intermittent and therefore difcult to obtain on a 12-lead ECG in the medical ofce. An event recorder is a small portable monitor that is attached to two electrodes on the patients chest and may be activated by the patient when he feels such symptoms as chest pain, dizziness, and palpitations. It may be worn for as long as 30 days to capture events likely to be missed by an ECG or even a Holter monitor.

Team Work Exercises

1. Divide into teams of 4 to 6 students each. Select one of the scenarios below and create a role-playing presentation for the rest of the class in which you fulll all criteria of the scenario. Provide handouts for the class that summarize the key points of your presentation. List on the handout all the resources you accessed for your presentation. a. Mrs. Dough walks into the ofce complaining of nausea and pain in her left arm and jaw. She is feeling slightly short of breath. She does not lose consciousness or experience a cardiac arrest. Your team must demonstrate, through role-playing, how this situation ought to be handled up tobut not includingthe point where Mrs. Dough is transferred to the hospital by ambulance. To each member of the team, you must assign roles, such as patient, patients spouse, administrative medical assistant, clinical medical assistant, nurse, physician, laboratory technician, and so forth. b. Mrs. Dough recently experienced a small MI, was treated at the hospital, and is in the ofce for her rst post-discharge visit. The physician has asked you to: review with her measures she can take to reduce her risk of a repeat MI, hypertension, and CAD teach her about her new medications, which include metoprolol, aspirin, and nitroglycerine. c. Your ofce team has been asked to visit a nearby elementary school for their Healthy Heart day. You have been asked to teach them about the anatomy of the heart and how the blood ows through the body. You must create a plan that gets the children physically involved and having fun while they are learning. You may do so using such methods as games, skits, puppet shows, or anything that is interactive, colorful, and fun. The students in the class will be the children (ages 6 to 11) in your audience.

d. Your ofce team has been asked to visit a nearby elementary school for their Healthy Heart day. You have been asked to teach them healthy activities and habits they can develop to grow up with healthy hearts. You must create a plan that gets the children physically involved and having fun while they are learning. You may do so using such methods as games, skits, puppet shows, or anything that is interactive, colorful, and fun. The students in the class will be the children (ages 6 to 11) in your audience. e. Your team is to create a story that utilizes as many cardiac and lymphatic medical terms and abbreviations as you can. The story may be serious or humorous. However, all medical terms must be accurately spelled and their use must t within the context of the story. After you have created your story, read it to the class. Each time a medical term or abbreviation is used, the storys reader must pause and allow another member of the team to translate the term or abbreviation for the listeners. 2. Divide into teams of 4 to 6 students each. Your instructor will provide each team with one or more cardiac rhythm strips. Analyze the strips to the best of your ability. When you have agreed on what the strip represents, you must present your ndings to the rest of the class and explain your rationale for the conclusions you have reached.

Case Studies
1. Mrs. Schultz is a 66-year-old female patient who complains that her heart is racing or skipping a beat and she sometimes feels dizzy. She does not know if it is worth bothering anyone about or if she should just go home and not worry about it. What will you say to her? What type of response would you anticipate the physician making? 2. Mrs. Smith has her 5-year-old son in the pediatricians ofce, stating that he has a sore throat and slight fever. The mother has noticed that the glands in his neck are swollen but that he also has lumps under his arms. What is the likely cause of the lumps under his arms?

Resources

Latest AIDS information, news, and research: www .aids.org American Heart Association: www.americanheart.org Auscultation Assistant: www. med.ucla.edu/ wilkes/inex.htm ECG Library: www.ecglibrary.com/ Heart Institute for Children: www.thic.com Leukemia and Lymphoma Society: www.leukemia.org/hm_lls

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Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell terms related to pulmonology identify key structures of the pulmonary system discuss the roles played by the pulmonary system describe the role of the medical assistant in the pulmonologists ofce identify common pulmonary diseases and disorders list commonly used word elements related to the pulmonary system and give at least 10 examples of how new pulmonary-related terms may be created by combining prexes, sufxes, and combining forms describe the medical assistants role in assisting with pulmonary procedures describe physical examination techniques used to evaluate the pulmonary system. General Competencies Patient Instruction
Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention

28
Upper respiratory infection Sinusitis Pharyngitis Common Lower Respiratory System Diseases and Disorders Pneumonia Inuenza Chronic obstructive pulmonary disease Bronchitis Asthma Emphysema Pulmonary tuberculosis Epstein-Barr virus Lung cancer

ABHES Competencies
Clinical Duties
Prepare patients for procedures Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries Perform respiratory testing

Pulmonology Procedures
Assisting with Examination Diagnostic Testing Pulmonary function tests Bronchoscopy Mantoux test Peak-ow measurement Treatments Metered-dose inhaler Nebulizer treatments Incentive spirometry Oxygen therapy

Procedures
Performing respiratory testing Teaching a patient to use an MDI Administering oxygen via nasal cannula

Chapter Outline
Structures and Functions of the Pulmonary System
Structures of the Pulmonary System Upper airway Lower airway Lungs Functions of the Pulmonary System Upper airway Lower airway Lungs

CAAHEP Competencies
Administrative Competencies Process Insurance Claims
Perform diagnostic coding

Chapter Summary Team Work Exercises Case Studies Resources

Clinical Competencies Diagnostic Testing

Perform respiratory testing

Patient Care
Prepare patients for and assist with routine and specialty examinations Prepare patients for and assist with procedures, treatments, and minor ofce surgeries

Medical Terminology Related to the Pulmonary System Common Pulmonary System Diseases and Disorders
Common Upper Respiratory System Diseases and Disorders Allergic rhinitis

495

Key Terms
antitussive

peak-ow meter

Handheld device used to measure an individuals lung capacity

pH scale

Medication that suppresses the cough reex

aspiration

Scale used to measure acidity or alkalinity of a substance

pleural membranes

Unintentional inhalation of any substance other than air

bronchoscopy

Examination of the bronchi through a specialized instrument called a bronchoscope

chest physiotherapy

Double membranes that cover the lungs and line the thoracic cavity
pulmonology

Field of medicine that studies and treats respiratory disorders

pulmonologist

Type of therapy that includes percussion (clapping) over the thorax or vibration and positioning to facilitate loosening and removal of respiratory secretions
circumoral cyanosis

Physician who specializes in the diagnosis and treatment of respiratory disorders

pneumonectomy

Blue coloring around the mouth due to inadequate oxygenation

corticosteroids

Surgical removal of an entire lung

pulmonary function test

Medications that suppress the immune response and decrease inammation

crackles

Measurement of air ow and lung volumes; also called spirometry

purulent

Abnormal crackly lung sound heard with a stethoscope

dyspnea

Consisting of or containing pus

rhonchi

Painful or difcult breathing

exhalation

Coarse gurgling sound heard on auscultation that is caused by secretions in the air passages
wedge resection

Act of breathing out; also called expiration

expectorant

Surgical removal of a small part of a lung

wheeze

Medication that liquees and loosens respiratory secretions to aid in expelling them
febrile

Somewhat musical sound heard in the lungs, usually with a stethoscope, that is caused by partial airway obstruction

Fever causing
hemoptysis

Coughing up blood
hypoxia

Decient level of oxygen

hypoxic drive

Backup system of respiration that stimulates breathing in a patient who is retaining carbon dioxide
incentive spirometer

Handheld device used by the patient to inhale a maximal breath to keep lungs expanded and functional
inhalation

Act of breathing in; also called inspiration

lobectomy

Surgical removal of a lobe of a lung

lymphadenopathy

Swollen, tender cervical lymph nodes

Mantoux test

Test to identify tuberculosis exposure

metered dose inhaler

Handheld device used to inhale medication into the lungs

nasal cannula

Oxygen tubing designed to deliver oxygen into a patients nose

nebulizer

Device that produces a ne spray or mist to deliver medication to the air passages and lungs

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Structures and Functions of the Pulmonary System

The pulmonary system, also called the respiratory system, is made up of the upper airways, lower airways, and the lungs. The pulmonary system facilitates breathing and the exchange of gases like oxygen and carbon dioxide that is so vital to life and health.
Nasopharynx Nasal cavity Oral cavity Epiglottis Vocal fold Right bronchus Oropharynx Laryngopharynx Esophagus Trachea Left bronchus Bronchi

Structures of the Pulmonary System

The pulmonary system is divided into the upper and lower airways and the lungs. (See Figure 28-1.)

Upper Airway
The main structures of the upper airway consist of the mouth, nose, sinuses, and pharynx (throat). The pharynx is further divided into the nasopharynx (back of the nose) and oropharynx (back of the mouth). The nose begins with the nares (nostrils) and extends back to the nasopharynx. The nasal passages are divided into right and left sides by the nasal septum. The hard palate divides the nasal cavity from the mouth, which sits beneath it. The sinus cavities are air-filled spaces named for the facial bones within which they are located. They include the maxillary, frontal, ethmoidal, and sphenoidal sinuses. Many of the upper airway structures are shared by the gastrointestinal and sensory systems.

Right lung

Left lung

Pleura Smooth muscle Alveolar duct Diaphragm

Capillary

Artery

Lower Airway
The lower airways consist of the epiglottis, trachea, bronchial tubes, and lungs. The trachea (sometimes called the windpipe) begins superiorly with the larynx (sometimes called the voice box) and extends inferiorly to the middle of the chest. It is approximately 5'' long and gets its shape and strength from numerous rings of cartilage. In the center of the chest, the trachea divides into the two primary bronchi, each of which leads to smaller and smaller bronchi and, eventually, to tiny bronchioles. The structure of bronchi changes to less cartilage and more smooth muscle as they become smaller. The bronchioles end at the alveoli, which are microscopic air sacs within the lungs. There are approximately 300 million alveoli in each lung. They are covered with a delicate capillary bed (microscopic blood vessels), which provide them with a rich blood supply.
Alveolar sac Vein Alveoli

FIG 28-1 Respiratory system.

referred to as a potential space because there is nothing there other than a small amount of this uid.

Functions of the Pulmonary System

The functions of the pulmonary system can be further broken down to those of the upper and lower airways and the lungs.

Lungs
The lungs are divided into lobes; the right lung has three and the left lung has two. The lungs are covered with two thin membranes known as the pleura. The visceral pleura lies directly on the lungs. The parietal pleura lines the inner wall of the thorax. A small amount of pleural uid lies in the space between the two membranes. This space is sometimes

Upper Airway
The structures of the upper airway act to cleanse, moisten, and warm inhaled air before it continues its journey to the lungs. Mucous membranes that line these structures

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contribute moisture to humidify the air. Cilia (tiny hairs) within the nasal cavity help lter the air by removing debris. The rich blood supply of all of these structures warms the air as it passes through. Sinus cavities serve to decrease the weight of the skull, provide resonance for the voice, and produce mucus, which helps eliminate microorganisms as it drains into the nasal cavities.

Lower Airway
The epiglottis acts as a doorway to the trachea and serves a vital protective function by opening to let in air and closing to keep out food and uid. The larynx vibrates as air passes through it, creating vocal sounds. The numerous C-shaped cartilage rings of the trachea provide strength and keep it open. The trachea and bronchi have ciliated mucous membrane linings, which serve to further moisten air and secrete mucus to trap foreign debris that has been inhaled. The cilia move in a wavelike fashion to propel debris upward. The trachea and bronchi are extremely sensitive and the presence of foreign particles stimulates a powerful cough reex that further helps to expel foreign debris.

Lungs
As the individual breathes in and out the lungs expand and contract. The elastic quality that allows the lungs to do this is sometimes called recoil. The pleural uid between the visceral and parietal pleura acts as a sort of lubricant, which helps the process along as the lungs continually expand and contract. A person takes oxygen (O2) into the lungs through the act of inhalation, or breathing in, which is usually an unconscious act. However, a person may exert conscious control to take extra large breaths or even hold his breath for a short time. At some point, however, he will have an overwhelming urge to breathe, which is triggered by a buildup of carbon dioxide (CO2) when a person stops breathing in oxygen. This buildup of CO2 in the blood causes it to become more

acidic. To be healthy, a persons blood must remain slightly alkalinewithin the narrow range of 7.35 to 7.45 on the pH scale, which is a tool for measuring the acidity or alkalinity of the blood. As the blood becomes more acidic, the pH level drops, triggering the urge to breathe. The act of inhalation brings fresh, oxygen-rich air into the persons lungs so it can be absorbed into his blood. The act of exhalation, or breathing out, allows the body to eliminate excess CO2, thus restoring a normal blood pH level. Contrary to what most people think, the stimulus to breathe is not lower oxygen levels in the blood, but the lowered pH level caused by CO2 buildup. Gas exchange, so vital to life, takes place within the millions of tiny alveoli contained within each lung. They expand somewhat like tiny balloons during inhalation as air enters and lls them. They contract and partially deate during exhalation as much of the air moves out of the lungs. Because the walls of the alveoli and the capillary beds are each just one cell thick, gases move easily back and forth. Excess CO2 leaves the capillaries and moves into the air space in the alveoli and is then exhaled. Oxygen moves from the air space in the alveoli into the capillary blood and is then distributed to various parts of the body via the circulatory system.

Medical Terminology Related to the Pulmonary System

Pulmonary disorders are common and affect every segment of the population at some time, leading them to seek medical care in both acute and ambulatory settings. To be effective in their role, medical assistants must become well versed in the language and vocabulary that pertain to the pulmonary system. The following tables list common medical terminology related to the pulmonary system.

Table 28.1 |

Word elements

This table contains word elements that pertain to the pulmonary system, along with examples of terms that use the combining form and a pronunciation guide. Element
Combining Forms aer/o bronch/o bronchi/o chondr/o cartilage air bronchus aerophagia ( o-FA-j a) er- e- bronchitis (brong-KI-ts) bronchiectasis (br ong-k EK-t s) e- a-s chrondroplasty (KON-dro-pl e) as-t swallowing air inammation of the bronchus dilation or expansion of the bronchus surgical repair of the cartilage

Meaning

Example

Meaning

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Table 28.1 | Element

Word elementscontd
Meaning
epiglottis larynx nose

Example
epiglottal ( -GLOT-al) ep- laryngitis (lar-n-JI-ts) nasogastric (n o-GAS-trk) a-z rhinitis (r-NI-ts)

Meaning
pertaining to the epiglottis inammation of the larynx pertaining to the nose and stomach inammation of the nose (runny nose)

Combining Forms epiglott/o laryng/o nas/o rhin/o

muc/o or/o stomat/o orth/o

mucus mouth

mucoid (MU-koyd) al) oral (O-r stomatitis (sto-m I-ts) a-T

resembling mucus pertaining to the mouth inammation of the mouth breathing in the straight (upright) position

straight

e- orthopnea (or-THOP-n a)

ox/o pharyng/o pleur/o pneum/o pneumon/o pulmon/o sinus/o thorac/o tonsill/o trache/o Prexes circumhypointraparaperipost-

oxygen pharynx pleura lung, air

anoxia ( OK-se- an- a) pharyngeal (far-IN-j al) e- pleurodynia (ploo-ro-DIN- a) e- e- pneumonia (n u-MO-n a) pneumonectomy (n on-EK-to-m u-m e)

condition of no oxygen pertaining to the pharynx pain in the pleura condition of the lung surgical excision of the lung pertaining to the lung resembling a sinus surgical puncture of the thorax inammation of the tonsils surgical incision into the trachea

lung sinus thorax tonsils trachea

pulmonary (PUL-m e-re) o-n sinusoid (SI-n us-oyd) thoracentesis (th a-s o-r en-TE-ss) tonsillitis (t l-I-ts) on-s tracheotomy (tra-k OT- e) e- o-m

around below, beneath within beside, near beside, near after, following

al) circumoral (s um-O-r er-k hypoxia (h-POKS- a) e- intrathoracic (n-tr o-RAS-k) a-th paranasal (p a-NA-s l) ar- a peritonsillar (p -TON-s-l er- ar) al) postnasal (p ost-NA-z

pertaining to around the mouth condition of low oxygen pertaining to within the thorax pertaining to beside or near the nose pertaining to beside or near the tonsils pertaining to the posterior portion of the nose

Sufxes -ary -algia -centesis -cyte -desis pertaining to pain surgical puncture cell binding pulmonary (PUL-m e-re) o-n stomatalgia (sto-m L-j a) a-TA e- pleurocentesis (ploo-ro-s en-TE-ss) chondrocyte (KON-dro-st) pleurodesis (ploo-ro-DE-ss) pertaining to the lungs mouth pain surgical puncture of the pleura cartilage cell binding the pleura

Continued

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Table 28.1 | Element

Sufxes -ectomy

Word elementscontd
Meaning
excision, surgical removal

Example
laryngectomy (lar-n-JEK-to-m e)

Meaning
surgical removal of the larynx

-logist

specialist in the study of

pulmonologist (p on-OL- st) ul-m o-j

specialist in the study and treatment of lung disorders

-ole -plasty -plegia -scope -scopy -stomy

small surgical repair paralysis instrument used to view visual examination mouthlike opening

bronchiole (BRONG-k ol) e- rhinoplasty (RI-n as-te) o-pl e- laryngoplegia (la-rng-g o-PLE-j a) laryngoscope (lar-IN-g op) o-sk o-p bronchoscopy (br ong-KOS-k e) tracheostomy (tra-k OS-to-m e- e)

small bronchus surgical repair of the nose paralyzed larynx instrument used to view the larynx visual examination of the bronchi mouthlike opening in the trachea

Table 28.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to the pulmonary system with a brief denition for each. Term
acute respiratory distress syndrome

Denition
Hypoxemia and respiratory failure due to severe inammatory damage to the lungs after severe infection or trauma

allergic rhinitis ( R-jk r-NI-ts) a-LE asthma (AZ-m a)

Inammation of the nasal membranes due to allergies; also called hay fever Disorder in which airways overreact to certain triggers with inammation, resulting in narrowing, mucus production, and dyspnea; also called reactive airway disease

atelectasis ( e-LEK-t s) at- a-s bronchitis (br ong-KI-ts) chronic obstructive pulmonary disease

Partial collapse of lung tissues, such as alveoli and bronchioles Infection of the bronchial passages, usually by a virus but possibly by bacteria Group of chronic lung disorders that includes emphysema, chronic bronchitis, and asthma and creates obstructive changes in the bronchi and alveoli; also called chronic obstructive lung disease (COLD)

croup (KROOP)

Acute viral disease, usually in children, marked by a barking, seal-like cough and respiratory distress

cystic brosis (SIS-tk f-BRO-ss)

Fatal genetic disease that causes frequent respiratory infections, increased airway secretions, and chronic obstructive pulmonary disease in children

emphysema ( em-f-SE-m a)

Common chronic obstructive respiratory disorder that causes permanent, destructive changes to respiratory structures

empyema ( em-p-E-m a) epistaxis ( -STAK-ss) ep- Epstein-Barr virus (EP-sten BAR)

Collection of infected uid (pus) in a body cavity, usually between the pleura Nosebleed Infection caused by the Epstein-Barr virus (EBV), which is a member of the herpesvirus family; also known as mononucleosis or glandular fever

glomerulonephritis (gl er- o-n I-ts) o-m u-l e-FR

Type of kidney infection

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Table 28.2 | Term

Pathologic Termscontd
Denition
Condition in which blood has collected between the pleural linings of the lungs Chronic retention of carbon dioxide in the blood Group of viral respiratory illnesses marked by fever, headache, muscle aches, rhinitis, fatigue, sore throat, dry cough, and gastrointestinal symptoms

aks) hemothorax (h o-THO-r e-m hypercapnia (h-p AP-n a) er-K e- a) inuenza (n-oo-EN-z

lung cancer

Group of several different types of cancer, including small cell, nonsmall cell, squamous cell, adenocarcinoma, and large cell lung cancer

e- orthopnea (or-THOP-n a) pharyngitis (far-n-JI-ts) pleural effusion (PLOO-r e-FU-zh al un) e- pneumonia (n u-MO-n a) aks) pneumothorax (n o-THO-r u-m pulmonary tuberculosis (PUL-m e-re tu-ber-k -ss) o-n u-LO sinusitis (s-n I-ts) us- upper respiratory infection

Need to remain upright in order to breathe effectively Sore throat Collection of uid in the pleural space Viral or bacterial infection of the lungs Condition in which air has collected between the pleural linings of the lungs Contagious lung infection caused by the Mycobacterium tuberculosis organism

Inammation of the lining of the sinus cavities Acute inammation of the mucous membranes of the nasal passages and throat caused by a virus; also called the common cold or coryza

severe acute respiratory syndrome

Viral respiratory illness marked by head and body aches, fever, and cough that may lead to severe pneumonia

stridor (STRI-dor)

Medical emergency marked by a high-pitched upper airway sound (heard without a stethoscope) that indicates airway obstruction

Table 28.3 |

Abbreviations

In pulmonology, as with other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed here save time and effort in documentation and written communications. Abbreviation
ABGs ARDS COPD CPR CO2 O2 PND

Term
arterial blood gases acute respiratory distress syndrome chronic obstructive pulmonary disease cardiopulmonary resuscitation carbon dioxide oxygen paroxysmal nocturnal dyspnea

Abbreviation
RT SARS SOB Stat TB URI VC

Term
respiratory therapy sudden acute respiratory syndrome shortness of breath immediately tuberculosis upper respiratory infection vital capacity

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Common Pulmonary System Diseases and Disorders

There are many disorders affecting the pulmonary system. Here are some of the most common ones with a summary of each, along with its corresponding ICD-9-CM code.

Common Upper Respiratory System Diseases and Disorders

Common upper respiratory system diseases and disorders include allergic rhinitis, upper respiratory infection, sinusitis, and pharyngitis.

Allergic Rhinitis
ICD-9-CM code: 477 (base code), 477.0 (due to pollen), 477.1 (due to food), 477.2 (due to animal hair), 477.8 (due to other allergen) The term rhinitis means inammation of the nasal membranes. When rhinitis is caused by allergies it is sometimes also called hay fever because the most common cause is allergy to seasonal plant pollens. It affects nearly 40 million people, or approximately 20% of the U.S. population. Costs associated with treating allergic rhinitis and its complications are over $5 billion per year. The primary risk factor for allergic rhinitis is a genetic predisposition. Susceptible people develop sensitivity to certain allergens and then experience reactions when subsequently reexposed to those allergens. Triggers are numerous. The most common triggers include pollen, dust, mold, and pet dander. Signs and symptoms of allergic rhinitis include sneezing, nasal congestion, itching, redness, postnasal drip, runny nose, and sinus congestion. Systemic symptoms may include malaise, fatigue, and sleepiness. Symptoms may last for hours or days. Diagnosis is based on the patients description of symptoms and physical examination ndings. Treatment includes the use of antihistamines, decongestants, and nasal steroids. Patients should be counseled to avoid allergens when possible and to consider the use of lters in their home. Desensitization may be accomplished through injections. Allergies are generally chronic but can usually be managed reasonably well with medications. Potential complications include otitis media, acute and chronic sinusitis, and eustachian tube dysfunction.

More than 200 viruses are known to cause the common cold, which is very contagious. Virus particles are contained within nasal secretions and are easily spread when individuals wipe their nose and then touch other people or objects. The virus can also be spread via tiny airborne droplets when someone sneezes. The most contagious time is within the rst 2 to 3 days of a cold. Symptoms vary with the specic virus but generally include runny nose, nasal congestion, sneezing, sore throat, cough, headache, malaise, pharyngitis (sore throat), muscle aches, headache, and decreased appetite. Very young children may run a fever as high as 102F, but older children and adults are usually afebrile. Symptoms occur within 2 to 3 days from exposure and usually last 7 to 10 days. Diagnosis is based on a description of symptoms and physical examination ndings. Treatment includes uids and rest. Over-the-counter medications including analgesics may lessen the severity of symptoms. Antibiotics are not appropriate because they have no effect on viruses. Most people recover fully from URIs but complications may include secondary otitis media, sinus infection, bronchitis, pneumonia, and an exacerbation of asthma in those with asthma.

Sinusitis
ICD-9-CM code: 461.9 (acute, unspecified), 473.9 (chronic, unspecied) Sinusitis is a condition in which the lining of the sinus cavities becomes inamed. An estimated 30 million people in the United States suffer from sinus disease and over $65 billion is spent each year on medical care and surgical treatments. Sinusitis is caused when the sinus cavities become blocked due to swelling or growth of polyps. Primary contributors include bacterial and viral infections. Other contributors include overuse of decongestant nasal sprays and smoking. A common sign of acute sinusitis is when a URI seems to improve and then worsens again. Pressure or pain is commonly felt in the face, including the cheeks, forehead, between the eyes, or even the teeth. Other symptoms may include nasal congestion, fever, malaise, and a cough and pharyngitis (due to postnasal drainage) that are worse in the mornings. Diagnosis is usually based on a description of symptoms and physical examination ndings. In some cases, x-rays, computed tomography (CT) scan, or magnetic resonance imaging (MRI) of the sinuses reveal thickening of the mucosa and presence of increased uid. The physician may prescribe antibiotics for 10 to 14 days. The medical assistant should be sure to tell the patient to take the medication for the entire period, even though symptoms may begin to improve after a few days. The physician may also prescribe decongestants. Other treatment includes rest, uids, moist heat compresses, humidiers, and hot showers (to breathe the warm, humidied air). Most people recover fully with

Upper Respiratory Infection

ICD-9-CM code: 460 Upper respiratory infection (URI), also called coryza, is more commonly known as the common cold because it is so common. In fact, it is the reason most frequently given for missed school and work, with an estimated 1 billion cases in the United States each year. Children experience an average of three to eight colds each year.

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appropriate diagnosis and treatment. Potential complications include chronic sinusitis, osteomyelitis, and orbital cellulitis.

Pharyngitis
ICD-9-CM code: 462 Pharyngitis is the inammation of the pharynx. In the United States, children have an average of ve episodes and adults have an average of two episodes of pharyngitis per year. The usual cause of pharyngitis is a viral URI and seasonal allergies, which cause postnasal drainage that irritates the throat. Organisms that may be responsible for bacterial pharyngitis include Streptococcus, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Neisseria gonorrhoeae. Infection is spread from person to person by direct contact and contact with oral secretions. Other causes of pharyngitis include sinus infection, diphtheria, and mononucleosis caused by the Epstein-Barr virus. Risk factors that make people more vulnerable to pharyngitis include inhaling pollutants, smoking, and secondhand smoke. Patients with pharyngitis describe the throat as scratchy and sore. Swallowing is painful and may be difcult. Upon examination, the pharynx appears red and edematous and the tonsils may be swollen and have white spots of purulent (pus) exudate. Other symptoms may include fever and cough. Cervical lymph nodes are usually tender and swollen. Diagnosis is based on a description of symptoms and physical examination ndings. A throat culture may be used to differentiate viral from bacterial pharyngitis. A quick in-ofce test, called the rapid Strep test, provides results in about 15 minutes. However, negative results must be conrmed by a culture because the test is not 100% accurate. Viral pharyngitis usually resolves without medication and responds well to conservative treatment, including analgesics and warm saline gargles. Antibiotics are prescribed for bacterial pharyngitis. Most people recover fully with conservative treatment. However, potential complications include rheumatic fever, scarlet fever (with streptococcal infections), tonsillary abscess, and glomerulonephritis (a type of kidney infection). Those who suffer from chronic infections may benet from a tonsillectomy.

In past years, a third of those infected died from pneumonia. However, since the advent of antimicrobial medications, most people with access to medical care recover. More than 3 million people in the United States develop pneumonia each year and more than a half million of them are hospitalized. Pneumonia may be caused by bacteria, viruses, or chemical irritants. In some cases, the infecting organisms become airborne when the ill person coughs or sneezes. If another person inhales the infectious organisms and the organisms grow in that persons lungs, pneumonia develops. Another common cause of pneumonia is aspiration (inhalation) of chemical irritants such as stomach uids, food, or drink, which might occur during cardiopulmonary resuscitation (CPR) or a choking episode. Those at greatest risk for developing pneumonia include those with weakened immune systems, chronic lung disease, heart disease, alcoholism, seizure disorders, and swallowing disorders. Symptoms of pneumonia include coldlike symptoms followed by fever, productive cough, shaking chills, shortness of breath, chest pain with deep breaths, muscle aches, and malaise. Diagnosis is based on a description of symptoms, physical examination ndings, and a chest x-ray, which may reveal whitened areas (opacities) that indicate consolidation (solidication due to engorgement). Lung sounds heard on auscultation usually include wheezes and crackles caused by inammation of the airways and uid accumulation. The physician may order a sputum sample to identify the causative microorganism. A culture and sensitivity test determine the most appropriate antimicrobial agent to use for treatment. Examination of a blood sample may reveal increased WBCs. Treatment is based on the cause. Bacterial pneumonia is treated with antibiotics. Patients with other forms of pneumonia are usually treated with supportive care, including oxygen, uids, and respiratory support. Prognosis and survival is generally good. However, there is a 5% mortality rate, usually affecting patients in a weakened state. Complications include pleural effusion and empyema.

Inuenza
ICD-9-CM code: 487 Inuenza, commonly called the u, is a common, contagious, acute viral respiratory illness. Outbreaks can occur as often as every year and affect approximately 20% of the U.S. population each year. Of those affected, over 200,000 are hospitalized and more than 35,000 die. Those at greatest risk are the very young, very old, and those with chronic health disorders. There are a number of u viruses, commonly categorized as types A, B, and C. They are most commonly spread from person to person through respiratory droplets and secretions from coughing, sneezing, and kissing. They are also spread through a persons contact with contaminated surfaces (such

Common Lower Respiratory System Diseases and Disorders

Common lower respiratory diseases and disorders include pneumonia, inuenza, chronic obstructive pulmonary disease, bronchitis, asthma, emphysema, tuberculosis, EpsteinBarr virus, and lung cancer.

Pneumonia
ICD-9-CM code: 486 Pneumonia is a viral or bacterial infection of the lungs that may be mild or severe and, in some cases, is life-threatening.

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as a door knob) and then touching the mouth or nose. A person may be infectious up to 1 day before symptom development and up to 5 days after. (See Virus transmission reduction.) Common signs and symptoms of the u include fever as high as 104F (40C), headache, muscle aches, nasal congestion or rhinitis, fatigue, sore throat, dry cough, and such GI symptoms as nausea, vomiting, and diarrhea. Diagnosis of inuenza is usually based on physical examination ndings and a description of symptoms. A positive throat culture conrms the diagnosis. If secondary bacterial pneumonia is suspected, the physician may order a sputum specimen for analysis. Treatment of inuenza usually includes supportive care, such as uids, rest, analgesics, and antipyretics. Sore throat may also be soothed by warm saltwater gargles and throat lozenges. Amantadine, an antiviral agent, may be helpful in some cases. In severe cases, hospitalization may be needed. Antibiotics are not effective against the u virus but may be appropriate for secondary bacterial infections. Aspirin should not be given to children because of the risk of Reye syndrome. Patient education should be aimed at prevention through u vaccination and standard precautions such as hand washing. Most individuals can also benet from a yearly u vaccination, which is generally available each fall. (See Inuenza vaccination.) Prognosis is generally good and most people recover

Patient Education

Inuenza Vaccination
Medical assistants commonly administer inuenza vaccinations. The following general information will help you answer questions your patients may have. Vaccination is recommended for health care providers and vulnerable individuals, such as the elderly, residents of long-term-care facilities, those with cancer and lung disease, those with weakened immune systems, infants between ages 6 and 23 months, and children on long-term aspirin therapy. Individuals should consult with their physician prior to being vaccinated. Inuenza vaccination should NOT be given to individuals: with allergies to chicken or to eggs who have experienced a previous severe reaction to u vaccine with a history of Guillain-Barr syndrome in the past 6 weeks under age 6 months who are currently ill with a febrile (fever-causing) illness (should wait until they are well to receive the vaccination).

Front ofceBack ofce connection

fully. However, complications many include dehydration, bacterial pneumonia, bronchitis, and sinus or ear infections.

Virus Transmission Reduction

Following are measures that front and back ofce staff can take to reduce transmission of cold and inuenza viruses: Keep tissue and a dispenser of antimicrobial lotion at the reception desk. Encourage patients to use both. Keep antimicrobial lotion at each nurses station and at strategic locations in the facility and encourage employee use. If toys or books are kept in the reception area for children, select those that are nontoxic, easy to disinfect, and unlikely to harbor microorganisms. Avoid coming to work if you have a communicable illness. Obtain an annual inuenza vaccination. Practice good self-care to keep your immune system strong. Remind patients, family, and friends about the value of good hand washing.

Chronic Obstructive Pulmonary Disease

ICD-9-CM code: 490 Chronic obstructive pulmonary disease (COPD) includes a variety of lung disorders that create obstructive changes in the air passages and alveoli. These disorders include chronic bronchitis, asthma, emphysema, bronchiectasis, cystic brosis, and pneumoconiosis. COPD affects 11% of the U.S. population. The greatest risk factor for COPD is smoking. Others include exposure to air pollution, dust, and chemicals and repeated lower respiratory infections. Although the pathophysiology is different in each disease, the result of all is impaired air exchange. As chronic air trapping occurs, the patients chest changes dimension, becoming more barrellike. The lungs also atten on the bottom, robbing the diaphragm of its effectiveness. Cilia, tiny hairlike structures in the airway, normally move foreign debris upward to be coughed out. However, in smokers, the cilia become clogged with tar and lose effectiveness. As a result of these and other physical changes, a patient with COPD will eventually begin to experience some or all of the following symptoms:

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Orthopnea is the need to remain upright in order to breathe effectively. Physicians commonly quantify the severity of orthopnea by the number of pillows a patient uses while sleeping (for example, three-pillow orthopnea). Hypercapnia is the chronic retention of CO2. In some cases, this changes the way a persons body determines when to breathe and he begins to function according to a hypoxic drive, which means he feels the urge to breathe when his O2 level gets too low instead of when his CO2 level gets too high. This change poses a risk when the patient needs supplemental O2 because, if his blood oxygen levels rise too high, he may lose the urge to breathe, leading to respiratory arrest. Hypercapnia can also cause mental cloudiness and lethargy. Chronic hypoxia is a chronic lack of oxygen. As gas exchange becomes less effective, breathing becomes more and more difcult. Eventually, the individual becomes O2-dependent. Yet, in the last stages of the disease, supplemental O2 is of little help. The person feels chronically short of breath and suffers from severe dyspnea (painful or difcult breathing) with the slightest exertion. (See Figure 28-2.)

Bronchitis
ICD-9-CM code: 466 (acute), 491 (chronic) Bronchitis is an infection of the bronchial passages that is usually caused by a virus. It can occur in acute and chronic forms. Both forms have the same characteristics except that chronic bronchitis persists for weeks, months, or even years and causes permanent destructive changes in the lungs. The infectious microorganisms are spread through respiratory secretions by coughing, sneezing, or direct contact. Those most vulnerable to bronchitis are those who smoke and those with chronic respiratory conditions.
Destructive changes of COPD

O2

The most common symptom of bronchitis is a persistent cough that typically produces thick sputum. Other symptoms include wheezing, shortness of breath, and mild fever. Acute bronchitis usually lasts for around 1 week but the cough may continue for several weeks. Lungs are usually clear to auscultation but occasionally scattered wheezes and crackles may be heard. The primary symptom of chronic bronchitis is a chronic cough that is generally worse in the mornings. Symptoms are exacerbated by other respiratory infections. Diagnosis is usually based on history and symptoms. Testing may be done to rule out other disorders and may include chest x-ray, blood and sputum analysis, and arterial blood gases analysis. In addition, pulmonary function tests, also called spirometry, are used to evaluate the respiratory system. These tests, commonly conducted in a pulmonology clinic, provide more detailed information about the patients lung capacity. Because the cause of bronchitis is usually viral, antibiotics are of little help. Treatment is generally conservative and includes uids, rest, air humidiers, and cough medication. A cough that produces thick secretions may be treated with expectorant medication, which helps loosen and liquefy secretions so they are more easily expelled. Coughs that are nonproductive may be treated with antitussive medication, which suppresses the cough reex. In some cases, bronchodilator medication may be used to help open narrowed airways. Corticosteroids, which suppress the immune response, may be used to decrease inammation. Patients with chronic bronchitis may eventually need oxygen therapy and more aggressive pulmonary care, including chest physiotherapy, which involves percussion (clapping) over the thorax or vibration and positioning to facilitate loosening and removal of respiratory secretions. Smoking cessation is encouraged. If a secondary bacterial infection is suspected, antibiotics may be prescribed. Patients with acute bronchitis usually recover completely, although the cough may linger for several weeks. The prognosis for those with chronic bronchitis is more guarded because of the cumulative damage, which results in obstructive changes.

Asthma
CO2
Mucus

Thickened alveolar wall FIG 28-2 Destructive changes in COPD.

Capillary

ICD-9-CM code: 493.90 (acute), 493.20 (chronic) Asthma is a disorder in which the airways overreact to certain triggers with inammation that results in narrowing and production of thick mucus, causing breathing difculty. Asthma usually affects individuals who also suffer from allergies. Asthma affects approximately 20 million Americans and costs an estimated $18 billion dollars each year in direct and indirect costs. It is estimated that each day 30,000 people suffer an asthma attack, 40,000 miss school or work, several thousand visit the emergency room, 1,000 are admitted to

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the hospital, and 14 people die. Asthma is the most common chronic disease suffered by children. It accounts for 25% of emergency room visits and 10 million outpatient visits. Even more alarming is the fact that asthma-related deaths have increased by more than 50% among all age groups and by 80% among children since 1980. Ethnic groups such as African Americans and Latino populations suffer higher rates of illness and death. These differences appear to be correlated with poverty, poor air quality, indoor allergens, and lack of access to adequate education and medical care. There are two types of asthma: allergic and nonallergic. Allergic asthma is caused by allergens such as pollen, dust mites, pet dander, or other irritants that are inhaled into the lungs and air passages, causing inammation. Nonallergic asthma is triggered by such factors as exercise, cold air, stress, anxiety, smoke, and viruses. Risk factors for asthma include genetics, poor air quality, and poverty. Signs and symptoms of both forms of asthma include coughing, wheezing, shortness of breath, and chest tightness. Increased respiratory effort and dyspnea commonly result in anxiety, tachycardia, and pallor. The individual prefers to sit upright for maximal lung expansion and may have difculty speaking in complete sentences. Auscultation of the lungs reveals tight-sounding lungs with wheezing and decreased breath sounds. In an emergent situation, diagnosis is usually based on the patients description of symptoms, physical examination ndings, oxygen saturation readings, and peak-ow measurement. A peak-ow meter is a handheld device the patient can use to measure the volume of air that he is able to inhale and exhale. The physician may order pulmonary function tests but usually defers them for the critical patient. Chest x-ray reveals changes related to hyperination of the lungs and mucus plugs. Allergy testing may also be done. Acute asthmatic episodes are treated with such medications as albuterol and epinephrine. Both medications cause relaxation of the smooth muscle in the airways, allowing them to open. Depending on the severity of the attack, corticosteroids may also be used because of their potent anti-inammatory effect and their ability to decrease airway reactivity. Long-term management includes identication of allergens, desensitization therapy, preventive medications such as steroid inhalers, and avoidance of known triggers. Prognosis is variable and depends on the type and severity of the asthma and the patients access to health care resources.

There are a number of contributors to the development of emphysema, including industrial exposure and repeated or chronic respiratory infections. However, the main risk factor is cigarette smoking. As the lungs are repeatedly subjected to the irritants and toxins in cigarette smoke, the delicate alveoli lose their elasticity and become permanently distended like tiny balloons that have been inated too many times. They also erode and thicken, thereby functioning less effectively. Loss of elasticity results in air trapping and the thorax begins to develop the barrel-like shape characteristic of COPD. The diaphragm also attens, losing much of its effectiveness. Most patients are asymptomatic until they lose over half of their lung function. This lack of symptoms leads many into a false sense of security, believing they still have time to quit smoking before any real damage is done. Initial signs of emphysema include dyspnea with exertion, which gradually worsens, and the development of a chronic productive cough. Weight loss occurs and as heart failure develops, lower-leg edema also develops. Fingernail clubbing develops due to microvascular changes. (See Figure 28-3.) The patient experiences progressively worse orthopnea and chronic hypoxia, which causes circumoral cyanosis (blue color around the mouth) during acute episodes. Other symptoms include tachycardia and hypertension. Diagnosis is based on history and physical examination ndings, chest x-ray, and pulmonary function tests. Tidal volume and residual volume are increased while vital capacity and expiratory volume are decreased. Radiologic studies reveal a attened diaphragm and cardiomegaly. On good days, the lungs may sound clear; however, auscultation with a stethoscope will reveal decreased breath sounds. On bad days, the lungs will sound wheezy with scattered crackles and rhonchi, which are coarse, gurgling sounds heard

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Emphysema
ICD-9-CM code: 492.8 Emphysema is a common chronic obstructive respiratory disorder that involves permanent damage to the alveoli and attening of the diaphragm, leading to COPD. Emphysema affects as many as 30 million Americans and causes over 100,000 deaths each year.

180

FIG 28-3 Fingernail clubbing.

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on auscultation caused by secretions in the air passages. Arterial blood gas (ABG) analysis may reveal chronically low oxygen saturation and carbon dioxide retention. Treatment for emphysema includes various medications to manage the disease and treat acute exacerbations. Some may be delivered via inhalation therapy with a metered-dose inhaler (MDI) or a nebulizer, which is a device that produces a ne spray or mist to deliver medication to the deep air passages of the lungs. For acute exacerbations, the physician may prescribe IV or oral corticosteroids. Expectorants may help make a productive cough more effective and antibiotics are appropriate if a secondary bacterial infection is suspected. Nutrition becomes an issue as patients lose their appetite and the ability to complete a meal without dyspnea. Eventually, supplemental oxygen is needed. However, patients must carefully follow physician recommendations because too much oxygen can sometimes cause complications. During the last few years of life, the patient with emphysema has great difculty performing basic selfcare tasks due to extremely poor activity tolerance. Emphysema causes permanent destructive changes to respiratory structures and has signicant impact on quality of life and longevity. Prognosis is poor and depends largely upon how early the patient receives diagnosis and treatment and whether further exposure to irritants is eliminated. Death from emphysema and other forms of COPD is common in the United States. (See Teaching about COPD.)

Patient Education

Teaching About COPD

The medical assistant should be sure to include these points when teaching a patient about chronic obstructive pulmonary disease (COPD): Stop or reduce smoking. Information on smoking cessation programs is available. Avoid secondhand smoke and other pollutants. Avoid exposure to others with contagious respiratory disorders. Obtain an annual inuenza vaccination. Plan small, nutritious meals with between-meal snacks. Consider drinking high-energy, nutritious supplements such as Ensure. Take a daily multiple vitamin. Take medication as prescribed. Keep emergency medication (such as an inhaler) handy. Pace activity with frequent rest periods. Use purse-lipped breathing when you feel severely short of breath. Do not smoke or use ames around oxygen. Keep well hydrated to help thin respiratory secretions.

Pulmonary Tuberculosis
ICD-9-CM code: 011.90 Pulmonary tuberculosis is a contagious lung infection that can also spread to and affect other organ systems. An estimated 30,000 Americans are affected by TB. Populations that suffer from poverty, crowding, unsanitary conditions, malnutrition, and poor access to health care suffer higher rates than others. Pulmonary TB is acquired most commonly by individuals who have weakened immune systems that do not isolate the primary infection, including very young and very old patients and those who are immunocompromised, such as patients with AIDS or those on antirejection or chemotherapeutic medication. TB is caused by infection with the organism Mycobacterium tuberculosis. Primary infection with M. tuberculosis usually begins in the lungs after inhalation of the bacterium shed by the cough or sneeze of a contagious individual. In most cases, the lungs successfully encapsulate the infection and the individual recovers without further complications. Pulmonary TB may develop several weeks after the primary infection or may develop or recur after lying dormant for a number of years. Those who are immunocompromised are more likely to experience such a reactivation at a later time. Up to 20% of individuals with pulmonary tuberculosis may be asymptomatic. Others have a productive cough,

hemoptysis (coughing up blood), fever, night sweats, weight loss, anorexia, fatigue, chest pain, and dyspnea. Diagnosis is based on history, symptoms, and physical examination ndings. Auscultation of the lungs may reveal crackles. Other findings include cervical lymph node enlargement and tenderness. The tuberculin skin test (PPD) is a rst-line test; a positive reaction to the test indicates exposure to tuberculosis but does not conrm the presence of active disease. In addition, when an individual has tested positive, the TB skin test will always test positive and is of no further use. Other diagnostic testing includes chest x-ray, which reveals multiple opacities (light areas) that may coalesce (run together) and tubercle lesions and cavities, and bronchoscopy (visual examination of the large air passages of the lungs) with collection of sputum (lung secretions) for culturing, which detects the presence of the tubercle bacillus, conrming the diagnosis. The course of treatment usually lasts 6 months or longer and includes administration of multiple medications, including rifampin (Rifadin), isoniazid (Nydrazid), and others. Because all antitubercular drugs have some toxicity, the medical assistant and physician must conduct thorough patient education and careful monitoring. The medical

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assistant should also emphasize the importance of completing treatment to prevent relapse and reduce the risk of antibiotic resistance. Symptoms generally resolve within 3 weeks, although chest x-ray will not reveal improvement until later. Prognosis is excellent if the disease is diagnosed and treated early. Delayed treatment can result in permanent lung damage. Incomplete treatment contributes to the emergence of drug-resistant strains.

but serious complication is splenic rupture, which can cause life-threatening hemorrhage.

Lung Cancer
ICD-9-CM code: 162.9 Lung cancer involves the proliferation of cancer cells in lung tissues. There are two general types of lung cancer: small cell and non-small cell. Lung cancer causes 90% of all cancerrelated deaths in the United States. Small cell lung cancer accounts for 20% of all lung cancer and develops almost exclusively in smokers. Non-small cell lung cancer comprises over approximately 80% of lung cancer cases. Squamous cell carcinoma, a type of non-small cell lung cancer, comprises approximately 30% of all lung cancer cases and is most common in men. Adenocarcinoma, another type of non-small lung cell cancer, comprises approximately 40% of all lung cancer cases and is most common in women and nonsmokers. A third type of non-small cell lung cancer, known as large cell carcinoma, comprises the other 10% of all lung cancer cases. African Americans have a higher risk of lung cancer, develop it at an earlier age, and are less likely to survive. The higher risk in this group is thought to be related to less access to health care, rather than genetics. The cause of each type of lung cancer is still not fully understood. However, research has proven that the single largest contributor to the disease is the use of tobacco, which is known to contain over 3500 chemicalsmany of them carcinogensas well as toxic metals and radioactive compounds. Other contributors to lung cancer include secondhand smoke, asbestos, air pollution, and radon, which is an odorless gas released from the breakdown of uranium in water and soil. As tissue cells are damaged by these substances, they change and, in some cases, become cancerous. Patients with lung cancer are commonly asymptomatic until the disease is far advanced. The most common rst symptom is an unexplained cough or a chronic smokers cough that worsens or changes in character. Other signs and symptoms include hemoptysis, dyspnea, chest pain, new onset of wheezing, prolonged hoarseness, fatigue, anorexia, weight loss, bone pain, headache, and repetitive episodes of bronchitis or pneumonia. Screening for lung cancer is controversial and is not currently recommended by the American Cancer Society. Chest x-rays and CT scans check for abnormal lesions or masses. However, the denitive diagnostic test for any form of cancer is analysis of a biopsied tissue specimen. Such specimens may be obtained through a sputum specimen, bronchoscopy, mediastinoscopy, transthoracic needle biopsy, thoracentesis, or video thoracoscopy. If cancer is detected, the physician stages it according to a system that classies it based on the extent of spread. Tests used to determine staging include MRI and PET scans. Staging is important in determining the most appropriate treatment plan.

Epstein-Barr Virus
ICD-9-CM code: 075 The Epstein-Barr virus (EBV ), also called infectious mononucleosis, is an infection marked by fever and fatigue. EBV has infected an estimated 95% of adults under age 40. When the virus infects a person during his teen or young adult years, it causes infectious mononucleosis between 35% and 50% of the time. Younger children are commonly asymptomatic or have such a mild case that it is indistinguishable from other mild viruses. Adults older than age 35 rarely have an active infection. EBV is a member of the herpesvirus family and is transmitted by intimate contact with saliva of an infected person, giving it the name kissing disease among young people. It is not usually transmitted via air as cold viruses are or via blood. Because many healthy people have the virus and dont know it, most are not at signicant risk for acquiring an active infection from anyone else. Therefore, no special precautions are recommended. Symptoms include fever, pharyngitis, lymphadenopathy (swollen and tender cervical lymph nodes), headaches, fatigue, and anorexia. Splenomegaly or hepatomegaly may also develop. If symptoms last longer than 4 months, chronic EBV infection may be present. Diagnosis is based on history, description of symptoms, and diagnostic tests. Common tests include the monospot test, antinuclear antibody (ANA) test, and CBC test, which may reveal elevated WBC count and elevation in a specic type of WBCs called lymphocytes. The Paul-Bunnell heterophile antibody test may be used to conrm the diagnosis. There is no cure for EBV and treatment aims to relieve symptoms, including bed rest, uids, and analgesics. Corticosteroids may help relieve pharyngitis and lymphadenopathy. The physician may recommend the avoidance of sports and demanding physical activities. Aspirin should not be given to young people. Because EBV is a virus, it does not respond to antibiotics. Symptoms usually resolve within 4 weeks and complete recovery occurs within 3 to 4 months. Once a person is infected, the virus commonly remains dormant in the body. In most cases, it causes no further problems for the individual. However, in rare cases it can play a role in the development of Burkitts lymphoma and nasopharyngeal carcinoma. A rare

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Treatment for the individual patient depends on a number of factors, including the type and stage of the cancer and the patients underlying health status. The physician may perform surgery to remove cancerous lesions if the cancer remains localized. Procedures include wedge resection (removal of only the affected part of the lung), lobectomy (removal of an entire lobe), or pneumonectomy (removal of an entire lung). Also, lymph node biopsy identies whether the cancer has spread into the lymphatic system. Chemotherapy, radiation therapy, or both are common treatments for lung cancer. Chemotherapy involves the use of medications to kill cancer cells, shrink them, or slow their growth, thereby making the patient more comfortable and prolonging life. Radiation therapy uses targeted x-rays to kill cancer cells or shrink tumors. The mode of delivery depends on the type and stage of the cancer. The prognosis for individuals with lung cancer is generally poor but varies somewhat, depending on the type of cancer and how early it is detected. Small cell cancer grows and spreads rapidly with a very poor prognosis. All forms of lung cancer that respond well to initial treatment commonly reappear months or years later and are less responsive to treatment at that time. The 5-year survival rate for all types of lung cancer is only 15%.

Front ofceBack ofce connection

Front Ofce Breathing Emergency

The administrative medical assistant should never make a patient who complains of shortness of breath wait in the reception area. She should act quickly to: notify the physician, nurse, or clinical medical assistant immediately assist the patient to a chair and send someone for a wheelchair make sure the patient is wheeled to an examination room right away obtain emergency contact information for a patient who arrives alone assist the clinical staff, if requested, by ordering emergency tests or consultations.

Pulmonology Procedures
Pulmonology is a medical specialty that focuses on the study and treatment of diseases and disorders of the respiratory system. However, all primary care providers evaluate and treat patients with common respiratory disorders. Patients with more severe or complex respiratory illness are usually referred to the pulmonologist, a specialist in the diagnosis and treatment of respiratory disorders. Some disorders treated by the pulmonologist, such as URI, arent considered serious medical disorders. However, because of their potential for adverse complications in compromised individuals, these disorders deserve as much attention as more serious medical disorders such as lung cancer. (See Front ofce breathing emergency.)

She should then assist the patient as needed with undressing and positioning. Patients should undress above the waist, put on the examination gown with the opening in the front, and sit upright on the examination table. Doing so allows the physician easy access to the patients thorax in order to perform inspection, palpation, percussion, and auscultation anteriorly, posteriorly, and laterally. The medical assistant should provide the patient as much privacy as possible, assist the physician as needed with the examination, and perform ordered diagnostic tests. She must also assist the pulmonologist as needed with any procedures.

Diagnostic Testing
Respiratory disorders are extremely common. Therefore, regardless of what type of setting they work in, most medical assistants help provide care for patients with some form of respiratory illness or disorder. Diagnostic tests commonly done in a pulmonology ofce include pulmonary function tests and bronchoscopy. Simple tests that might be done in any medical ofce include the Mantoux test and peak-ow measurement.

Assisting with Examination

To reach an accurate diagnosis, the pulmonologist must assess the patients medical history, including a description of symptoms, as well as perform a physical examination of upper and lower airways. In an examination, the medical assistant must prepare the patient by checking vital signs and obtaining the health history, which should include data regarding allergies, new respiratory symptoms, and medications.

Pulmonary Function Tests

Pulmonary function tests (PFTs), also called spirometry, are a group of tests used to evaluate the respiratory system and determine the degree of airway obstruction caused by obstructive disorders. The test measures various aspects of expiratory ow and lung volume.

Total lung capacity is the total volume of air in the lungs after a maximal inhalation. It is reduced in patients with

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restrictive lung disease and increased in those with obstructive lung disease. Tidal volume is the volume of air typically inhaled and exhaled with each normal breath. It is reduced in elderly patients and those with restrictive lung disease. Vital capacity is the volume of air that can be exhaled from the lungs after a maximal inspiration. It is reduced in elderly patients and those with atelectasis and pulmonary edema. Residual volume is the amount of air remaining in the lungs after a forced maximal exhalation. It is increased in elderly patients and those with COPD. Functional residual capacity is the amount of air remaining in the lungs after a normal exhalation. It is increased in elderly patients and those with COPD. (See Figure 28-4.) Forced expiratory volume (FEV) is the amount of air that can be quickly exhaled. FEV1 is the volume of air that can be forcibly exhaled in 1 second. Forced vital capacity (FVC), also called FEV6, is the amount of air that can be completely and forcibly exhaled after a maximal inhalation. (See Procedure 28-1: Performing respiratory testing.)

Total lung capacity

Volume

Tidal volume Residual volume

Vital capacity Functional residual capacity

Time FIG 28-4 Pulmonary function test.

PROCEDURE 28-1

Performing respiratory testing

Task Assist a patient in the use of a spirometer for respiratory testing. Conditions Spirometer with recording paper Disposable tubing Disposable mouthpiece Disposable nose clips Biohazardous waste container Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist a patient in the use of a spirometer to complete respiratory testing. Performance Standards 1. Greet and identify your patient to prevent errors. Introduce yourself and explain the procedure to ease patient anxiety. 2. Wash or sanitize your hands to ensure infection control. 3. Assemble supplies and equipment. Apply new disposable tubing and mouthpiece. 4. Obtain the patients height and weight to accurately calculate predicted values. 5. Enter the patients age, gender, height, and weight into the computer to ensure accurate calculation of predicted values. 6. Ask the patient to loosen tight clothing and sit upright near the machine to increase the patients ease when performing breathing maneuvers. 7. Describe and demonstrate the breathing maneuver to the patient to help him understand how to perform the procedure and feel less self-conscious about doing it himself. 8. Gently apply the nose clips to his nose to keep air from escaping out of his nose and coach him in performing the maneuver to help him complete the procedure successfully, using these instructions: a. Take in as deep a breath as you possibly can. b. Put the mouthpiece in your mouth with your lips snugly around it. c. Blow out forcefully as hard as you can for as long as you can until your lungs feel completely empty.

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PROCEDURE 28-1contd

Apply nose clips to patients nose and coach him through the steps of the maneuver.

9. Repeat the maneuver until three optimal readings have been obtained to ensure accurate results. 10. Remove the nose clips, disposable mouthpiece, and tubing. Discard them all in the biohazardous waste container. Allow the patient to rest for a few minutes because the patient may feel slightly dizzy from the deep breathing. 11. Sanitize your hands, print the report, and enter all data in the patients medical record, including his name, the date, the time, the name of the test, and your signature to ensure the accuracy and completeness of the medical record.

Date 07/07/08; 10:21 a.m. Spirometric testing completed. See report for details. -----------------------------------------------------------S. Gonzales, CMA

12. Clean the spirometer according to the manufacturers instructions and put away all equipment to ensure infection control and prepare the equipment for the next use.

Bronchoscopy
Bronchoscopy is a procedure in which the physician views a patients airways using a bronchoscope in order to examine them, remove foreign objects or a growth, or collect tissue for biopsy. The physician may use a rigid or exible bronchoscope, depending on the purpose. Flexible bronchoscopes are more useful for viewing small airways and removing small tissue specimens and usually do not require general anesthesia. Rigid bronchoscopes are more useful for treating bleeding and removing foreign objects or large tissue samples and usually require general anesthesia. The physician performs a bronchoscopy in a hospital setting or the procedure room of a medical clinic. The medical assistant should be sure to explain the procedure to the patient as well as provide patient

education on how to prepare for the test. (See Bronchoscopy teaching, page 512.) A large x-ray machine called a fluoroscope may be used to transmit a picture to a monitor, which provides an enlarged picture and the ability to record a video of the procedure.

Mantoux Test
The Mantoux test, also called the puried protein derivative (PPD) test, detects tuberculosis infection. The test involves the intradermal injection of puried protein derivative just beneath the top layer of the skin on the inner aspect of the forearm. The nurse or medical assistant evaluates the site between 48 and 72 hours later for evidence of induration

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Patient Education

Bronchoscopy Teaching
When preparing a patient for a bronchoscopy, the medical assistant should be sure to cover these topics.

After the procedure

You will rest for 2 to 3 hours afterward. If a biopsy was done you may undergo a chest x-ray to rule out pneumothorax (air leakage). Do not operate a car or other equipment. Be sure to have someone available to drive you home. You may have a sore throat, which you can relieve by using warm saltwater gargles or sucking on throat lozenges. You may have a hoarse voice. If a biopsy was taken, you may cough up very small amounts of blood for a few hours. Do not smoke for at least 24 hours. Call the physician if you: cough up more than 2 Tbs of blood have difculty breathing run a fever greater than 100F (38C).

First steps
You will be able to discuss the procedure with the physician beforehand, so you can get answers to all of your questions. The physician will ask you to sign a consent form. The physician or medical assistant will ask some questions, including: What medications are you taking? Do you bleed easily? Are you or could you be pregnant?

Prior to the procedure

You may undergo a chest x-ray to help the physician identify the area to look at during the procedure. Eat and drink nothing within 8 to 10 hours of the procedure. Empty your bladder just before the procedure. You may be asked to remove: dentures eyeglasses or contacts hearing aids jewelry wigs makeup all or most of your clothing (you will be given a gown to wear). You may be given medication, such as: topical anesthetic spray medication to relax you medication to dry up oral secretions.

General information
The procedure will not interfere with your ability to breathe. You may receive oxygen through your nose. The staff will monitor your heart rate, blood pressure, and oxygen levels throughout the procedure. The procedure usually takes 1 hour or less. Results of a biopsy or culture are usually available 2 to 7 days after the procedure.

(hardening). An area of induration larger than 10 mm is considered positive, which means the patient has a current or prior tuberculosis infection.

Peak-Flow Measurement
A peak-flow meter is a handheld device used to measure a patients lung capacity. It provides less detailed information than pulmonary function tests but has the advantage of being portable and easy to use. Therefore, patients may obtain an objective measurement of lung capacity at home, work, school, or elsewhere whenever they feel short of breath. The patient can compare these measurements with her normal baseline values to determine whether to take medication or call the medical office. To use the

peak-flow meter, the patient takes a deep breath and blows into the meter as quickly and forcefully as possible. Keeping a peak-flow diary helps the patient determine what her normal baseline values are and allows comparison and objective measurement during times of illness or exacerbation of an underlying respiratory disorder. It is especially useful for patients with asthma. (See Figure 28-5.)

Treatments
Treatments for respiratory disorders include use of a metered-dose inhaler, a nebulizer, incentive spirometry, and oxygen therapy.

CHAP TER 28

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513

Patient Education

Using a Spacer
Patients who have difculty using a metered-dose inhaler (MDI) commonly have greater success using an MDI with a spacer. The medical assistant should teach a patient how to use an MDI by following these steps: 1. Control breathing using pursed-lip breathing. 2. Shake the inhaler. 3. Remove the caps from mouthpiece and spacer. 4. Insert the inhaler into the spacer. 5. Place your lips around the spacer mouthpiece. 6. Depress the inhaler so that the spray enters the spacer. 7. Inhale slowly. 8. Hold your breath for 5 to 10 seconds. 9. Repeat the procedure (if directed). 10. Clean the spacer and MDI per instructions.
FIG 28-5 Peak-ow meter.

Metered-Dose Inhaler
Patients with respiratory disorders such as asthma and emphysema are commonly given a prescription for a metered-dose inhaler (MDI), which allows the patient to deliver medication directly into his air passages and lungs. MDIs with spacers are also available for patients who have trouble using MDIs. (See Using a spacer.) Inhalers may be prescribed for use on a regular schedule or on an as-needed (prn) basis. However, in instances when use of an inhaler does not provide adequate relief of symptoms, the patient may administer medication using a nebulizer. (See Figure 28-6.) The medical assistant may teach the patient to use an incentive spirometer for postoperative or home use. The patient uses this handheld device several times throughout the day to inhale a maximal breath to keep lungs expanded and functional. The patient may also receive oxygen administration in the medical ofce on a temporary basis or may need instruction for home oxygen use. (See Procedure 28-2: Teaching a patient to use an MDI, page 515.)

the patient to breathe better. Such an effect is especially useful for patients experiencing an exacerbation of a disorder such as asthma or emphysema. As a general rule, doctors prefer to prescribe inhalers, rather than nebulizers, because they are cheaper, more portable, and deliver less medication, which means less risk of adverse effects. However, nebulizers work especially well for infants and very small children who are unable to use MDIs effectively. Although physicians prefer MDIs for use by older individuals, a nebulizer may be prescribed for an individual with serious respiratory disease or severe asthma attacks. In selected cases, the physician will also prescribe nebulizers for home use. However, nebulizer use is most common in clinics and hospitals. If the physician prescribes a home-use nebulizer for a patient, the medical assistant should be sure to provide adequate education to ensure the maximal therapeutic benet. (See Using a home nebulizer, page 516.)

Incentive Spirometry
An incentive spirometer is a handheld device used by a patient to fully expand the lungs by inhaling as deeply as possible to keep lungs clear. Patients who use this device are commonly postoperative patients and those at risk for developing atelectasis (partial lung tissue collapse). There are many styles of incentive spirometers; however, all have similar components, including a mouthpiece, tube, and ball or piston. The patient inserts the mouthpiece into his mouth and then must breathe in slowly and as deeply as he can. As he does so, a small ball or piston rises in the tube, which has

Nebulizer Treatments
A nebulizer is a device that produces a ne spray or mist to deliver medication to the air passages and lungs. It creates the mist by rapidly passing air through a liquid or by vibrating a liquid at a high frequency so that the particles produced are extremely small and become aerosolized. For example, albuterol (Proventil, Accuneb), which relaxes muscles in the airways, is delivered in this manner. This muscle relaxation allows air passages to open more fully, enabling

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FIG 28-6 (A) Nebulizer. (B) MDI. (C) MDI with spacer.

markings on it. The patient should hold his breath for as long as possible and then breathe out. After resting for a few seconds, the patient should repeat the process. Postoperative patients should complete a set of 10 breaths every hour or two while awake. In most cases, the patient can stop using the incentive spirometer when they return home from the hospital. However, patients who are prone to respiratory

infections or are sedentary may be instructed to use an incentive spirometer at home. These individuals should follow the instructions of their physician.

Oxygen Therapy
Patients who suffer from acute or chronic respiratory disorders sometimes need supplemental oxygen therapy. In most

CHAP TER 28

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515

PROCEDURE 28-2

Teaching a patient to use an MDI

Task Teach a patient how to use a metered-dose inhaler (MDI). Conditions Metered-dose inhaler Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully teach a patient to use an MDI. Performance Standards 1. Greet and identify your patient to prevent errors. Introduce yourself and explain the procedure to ease patient anxiety. 2. If possible, ask the patient to watch an MDI demonstration video to introduce the patient to the proper use of an MDI. 3. Wash or sanitize your hands to ensure infection control. 4. Using a placebo MDI or one prescribed for the patient, point out the mouthpiece and cover and the medication canister. Indicate how the canister is depressed to initiate a puff of medication to familiarize the patient with the parts and function of the device. 5. Instruct the patient to use purse-lipped breathing to slow and control his breathing rate. Remove the cap from the mouthpiece and shake the MDI for 5 to 10 seconds to mix the medication, preparing the MDI for use. 6. Hand the MDI to the patient and instruct him to hold it upside down 1" to 112" in front of his open mouth to enable him to inhale more of the aerosolized medication into his lungs, rather than depositing it on the back of his mouth. 7. Instruct the patient to exhale and then, just after beginning to inhale, to depress the canister. The patient should continue to inhale slowly for 5 to 6 seconds to help move more of the aerosolized medication into the deeper airways and leave less on the back of the throat. 8. Instruct the patient to hold his breath for 8 to 10 seconds, if possible, and then to exhale through pursed lips to facilitate the deposit of the medication into his lungs before exhalation. 9. If more than one puff is prescribed, instruct the patient to wait for several minutes before repeating the procedure to allow the patient to rest and provide time for the initial dose to work, which (with medications such as bronchodilators) will enable more effective inhalation of the second dose. 10. Document the session in the patients medical record to reect the teaching that occurred and ensure a complete, accurate medical record.
Date 11/03/08; 9:55 a.m. Instructed Pt in use of MDI. Return demonstration performed -----------------------------------------S. Gonzales, CMA

cases, the need is temporary. However, in the case of some chronic disorders such as COPD, patients may become chronically oxygen-dependent. The goal of oxygen therapy is to relieve or prevent hypoxemia (low blood oxygen levels). Regardless of the need, oxygen administration, as with any drug, is dependent on a physicians order. In some cases, improper administration of oxygen can cause adverse effects. In addition, some patients with COPD, who chronically retain carbon dioxide (CO2), can actually lose their drive to breathe if too much oxygen is administered. The standard ow rate for such patients is usually 1 to 2 L per minute. Home-delivery vendors deliver the oxygen and related equipment to the patient as well as set it up and instruct the patient on its proper use. However, the physician and medical assistant must closely monitor the patient on oxygen therapy and provide comprehensive education for safe, effective home use, including fire hazards around oxygen. Although it will not burn spontaneously, oxygen

can help to ignite and fuel a fire if a spark or flame is present. Different devices deliver different percentages of oxygen, referred to as fraction of inspired oxygen (FIO2). The most common device for oxygen delivery in the clinic or home setting is disposable tubing with a nasal cannula, sometimes referred to as nasal prongs, which are attached to an oxygen tank or a wall outlet. The prongs of the cannula are usually curved in shape and t most comfortably in the patients nose with the prongs pointed downward toward the base of the patients nose. (See Figure 28-7.) The nasal cannula is for low-ow oxygen only. The most common setting is 2 L/minute, although anywhere between 1 and 6 L may be administered. However, a ow rate greater than 4 L will quickly dry the nasal mucosa and a humidier should be attached for prolonged use. For ow rates above 5 or 6 L, the patient should use a mask. (See Procedure 28-3: Administering oxygen via nasal cannula, page 516.)

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Patient Education

Using a Home Nebulizer

The medical assistant teaching a patient how to use a home nebulizer should be sure to include these steps: Breathe normally most of the time, but take an occasional deep breath and hold it for 5 to 10 seconds to help distribute the medication into the deep air passages. If administering a nebulizer to an infant or small child, use a mask. If the child will not tolerate wearing a mask, hold the mask in front of her face as she breathes. Sit upright to ensure maximal lung expansion. Clean the nebulizer and equipment after each use according to the manufacturers instructions to avoid the growth of microorganisms. Bronchodilators provide immediate relief but commonly cause the temporary adverse effects of nervousness, tremors, heart palpitations, and increased blood pressure. Steroids can cause oral thrush and sore throat, so be sure to rinse the mouth after use.

FIG 28-7 Oxygen therapy using a nasal cannula.

PROCEDURE 28-3

Administering oxygen via nasal cannula

Task Administer oxygen to a patient using a nasal cannula. Conditions Nasal cannula Oxygen tubing Oxygen source Oxygen ow meter Appropriate room signs Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully administer oxygen to a patient using a nasal cannula. Performance Standards 1. Greet and identify your patient to prevent errors. Introduce yourself and explain the procedure to ease patient anxiety. 2. Wash or sanitize your hands to ensure infection control. 3. Connect the nasal cannula to the oxygen tubing (unless tubing is packaged preconnected). Attach the tubing to the oxygen source and set it at the prescribed level to avoid having to adjust the oxygen ow when administering it to the patient. Check for oxygen ow out of the nasal cannula to ensure patency of the tubing. 4. Place the tips of the cannula into the patients nares with the curved prongs pointing downward to ensure that the oxygen will ow into the nasal passages, rather than against the roof of the nose. 5. Place the tubing on either side of patients head and wrap it behind the patients ears (similar to the ear pieces on a pair of glasses) so that the tubing then lies forward on his chest. Adjust the plastic slide so that the tubing is comfortably snug under the patients chin to ensure that the tubing is secure during movement but the patient is comfortable. 6. Document the procedure in the patients medical record to ensure a complete, accurate medical record.
Date 08/07/08; 8:55 a.m. 02 applied at 2 L per NC.--------------------S. Gonzales, CMA

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Chapter Summary

Oxygen should be administered by physician order only. Consistent monitoring and comprehensive education on oxygen home use is essential.

Oxygen is essential for human life. The pulmonary system allows the human body to exchange oxygen for carbon dioxide through inspiration and expiration. Key structures of the pulmonary system include the mouth, nose, sinuses, nasopharynx, oropharynx, trachea, bronchi, and lungs. Gas exchange occurs in the tiny alveoli, which are microscopic air sacs. Medical assistants must be well versed in the language and vocabulary that pertain to the pulmonary system. In addition to knowing common word elements, they should be familiar with common pathological terms and abbreviations. Some of the most common disorders of the pulmonary system include allergic rhinitis, URI, sinusitis, pharyngitis, pneumonia, inuenza, tuberculosis, mononucleosis, lung cancer, and obstructive disorders such as bronchitis, asthma, and emphysema. Pulmonology is a medical specialty that focuses on the study and treatment of diseases and disorders of the respiratory system. Medical assistants assist physicians in pulmonology as well as in other settings with patient examinations, diagnostic testing, and procedures. Pulmonary function tests (PFTs) are a group of tests used to evaluate the respiratory system and are used to determine the degree of airway obstruction that exists with obstructive disorders. The physician performs a bronchoscopy using a bronchoscope to examine the patients airways, remove a foreign object or growth, or collect tissue for biopsy. The Mantoux test identies whether an individual has been exposed to tuberculosis. A peak-ow meter is a handheld device that may be used to measure a patients lung capacity. It provides less detailed information than pulmonary function tests but has the advantage of being portable and easy to use. A metered-dose inhaler (MDI) is a handheld device that delivers medication directly into the air passages and lungs. Physicians prescribe inhalers for use on a regular schedule or on an as-needed basis. An incentive spirometer is a handheld device used by a patient to fully expand the lungs by inhaling as deeply as possible. Postoperative patients and those at risk for developing atelectasis commonly use this device. Patients who suffer from acute or chronic respiratory disorders sometimes need supplemental oxygen therapy. The goal of oxygen therapy is to relieve or prevent hypoxemia.

Team Work Exercises

1. Divide into groups of three or four students. Each group must role-play one of the following scenarios (as determined by the instructor) for the rest of the class: a. An 8-year-old child is diagnosed with asthma. The physician prescribes an albuterol inhaler. The medical assistant must teach the child and parent(s) how to use it with and without a spacer. b. A 72-year-old man with COPD is taking a nebulizer home so that he can have home treatments three times per day, as needed. He is extremely hard of hearing and somewhat forgetful. Therefore, the medical assistant must teach the patient and his wife how to use the nebulizer. c. Mrs. Vargas is a 38-year-old woman who will be undergoing a bronchoscopy. She speaks and understands very little English. The medical assistant must provide Mrs. Vargas and her teenage daughter with instructions regarding what to expect before and after the procedure. An interpreter will be used. 2. Divide into groups of three to four students. Each team must compose a story. In writing the story, the team must use as many medical terms, pathological terms, and abbreviations included in this chapter as possible. The stories may be serious, funny, or silly. However, the terms must be used accurately within the context of the story. The instructor will determine a time limit for writing the story. At the end of the time period, a representative of each team must read the story aloud to the rest of the class.

Case Studies
1. Albert Washington is a 67-year-old patient with COPD. He comes to the clinic complaining of feeling worse than usual with a frequent cough that produces thick green stuff. The physician asks the medical assistant to collect a sputum specimen from Mr. Washington. Describe what the medical assistant should do. 2. Mr. Washington (see previous case study) states that he sometimes turns his home oxygen up when he feels especially short of breath. His wife is concerned and states that she doesnt believe he should be doing this. They cannot agree on this issue and have asked the medical assistant to settle their argument. What should the medical assistant tell them?

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Resources

American Cancer Society information on lung cancer: www.cancer.org American Lung Association: www.lungusa.org CDC inuenza guidelines: www.cdc.gov/u Information on asthma and allergies: www.aaaai.org and www.aafa.org Information on lung diseases: www.nlm.nih.gov/medlineplus/ lungdiseases.html

Information on pneumonia: www.medicinenet.com/pneumonia Information on pulmonary disorders and conditions:www .pulmonologychannel.com National Emphysema Foundation: www .emphysemafoundation.org

CHAPTER

Endocrinology
Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell terms related to endocrinology identify key structures of the endocrine system describe the functions of the endocrine system describe the role of the medical assistant in endocrinology identify common endocrine diseases and disorders list the major hormones of the endocrine system list the major glands of the endocrine system differentiate between type I and II diabetes mellitus identify complications of diabetes mellitus identify patient education regarding endocrine system diseases and disorders list commonly used word elements related to the endocrine system and give at least 10 examples of how new endocrine related terms may be created by combining prexes, sufxes, and combining forms describe the medical assistants role in assisting with endocrinology procedures list common tests for endocrine system diseases and disorders. Clinical Competencies Patient Care
Prepare patients for and assist with routine and specialty examinations Prepare patients for and assist with procedures, treatments, and minor ofce surgeries

29
Ovaries Testes Negative feedback system

Medical Terminology Related to the Endocrine System Common Endocrine System Diseases and Disorders
Types of Diabetes Type 1 diabetes Type 2 diabetes Gestational diabetes Thyroid Disorders Hypothyroidism Hyperthyroidism

General Competencies Patient Instruction

Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention

ABHES Competencies
Administrative Duties
Perform diagnostic coding

Endocrinology Procedures
Assisting with Examination Endocrine System Tests Fasting blood glucose Glucose tolerance test Glycosylated hemoglobin Urine glucose test Glucometer testing Thyroid tests Thyroid scan Radioactive iodine uptake

Clinical Duties
Prepare patients for procedures Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries

Instruction
Teach patients methods of health promotion and disease prevention

Procedures
Teaching a patient to provide foot care

Chapter Summary Team Work Exercises Case Studies Resources

Chapter Outline
Structures and Functions of the Endocrine System
Structures of the Endocrine System Functions of the Endocrine System Pineal gland Pituitary gland Thyroid gland Adrenal glands Pancreas Thymus gland

CAAHEP Competencies
Administrative Competencies Process Insurance Claims
Perform diagnostic coding

519

Key Terms
endocrinologist

Medical doctor who specializes in the diagnosis and treatment of endocrine diseases and disorders
endocrinology

Structures and Functions of the Endocrine System

The endocrine system is made up of all the major glands of the body. It regulates many body functions through the action of various hormones. (See Figure 29-1.)

Study of the structures and functions of the endocrine system

exophthalmos

Symptom of protruding eyeballs, usually caused by a severe form of hyperthyroidism called Graves disease
fasting

Structures of the Endocrine System

The pituitary gland is a small, round, pea-sized structure attached to the lower surface of the hypothalamus in the brain. The pituitary gland is divided into an anterior lobe and a posterior lobe. The thyroid gland, one of the largest endocrine glands, is highly vascular and is located in the base of the neck. It is shaped similar to the letter H and has two lobes located on each side of the trachea, which are connected by a narrow band. Four tiny parathyroid glands lie on the posterior surface of the thyroid gland within its connective tissue. The two adrenal glands are triangular in shape and located on top of each kidney within the retroperitoneal cavity (in the back of the abdomen). They are made up of an outer layer called the adrenal cortex and an inner part called the adrenal medulla. The pancreas is a long, somewhat at organ that is located in the upper left quadrant of the abdomen. The endocrine portion of the pancreas includes the pancreatic islets, also called the islets of Langerhans. The pineal gland, sometimes referred to as the pineal body, is shaped like a pine cone and located in the brain above and behind the thalamus. The thymus gland consists of two symmetrical lobes located in the mediastinum (midchest area). It is proportionately larger in infants and children and shrinks in size as people age. The reproductive glands, sometimes called the gonads, are the ovaries and testes. The ovaries are at, oval-shaped structures located on each side of the uterus in the lower abdominal cavity, attached to the broad ligament. The ovaries contain the graaan follicles, in which are the immature ova, or eggs. The testes are egg-shaped glands located in the scrotum of the male reproductive tract.

Practice of denying the body all food or nutrition, usually for a specied period of time before laboratory tests or surgical procedures
glucometer

Instrument used to measure glucose levels in the blood

glucosuria

Presence of glucose in the urine

goiter

Enlarged thyroid gland

growth hormone

Hormone secreted by the pituitary gland to stimulate growth of bones and tissues; also called somatotropin
hyperglycemia

Abnormally high blood glucose level

hyperthyroidism

Condition of having excessive levels of thyroid hormone in the body

hypertrophy

Excessive growth of tissue

hypoglycemia

Abnormally low blood glucose levels

hypoglycemic

Drug that lowers blood glucose levels

hypothyroidism

Condition of inadequate levels of thyroid hormone in the body

negative feedback system

Control system in which an increase or decrease in a substance stimulates an opposite response by a hormone
peripheral

Away from the trunk of the body; in the extremities

polydipsia

Increased thirst
polyphagia

Increased appetite
polyuria

Increased urination
venous

Functions of the Endocrine System

The endocrine system is a complex network of glands that regulate and secrete hormones that act directly on target organs or stimulate other glands to secrete different hormones. Hormone levels in the blood vary according to bodily functions. Glands sense the varying levels and work to increase or decrease the level of glandular secretion to maintain a balance. In most cases, hormones work in pairs to maintain the appropriate balance, with one hormone acting

Pertaining to the veins or the blood in the veins

CHAP TER 29

Endocrinology

521

Hypothalamus Pineal gland Pituitary (hypophysis) gland

Thyroid gland Thymus gland Parathyroid glands (4)

Heart

Adrenal (suprarenal) glands (2)

Stomach

Pancreas Kidney

Fat

Ovaries (2) in females

Testes (2) in males

FIG 29-1 Endocrine system.

to raise levels of other substances when needed and the other acting to lower levels when needed. For example, the hormones calcitonin and parathyroid hormone function in an opposite, yet complementary, fashion to maintain an optimal level of calcium in the blood. Endocrine glands are also responsible for the development and maturation of individuals from children to adolescents and, eventually, to adults capable of reproduction. Endocrine glands also play a role in the bodys ability to metabolize food and store energy.

Pineal Gland
The pineal gland produces the hormone melatonin, which inuences the bodys natural circadian rhythm, or sleepwake cycle.

Pituitary Gland
The pituitary gland is commonly called the master gland because it controls all of the other glands in the body. Even so, it is actually controlled by the hypothalamus. The anterior and

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posterior lobes of the pituitary gland produce many different hormones.

Pancreas
In addition to its important role in the digestive process, the pancreas secretes insulin and glucagon. The beta cells of the pancreas secrete insulin after food is eaten to metabolize carbohydrates and break them down into glucose. Insulin stimulates cells to take up glucose from the blood so that it can be used for energy. As a result, blood glucose levels decrease. The alpha cells of the pancreas secrete glucagon to increase glucose levels in the blood by stimulating the liver to release stored glucose, called glycogen. Glycogen is also stored in the muscles and can convert into glucose during times of need, such as during exercise or prolonged periods without meals.

Anterior Lobe
The anterior lobe is responsible for secreting six different hormones:

growth hormone (GH), which promotes the growth of body structures, such as bones thyroid stimulating hormone (TSH), which affects the growth and functioning of the thyroid gland follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which are referred to as gonadotropins because they act on the gonadsthe ovaries in the female to produce an ovum and the testes in the male to produce sperm prolactin, which acts on mammary glands to produce milk adrenocorticotropic hormone (ACTH), which acts on the adrenal glands to secrete glucocorticoids, including cortisol.

Thymus Gland
The main function of the thymus gland is to produce Tlymphocytes that are necessary for the immune system. It plays an active role in the immune system in childhood but shrinks and becomes less active as a person ages.

Posterior Lobe
The posterior lobe secretes two hormones:

Ovaries
The ovaries produce an ovum during each menstrual cycle and secrete estrogen and progesterone. Estrogen helps develop sexual characteristics in the female, including breasts and pubic hair. It also plays a vital role in the menstrual cycle and is important in the prevention of osteoporosis in postmenopausal women. Progesterone is necessary to prepare and maintain the uterus for a fertilized ovum.

oxytocin, which acts on the uterus to promote contractions during labor and delivery of a baby antidiuretic hormone (ADH), which acts on the kidneys to increase the absorption of water. (See Figure 29-2.)

Thyroid Gland
The thyroid gland produces the two thyroid hormones, triiodothyronine (T3) and thyroxine (T4), which are responsible for growth throughout childhood and regulation of body metabolism. For the thyroid gland to function properly, iodine must be obtained in the diet. The thyroid gland also secretes the hormone calcitonin, which is responsible for regulating calcium and phosphorus levels in the blood. The parathyroid glands on the surface of the thyroid gland secrete parathormone (PTH), which also helps regulate calcium and phosphorus levels in the blood.

Testes
The testes secrete testosterone, which is responsible for the development of male characteristics during puberty, such as deepening of the voice, growth of facial and pubic hair, and increased muscle development. It is also necessary in the production of sperm.

Negative Feedback System

Within the endocrine system, glands and hormones work together to maintain homeostasis in the body by utilizing a negative feedback system. The system is considered negative because it works in opposites to maintain an optimal level of certain substances in the body. Each gland produces a hormone that serves to oppose another substance. The gland may increase or decrease production of the hormone to stimulate a corresponding decrease or increase of the other substance. Thus, this system works much like a thermostat functions, activating the production of heat in response to falling temperatures (a decrease in the normal level) or decreasing heat production in response to achieving the optimal heat level or a level that is too high. Almost all endocrine glands operate in a negative feedback system. For example, the parathyroid glands secrete parathyroid hormone, which regulates blood calcium levels. A decrease in calcium levels in the blood (below the

Adrenal Glands
The adrenal glands secrete several hormones:

Epinephrine, also known as adrenalin, is released during the ght-or-ight response to increase the bodys ability to cope with stress or trauma. Epinephrine enables the body to respond to stressful situations by converting stored glucose into energy, dilating the pupils, opening the airways, and decreasing peristalsis. Aldosterone plays a role in regulating and maintaining the bodys balance of water as well as sodium and other electrolytes. Cortisol is the bodys natural steroid and works to decrease inammation. Androgens are responsible for the secondary sexual characteristics in females and males.

CHAP TER 29

Endocrinology

523

Hypothalamus

Neurosecretory cells (release hormones)

A
Mammillary body

Optic chiasma

Hypophyseal portal veins Superior hypophyseal artery Anterior lobe vein Anterior pituitary Hormones of anterior pituitary

Capillaries Hypothalamichypophyseal tract Hormones of posterior pituitary Posterior lobe vein Posterior pituitary

Inferior hypophyseal artery

Anterior pituitary hormones Posterior pituitary hormones Bones and tissues

Adrenal cortex

Adrenocorticotropic hormone (ACTH)

Growth hormone (GH) Hypothalamus

Kidney tubules

Thyroid

Thyroid stimulating hormone (TSH)

Antidiuretic hormone (ADH)

Anterior pituitary Gonadotropins (FSH, LH) Oxytocin Prolactin

Posterior pituitary

Uterus
Testes

Mammary glands Ovaries

FIG 29-2 Pituitary gland. (A) Anterior and posteroir view. (B) Hormones and target glands.

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normal level) stimulates the parathyroid glands to secrete more parathyroid hormone. Parathyroid hormone stimulates the bones to release more calcium. It also facilitates calcium uptake from the kidneys into the bloodstream. Thus, blood calcium levels increase back to the normal level. In addition, if blood calcium levels increase (above the normal level), the parathyroid glands decrease production of parathyroid hormone. Either way, the response of the parathyroid glands is a negative (opposite) response to the stimulus of a decrease or increase in blood calcium levels.

Medical Terminology Related to the Endocrine System

Endocrine disorders are common and affect every segment of the population at some time, leading them to seek medical care in acute and ambulatory care settings. To be effective in their role, medical assistants must become well versed in the language and vocabulary that pertain to the endocrine system. The following tables list common medical terminology related to the endocrine system.

Table 29.1 |

Word Elements

This table contains combining forms, prexes, and sufxes related to the endocrine system, along with examples of terms that use the word element, a pronunciation guide, and a denition for each. Combining Form
Combining Forms aden/o adrenal/o adren/o calc/o gluc/o glyc/o hydr/o oophor/o ovari/o orch/o orchi/o orchid/o test/o pancreat/o parathyroid pancreas parathyroid testes gland adrenal gland calcium sugar glucose water ovary adenopathy (ad-e-NOP-a-the) adrenalectomy (ad-re-nal-EK-to-me) adrenal (ad-RE-nal) hypercalcemia (h-per-kal-SE-me-a) glucogenesis (gloo-ko-JEN-e-ss) glycosuria (gl-ko-SU-re-a) hydrolysis (h-DROL--ss) oophorectomy (o-of-o-REK-to-me) ovarioptosis (o-va-re-op-TO-ss) orchopathy (or-KOP-a-the) orchiectomy (or-ke-EK-to-me) orchidopexy (or-k-do-PEK-se) testomegaly (tes-to-MEG-a-le) pancreatography (pan-kre-a-TOG-ra-fe) parathyroidectomy (par-a-th-royd-EK-to-me) Disease of a gland Surgical removal of the adrenal gland Pertaining to the adrenal gland Excessive calcium in the blood Creating glucose Sugar in the urine Destruction of water Surgical removal of the ovaries Prolapse of the ovary Disease of the testes Surgical removal of the testes Surgical xation of the testes Enlargement of the testes Process of recording the pancreas Surgical removal of the parathyroid gland thym/o thyroid/o toxic/o Prexes anantiwithout, absence of against anorchidism (an-OR-k-dzm) antiglycemic (an-t-gl-SE-mk) Absence of testes Pertaining to against sugar (refers to a medication that lowers the blood glucose level) thymus thyroid toxin, poison thymoma (th-MO-ma) thyroiditis (th-royd-I-ts) toxicologist (toks--KOL-o-jst) Tumor of the thymus Inammation of the thyroid Specialist in the study of toxins

Meaning

Example

Meaning

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Table 29.1 |

Word Elementscontd
Meaning
good, normal excessive, above below, beneath

Combining Form
Prexes euhyperhypoSufxes -algia -cele -ectomy -ic -lith -logist -megaly -oma -osis

Example
euthyroid (u-THI-royd) hyperglycemia (h-per-gl-SE-me-a) hypocalcemia (h-po-kal-SE-me-a)

Meaning
Good or normal thyroid Excessive blood sugar Below (low) blood calcium

pain hernia surgical removal pertaining to stone specialist in the study of enlargement tumor abnormal

orchialgia (or-ke-AL-je-a) ovariocele (o-VA-re-o-sel) orchiectomy (or-ke-EK-to-me) pancreatic (pan-kre-AT-k) pancreatolith (pan-kre-AT-o-lth) toxicologist (toks--KOL-o-jst) thyroidomegaly (th-royd-o-MEG-a-le) thymoma (th-MO-ma) toxicosis (toks--KO-ss)

Pain in the testes Herniation of the ovary Surgical removal of a testicle Pertaining to the pancreas Pancreatic stone Specialist in the study of poisons Enlargement of the thyroid Tumor of the thymus Abnormal condition of toxin or poisoning

-otomy -pexy -rrhexis

incision surgical xation rupture

thyroidotomy (th-royd-OT-o-me) orchidopexy (OR-kd-o524-se) ovariorrhexis (o-va-re-o-REK-ss)

Incision into the thyroid Surgical xation of a testicle Rupture of an ovary

Table 29.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to the endocrine system, along with a pronunciation guide and a brief denition for each. Term
acromegaly ak-ro-MEG-a-le

Denition
Rare disorder in which the pituitary gland becomes overactive after the individual has reached adulthood, secreting excessive amounts of human growth hormone (hGH), which affects the bones and tissues of the face and extremities causing them to become disproportionately enlarged compared with the rest of the body

Addison disease AD--sun d-ZEZ congenital hypothyroidism kon-JEN--tal h-po-THI-royd-zm Cushing syndrome KOOSH-ng SIN-drom diabetic ketoacidosis d-a-BET-k ke-to-as--DO-ss

Disorder involving adrenal gland failure, which results in a chronic metabolic disorder that requires steroid hormone replacement therapy Type of hypothyroidism present at birth that results in arrested physical and mental development; formerly called cretinism Rare disorder caused by prolonged, excessive secretion of glucocorticoids by the adrenal glands, resulting in altered fat distribution and muscle weakness; also called hypercortisolism Abnormal condition that occurs in uncontrolled diabetes and results in the accumulation of ketone bodies secondary to the oxidation of fats; also called diabetic coma

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Table 29.2 | Term

Pathologic Termscontd
Denition
Disorder caused by lack of vasopressin and marked by output of abnormally large amounts of dilute urine, which results in increased thirst and the need for a dramatic increase in uid intake

diabetes insipidus d-a-BE-tez n-SI-p-dus

diabetes mellitus d-a-BE-tez mel-I-ts dystocia ds-TO-se-a eclampsia e-KLAMP-se-a gestational diabetes jes-TA-shun-al d-a-BE-tez gigantism JI-gan-tzm goiter GOY-ter Graves disease GRAVZ d-ZEZ hyperpituitarism h-per-p-TU--tar-sm hyperthyroidism h-per-THI-royd-zm hypopituitarism h-po-p-TU--ta-rzm hypothyroidism h-po-THI-royd-zm insulin shock IN-su-ln SHOK macrosomia mak-ro-SO-m-a

Chronic metabolic disorder in which the pancreas secretes insufcient amounts of insulin or the body is insulin resistant Difcult labor caused by a small pelvic outlet or a large baby, commonly related to macrosomia

Condition caused by pregnancy-induced hypertension in which the woman experiences severe hypertension, convulsions, and coma Diabetes that begins during pregnancy secondary to insulin resistance and altered glucose metabolism Disorder in which the pituitary gland secretes excessive amounts of hGH during childhood, resulting in an abnormally large adult Enlarged thyroid gland

Form of hyperthyroidism caused by an autoimmune response that may cause exophthalmos

Disorder in which the pituitary gland secretes excessive amounts of hGH

Condition of having excessive levels of thyroid hormone in the body

Condition that involves diminished secretion of pituitary hormones as a result of dysfunction of the anterior lobe of the pituitary gland; also called underactive pituitary gland Condition of having inadequate levels of thyroid hormone in the body

Condition caused by too much insulin, in which the blood glucose level is too low; usually below 40 mg/dl; also called hypoglycemia Condition of an abnormally large neonate caused when glucose crosses the placenta from a diabetic mother, causing the infants pancreas to make more insulin and storage of excess glucose in the babys body in the form of fat

myxedema mks-e-DE-ma

Life-threatening condition of severe hypothyroidism, including such symptoms as fatigue; dry, brittle hair; cold intolerance; weight gain; constipation; mental apathy; physical sluggishness; muscle aches; and skin changes due to inltration by mucopolysaccharides, which gives it a waxy, coarsened appearance with nonpitting edema

nephropathy ne-FROP-a-the neuropathy nu-ROP-a-the panhypopituitarism pan-h-po-p-TU--tar-zm

Disease of the kidneys commonly caused by poorly controlled diabetes

Disease of the nerves with many causes, including diabetes

Condition resulting from diminished secretion of all hormones secreted by the anterior pituitary gland

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Table 29.2 | Term

Pathologic Termscontd
Denition
Form of hypopituitarism that results from the deciency of hGH during childhood, resulting in stunted growth Complication of pregnancy marked by increasing blood pressure, urine protein, and edema

pituitary dwarsm p-TU--tar-e DWAR-zm pregnancy-induced hypertension PREG-nan-se n-DOOST h-per-TEN-shun retinopathy ret-n-OP-a-the thyrotoxicosis th-ro-toks--KO-ss type 1 diabetes d-a-BE-tez type 2 diabetes d-a-BE-tez

Disease of the retina, commonly caused by diabetes

Sudden, life-threatening episode of worsening of hyperthyroidism symptoms

Chronic metabolic disorder characterized by an absence of insulin production, resulting in hyperglycemia; also called juvenile onset diabetes and insulin-dependent diabetes mellitus (IDDM) Metabolic disorder caused by decreased insulin production and decreased sensitivity of the body to the insulin that is produced, which results in hyperglycemia; also called adult onset diabetes and non-insulin-dependent diabetes mellitus (NIDDM)

Table 29.3 |

Abbreviations

In endocrinology, as in other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed here save time and effort in documentation and written communications. Abbreviation
ADH ACTH BG BS Ca CA DM FBG

Denition
antidiuretic hormone adrenocorticotropic hormone blood glucose; also called blood sugar blood sugar; also known as blood glucose calcium cancer diabetes mellitus fasting blood glucose; also called fasting blood sugar

Abbreviation
GH IDDM

Denition
growth hormone insulin-dependent diabetes mellitus; also called type 1 diabetes

K LH Na NIDDM

potassium leuteinizing hormone sodium non-insulin-dependent diabetes mellitus; also called type 2 diabetes

PTH

parathormone; also called parathyroid hormone

FBS

fasting blood sugar; also called fasting blood glucose

T3 T4 TSH

triiodothyronine thyroxine thyroid-stimulating hormone

fsbs FSH

nger stick blood sugar follicle-stimulating hormone

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Common Endocrine System Diseases and Disorders

There are many disorders affecting the endocrine system. Some of the most common include type I and type II diabetes mellitus, gestational diabetes, hypothyroidism, and hyperthyroidism.

Types of Diabetes
Diabetes may occur in three forms, including type 1, type 2, and gestational diabetes.

Type I Diabetes
ICD-9-CM code: 250.90 (fth digit modier required) Diabetes mellitus is a chronic metabolic disorder characterized by hyperglycemia (abnormally high blood glucose level). Type I diabetes is commonly referred to as insulin-dependent diabetes mellitus (IDDM) and is sometimes also called juvenile onset diabetes. However, people can develop type 1 diabetes into early adulthood. An estimated 0.3% to 0.4% of the population has type I diabetes. Onset usually begins in childhood. Highrisk groups include Native Americans, African Americans, Pacic Islanders, and Mexican Americans. Incidence may be as high as 20% in these groups. Type I diabetes is caused by autoimmune destruction of the beta cells in the pancreas, which are responsible for producing insulin, a hormone that makes glucose available to the cells of the body for energy. This lack of insulin causes blood glucose levels to rise out of control while the cells of the body are starved for glucose. Onset of type I diabetes is commonly acute. A person usually experiences polydipsia (increased thirst), polyphagia (increased appetite), polyuria (increased urination), and weight loss. The physician commonly makes an initial diagnosis after the person is hospitalized with diabetic ketoacidosis (DKA), which occurs from continued, severe hyperglycemia. DKA commonly has a gradual onset, preceded by infection or illness. Symptoms include abdominal pain, cramps, nausea, vomiting, headache, irritability, tachycardia, hypotension, fruity breath odor, and ushed, dry skin. Many of these symptoms are related to the severe dehydration that occurs. The condition will deteriorate into a diabetic coma and can be fatal if not treated. Diagnosis of diabetes mellitus is based on medical history, signs and symptoms, and results of diagnostic testing. Diagnostic tests include a random blood glucose level, fasting blood glucose level, glycosylated hemoglobin level, and a glucose tolerance test. Presence of the classic symptoms and two separate fasting blood glucose levels of more than 126 mg/dl or a random glucose level over 200 mg/dl conrms the diagnosis. Treatment for type I diabetes includes dietary modication, regular exercise, careful foot and eye care, and supplemental insulin. Because gastric juices (stomach acid) will break down

insulin, it must be injected, rather than administered orally. Therapy must be individualized. Some people do well with one or two injections per day of long-acting insulin, but others may require several injections per day of shorter-acting insulin. Another option is a continuous infusion of short-acting insulin using an insulin pump. This device is attached to a catheter that is inserted into the abdomen, releasing a steady amount of insulin into subcutaneous tissue. This manner of administration closely mimics the bodys natural way of infusing insulin from the pancreas. The management goal is to maintain a balanced blood glucose level without great uctuations. In years past, the prognosis for those with type I diabetes was grim and few lived beyond childhood. As treatment options have improved, life expectancy has increased significantly. However, many patients still continue to suffer from devastating long-term consequences, including blindness caused by retinopathy, limb loss caused by peripheral neuropathy, peripheral vascular disease, and eventual kidney failure caused by nephropathy. Fortunately, diabetes is better understood today and treatment options are more effective. Risk of these disabling long-term complications, while still real, has lessened considerably. In fact, research indicates that those who develop good self-care habits and maintain tight control over blood glucose levels on a daily basis can now lead long, productive, reasonably healthy lives. (See Diabetic self-care.)

Type II Diabetes
ICD-9-CM code: 250.90 (fh digit modier required) Type II diabetes is an endocrine disorder marked by decreased insulin production and decreased sensitivity to insulin. It is also referred to as non-insulin-dependent diabetes mellitus (NIDDM) and adult-onset diabetes. It usually appears after the age of 40 but can occur at any age. It is estimated that 6.6% of the population has type II diabetes. However, it is probable that many people remain undiagnosed because they are usually asymptomatic in the early years. Those at greatest risk are obese middle-aged people with sedentary lifestyles. The incidence of type II diabetes is rapidly growing in this country due to childhood and adult obesity. Type II diabetes is caused by decreased insulin production and decreased sensitivity of the body to the insulin that is produced. As a result, individuals develop hyperglycemia. The cause of type II diabetes is linked to family history, obesity, and a sedentary lifestyle. In the early stages, most patients with type II diabetes are asymptomatic and may, therefore, be unaware that they have diabetes. As hyperglycemia worsens, signs and symptoms are similar to those for type I diabetes, including polydipsia, polyphagia, and polyuria. In addition, the patient may notice weight gain and delayed wound healing. Onset of symptoms with type II diabetes is more gradual and the development of DKA is less likely. Diagnosis for type II diabetes is similar to type I and is based on medical history, signs and symptoms, and results of

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Patient Education

Diabetic Self-Care
In teaching the diabetic patient proper self-care measures, the medical assistant should be sure to include the following information: Eat frequent, small, well-balanced meals throughout the day, rather than three large meals. Monitor intake of carbohydrates and calories, according to the plan recommended by your physician or dietitian. Engage in moderate, regular physical exercise according to the recommendations of your physician. Check your blood glucose levels routinely, according to the recommendations of your physician. There are many types of glucometers on the market; nd and use the one that best ts your lifestyle and personal needs. Consider using a system of mapping your injection sites to prevent overuse of any one site. Consult with a dietitian to determine dietary guidelines that best meet your needs. Develop a habit of regularly inspecting and caring for your skin and feet. Keep a list of resources handy for when you have questions or concerns.

occur gradually over time. Complications include retinopathy leading to blindness, nephropathy leading to kidney failure, and neuropathy and peripheral vascular disease, leading to delayed wound healing, tissue necrosis, and limb loss. (See Foot and skin care, page 531.) Diabetics are also at increased risk for heart disease, which puts them at risk for heart attack.

Gestational Diabetes
ICD-9-CM code: 648.80 Gestational diabetes is diabetes that begins during pregnancy due to insulin resistance and altered glucose metabolism. Gestational diabetes affects approximately 4% of all pregnant women, or around 135,000 American women each year. Those at greatest risk include women over age 25, those with a history of gestational diabetes during a previous pregnancy, those with a family history of diabetes, and those who are overweight at the start of pregnancy. Additional risk factors include African American, Native American, or Hispanic ethnicity and having had a previous stillbirth or a baby weighing more than 9 lb at birth. The cause of gestational diabetes is not fully understood. It is known that placental hormones, which help the baby grow, cause insulin resistance in the mothers body. Subsequently, the mother develops hyperglycemia as glucose levels rise in her blood. Gestational diabetes usually subsides after delivery. However, such women have a 50% chance of developing type II diabetes later in life. Gestational diabetes usually doesnt begin until the 24th to 28th week of pregnancy (5th or 6th month) and most women are asymptomatic. Those who do experience symptoms usually exhibit polydipsia, polyphagia, and polyuria. Screening for gestational diabetes is just one of the many reasons women should seek health care before and during pregnancy. Measuring blood glucose level and screening for diabetes is part of routine perinatal care. Diagnosis of diabetes is similar to other types of diabetes. Many physicians recommend a glucose challenge test between 24 and 28 weeks gestation. Management of gestational diabetes is similar to that for other forms of diabetes and includes careful attention to diet; regular, moderate exercise; monitoring glucose levels; and supplemental insulin as needed. With careful management, the woman can experience a normal, healthy pregnancy and delivery. However, there are potential complications that can arise, especially when maternal hyperglycemia is poorly controlled. The most lifethreatening of these is pregnancy-induced hypertension (PIH), which can cause eclampsia, in which the woman experiences severe hypertension, convulsions, and coma. Another complication is the need for a caesarean section (c-section) delivery due to macrosomia, which is an abnormally large baby at birth. Macrosomia is caused by the transfer of maternal glucose across the placenta, giving the baby hyperglycemia. In response, the babys pancreas makes more insulin, which then causes the excess glucose to be stored in

diagnostic testing. Diagnostic tests include a random blood glucose level, fasting blood glucose level, glycosylated hemoglobin level, and a glucose tolerance test. Presence of the classic symptoms and two separate fasting blood glucose levels of more than 126 mg/dl or a random glucose level over 200 mg/dl conrms the diagnosis. Some patients with type II diabetes can control their blood glucose level with diet and regular exercise, whereas others may need to take oral hypoglycemic medications that stimulate the pancreas to produce insulin or make the body more responsive to insulin. (See Hypoglycemia versus hyperglycemia, page 530.) As a result, glucose becomes available to the cells of the body and blood glucose level normalizes. In some patients, the pancreas eventually stops producing insulin. When this happens, they must begin injecting insulin to manage glucose levels. (Regardless of whether insulin production ceases altogether, the diabetes type remains type II; it does not change to type I.) Diabetes is a chronic disease for which there is no identied cure. However, with proper diagnosis and management most diabetics can lead long, healthy lives. The key is daily management that prevents the destructive changes that

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Hypoglycemia versus hyperglycemia

This table lists the laboratory values for hypoglycemia and hyperglycemia, along with the onset, most common signs and symptoms, cause, and most common treatment for each.

Onset
Hypoglycemia (glucose < 40 mg/dl) Acute

Signs and Symptoms

Fatigue, tremor Hunger Restlessness, dizziness, confusion Irritability, combativeness Heart palpitations Moist, clammy skin Eventual loss of consciousness

Cause
Too much insulin Not enough food Excessive exercise Vomiting or diarrhea

Treatment
Conscious patient with gag reexoral administration of some form of simple sugar, such as glucose tablets, orange juice, nondiet soda, and hard candy Unconscious patient subcutaneous, IV, or IM administration of glucagon followed by a snack or meal of complex carbohydrates and protein after blood glucose rises

Hyperglycemia (glucose > 120 mg/dl)

Gradual

Fruity breath odor Deep, rapid respirations Polydipsia, polyphagia, polyuria, glucosuria Weight loss Dry, ushed skin Lethargy, confusion, eventual coma

Not enough insulin or missed insulin doses Too much food Lack of activity Stress, illness, infection

Insulin administration after checking blood glucose level Administration of an oral hypoglycemic agent per physician recommendation Diet control, weight loss, and exercise combined with insulin or oral hypoglycemic agents

the babys body in the form of fat. As a result, the baby may suffer shoulder dystocia (shoulder injury) and severe hypoglycemia at birth. This baby also has a higher risk for respiratory problems, jaundice, and stillbirth. In addition, such babies are at risk for future obesity and the development of type II diabetes.

Thyroid Disorders
Hypothyroidism
ICD-9-CM code: 243 (congenital hypothyroidism), 244.9 (myxedema) Hypothyroidism is the condition of having inadequate levels of thyroid hormone in the body. There are several types of hypothyroidism, which are named according to their cause. Congenital hypothyroidism, formerly called cretinism, is a congenital condition of thyroid hormone deciency characterized by arrested physical and mental development. The term cretin, originally used to describe the disorder in the 18th century, was used widely in the 19th and 20th centuries.

However, the meaning of the term has more recently been deemed derogatory and is, therefore, not commonly used in medicine today. Myxedema is a severe form of hypothyroidism that develops in the older child or adult. The incidence of congenital hypothyroidism is rare in industrialized countries, due to early diagnosis and treatment of newborns. However, in many countries where diets are commonly iodine-decient, the problem is much more prevalent. Congenital hypothyroidism results from abnormal function of the fetal thyroid gland. In many cases, an underlying cause of hypothyroidism is dietary deciency of iodine, an essential trace element required for synthesis of thyroid hormones. Other causes of hypothyroidism include surgical removal of the thyroid gland and some medications. General hypothyroidism causes diminished basal metabolism. Signs and symptoms of myxedema, a term used for the collective symptoms of severe hypothyroidism, include fatigue; dry, brittle hair; cold intolerance; weight gain; constipation; mental apathy; physical sluggishness; and muscle

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Patient Education

Foot and Skin Care

Type II diabetes puts a patient at increased risk for limb amputation from nonhealing wounds and ulcers. Thus, the medical assistant should provide to the patient with diabetes comprehensive patient education on foot and skin care, including: Inspect your skin daily, paying special attention to your feet. Use a mirror to inspect the soles of your feet. Wash your feet daily with a mild soap and warm (not hot) water; dry thoroughly. Apply lotion to keep skin soft and supple. Trim toenails carefully, clipping straight across to avoid ingrown nails. If doing so is too difcult, have the physician trim your toenails. Always wear well-tting shoes, even in the house. Break in new shoes gradually to avoid blisters. Never go barefoot. Inspect your shoes before putting them on to make sure there is nothing inside of them. Wear house slippers and keep a night light on to prevent foot injury when getting up during the night. Report redness, sores, or breaks in the skin to your physician as soon as possible.

Inspection using a hand mirror

aches. The character of the skin changes due to inltration by mucopolysaccharides, giving it a waxy or coarsened appearance with nonpitting edema. Left untreated, hypothermia, coma, and death may result. Another common symptom of hypothyroidism is enlargement of the thyroid gland, sometimes called goiter. Congenital hypothyroidism causes poor growth and results in a very short adult. In addition, bone growth and maturation are impeded, sexual development is severely delayed, and infertility is common. (See Figure 29-3.) Thyroid function tests detect hypothyroidism long before symptoms become apparent. A high plasma TSH and a low free T4 index conrm the diagnosis. Treatment of most forms of hypothyroidism consists of lifelong administration of synthetic thyroid hormones. The addition of iodine to packaged table salt in many countries has alleviated the incidence of diet-related hypothyroidism, thereby reducing the incidence of goiter. The prognosis for those with hypothyroidism is generally good, depending on how early the diagnosis is made and treatment started. In most cases, symptoms will improve or resolve.

Hyperthyroidism
ICD-9-CM code: 242.0 Hyperthyroidism is a condition of excessive levels of thyroid hormone in the body. The most common form of

hyperthyroidism is called Graves disease. The thyroid gland produces thyroid hormones that regulate metabolism. When production of thyroid hormones increases, the bodys metabolism increases. Hyperthyroidism is 10 times more common in women than in men and is more common after the age of 15. Incidence is about one per 1000 women. About 80% of patients may develop goiter. There are several causes of hyperthyroidism, including nodular goiter, toxic adenomas, hyperemesis gravidarum (extreme nausea and vomiting during pregnancy), excessive thyroid replacement, excessive iodine intake, or pituitary adenoma. However, the most common cause is Graves disease, which is an autoimmune disorder. Signs and symptoms of hyperthyroidism are related to stimulation of the sympathetic nervous system and increased circulating thyroxine, both of which stimulate metabolism. Signs and symptoms include tachycardia, palpitations, hypertension, tremor, anxiety, nervousness, insomnia, hyperreexia, depression, weight loss in spite of increased food intake, heat intolerance, hair thinning, and exophthalmos (protruding eyeballs). (See Figure 29-4.) Hypertrophy (excessive growth) of the thyroid gland may also cause goiter. Thyrotoxicosis is an episode of sudden worsening of symptoms and may be life-threatening.

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Medical examination and blood tests easily detect thyroid disorders; however, early detection is vital for successful treatment. Blood tests may show a decreased TSH level and increased T3 and T4 levels. Treatment of hyperthyroidism consists of medications to suppress thyroid function and surgical removal of part or all of the thyroid gland. Prevention as well as early detection and treatment are the keys to minimizing the impact of this disorder. Therefore, annual physical examinations for adults and scheduled well-baby visits for infants and children are encouraged. Prognosis for those with hyperthyroidism is generally good but is somewhat variable, depending on the underlying cause. In most cases, a balanced level of thyroid hormones can be restored.

Endocrinology Procedures
Endocrinology is a medical specialty that focuses on the study and treatment of diseases and disorders of the endocrine system. A physician who specializes in this area of medicine is an endocrinologist. Many patients who have endocrine disorders initially see internal medicine or family practice physicians, who then refer them to an endocrinologist. Internal medicine physicians may also be involved in follow-up care.
FIG 29-3 Congenital hypothyroidism.

Assisting with Examination

To reach an accurate diagnosis, the endocrinologist must obtain a medical history, including a description of symptoms. In an examination, the medical assistant must prepare the patient by checking vital signs and obtaining a health history, which should include data regarding allergies, signs and symptoms, and medications. She should then assist the patient as needed with undressing and positioning. Patients should undress and put on the examination gown with the opening in the front. The medical assistant provides patient privacy and assists the physician as needed with the examination and performs ordered diagnostic tests. She must also assist the endocrinologist as needed with any procedures. Patients with diabetes are commonly seen by the endocrinologist as well as physicians in nearly every other specialty area. For this reason, medical assistants help provide care for diabetic patients, regardless of where they work. Such patients commonly need ongoing education to learn about their disorder and good self-care practices. A common topic of discussion is skin and foot care because diabetes usually results in delayed wound healing and is a major reason for surgical amputation. With this in mind, medical assistants must be prepared to teach their patients how to protect and care for their skin, especially their feet. (See Procedure 29-1: Teaching a patient to provide foot care.)

FIG 29-4 Exophthalmos (Graves disease).

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PROCEDURE 29-1

Teaching a patient to provide foot care

Task Teach a patient to perform daily foot care. Conditions Warm water Mild soap Three or more towels Soft wash cloth Moisturizing lotion Hand mirror Emery board Clean, dry socks Shoes Foot rest Examination gloves Wash basins (2) Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully teach the patient to perform daily foot care. Performance Standards 1. Introduce yourself and explain the purpose of the teaching session and the importance of routine foot care, including these points: a. Daily skin care helps the diabetic patient maintain healthy, intact skin. b. Daily care enables the patient to detect skin problems early so that the physician can initiate timely intervention. c. Maintaining healthy skin and detecting problems early help the diabetic patient prevent limb loss caused by nonhealing wounds and infections. 2. Instruct the patient to wash his hands with lukewarm water and soap, rinse them in lukewarm water, and dry them thoroughly. Patients with peripheral neuropathy may have difculty sensing water temperature so a cooler temperature is safest. Explain that hand washing helps prevent cross-contamination of microorganisms from the hands to the feet. 3. Instruct the patient to sit in a chair and remove his shoes and socks. 4. Wash or sanitize your hands to ensure infection control and assemble supplies, including: a. placing a towel or absorbent pad on the oor beneath the patients feet (other supplies may rest on this towel) b. placing both basins near the patients feet (one half full of lukewarm water with a small amount of soap added and one half full of clean rinse water) c. placing a footrest near the patients feet and a towel or absorbent pad on top of it. 5. Instruct the patient to place his left foot in the basin of soapy water and let it soak for a minute or two. Explain that this allows soil particles to soften and loosen up. 6. Put on examination gloves. Use a clean, soft washcloth to wash the patients foot, gently scrubbing all surfaces, including between the toes. Be extra gentle with any areas that are reddened, tender, or have broken skin to avoid causing further injury. 7. Guide the patients foot from the basin of soapy water to the basin of rinse water. Gently rub all surfaces. Explain to the patient that all of the soap must be removed. 8. Place the patients clean foot on the padded footrest and gently pat all surfaces dry, which is less likely to cause injury than rubbing. Examine the skin in all areas as you do so. Explain that dry skin is less likely to break down or harbor microorganisms and clean skin is easier to examine. 9. Hold the hand mirror below the sole of the patients foot and ask him to examine his foot. Explain the importance of seeing every surface of his foot. Tell the patient to inspect all surfaces of the foot, including the toes, toenails, and between the toes. Explain that diabetic patients with peripheral neuropathy may have injuries they do not feel. Examination at this point also allows the foot to air-dry completely before the next step. 10. Inspect the patients toenails for length and jagged edges. Using the emery board, le the toenails as needed to shorten and smooth the ends. (Be sure not to shorten them too much, however.) Inform the physician if the patient has extremely thick, hypertrophied toenails because a consultation with a podiatrist may be indicated. Explain that excessively long or jagged nails could result in injury from pressure or tearing. Instruct the patient to report any areas of redness, broken skin, or ulcerations to the physician as soon as possible. 11. Apply a small amount of moisturizing lotion to the patients clean foot but not between the toes. Explain that moisturized skin is less likely to crack but that the area between the toes tends to harbor moisture and could become a breeding ground for microorganisms.
Continued

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PROCEDURE 29-1contd

12. Remove the examination gloves. Examine the patients clean socks for areas of wear or hidden seams. Explain that such areas could place excessive pressure on the patients foot. 13. Examine the patients left shoe, including these steps: a. Examine the inside for any foreign objects or wear or wrinkles in the shoe lining. Explain that the inside of the shoe should be examined each time it is put on because pressure ulcers can develop quickly from pressure caused by foreign objects or wrinkles. b. Examine the sole of the shoe. Explain that a at, nonskid surface provides a good base of support and is less likely to slip when walking. c. Explain that shoes should be worn at all times, even in the house, to prevent foot injury from stubbing the toes or stepping on objects. d. Explain that new shoes must be broken in slowly and carefully to prevent foot injury, blisters, or other areas of pressure or friction.

e. Explain that slippers with nonskid soles should be kept by the bed and worn when getting up during the night and a nightlight should be kept on to prevent foot injury from stubbing the toes or stepping on objects. 14. Assist the patient as needed in putting his left sock and shoe on. 15. Instruct the patient to repeat steps 6 to 15 with his other foot, providing cueing as needed. Return demonstration provides opportunity to reinforce teaching and allows the medical assistant to verify the patients understanding and ability to perform foot care. 16. Wash your hands and document the procedure in the patients medical record to ensure a complete, accurate medical record.
Date 05/11/08; 10:50 a.m. Pt education regarding foot care completed. Pt performed return demonstration satisfactorily. --------S. Gonzales, CMA

Endocrine System Tests

Diagnostic tests commonly completed or ordered in the endocrinologists ofce include fasting blood glucose, glucose tolerance test, glycosylated hemoglobin, urine glucose test, glucometer testing, thyroid test, thyroid scan, and radioactive iodine uptake.

Front ofceBack ofce connection

Scheduling the Fasting Patient

When scheduling a patient for laboratory tests that require a period of fasting, the administrative medical assistant should remember that some patients are vulnerable to hypoglycemia. Therefore, she should consult carefully with the patient and physician to determine the best appointment time. She should also consult with the physician about whether the patient is to take regularly scheduled medications that morning, including insulin or antidiabetic agents. In any case, she must make sure the patient understands the information regarding pretest measures as well as the reason for the test and the necessary fast. In addition, the medical assistant should remind the patient to bring a snack to eat as soon as the test is complete.

Fasting Blood Glucose

The fasting blood glucose (FBG) test, also called a fasting blood sugar (FBS) test, measures glucose levels in the blood when the patient has not eaten or drunk anything for approximately 8 to 12 hours before the test. (See Scheduling the fasting patient.) This test can use a sample of venous blood, taken from a vein using a needle (venipuncture), or peripheral blood, taken from a nger using a lancet. Normal blood glucose levels average 70 to 110mg/dl. The medical assistant can measure blood glucose levels from a nonfasting patient as well. However, she must record how long it has been since the patient last ate. For example, if the patient ate a snack 2 hours before the test, the medical assistant should record it as 2 hours pp, which indicates that she took the sample 2 hours postprandial, or after eating.

Glucose Tolerance Test

The physician orders a glucose tolerance test (GTT) when she wants to evaluate how the body breaks down a concentrated amount of glucose over a period of time, such as 2, 3, or 5 hours. This test is useful for diagnosing various types of

diabetes, including gestational diabetes. The patient must fast for a specied period of time before providing a blood specimen. For an oral GTT, the medical assistant must instruct the patient to drink 8 oz of a concentrated glucose solution. Glucose may also be administered IV. The medical assistant must then collect a second specimen 1/2 hour after the patient takes the glucose, and then again at 1 hour,

CHAP TER 29

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2 hours, 3 hours, and so on, depending on the length of the test. Typically, the medical assistant will ask the patient to collect a urine sample with each blood sample to evaluate glucose in the urine. Because patients with diabetes are unable to metabolize glucose at a normal rate, blood tests will show elevated glucose levels and urine test results may show the presence of glucose. A glucose level greater than 200 mg/dl 2 hours after a glucose challenge of 75 mg indicates a possible diagnosis of diabetes.

Glycosylated Hemoglobin
The glycosylated hemoglobin test (Hgb A1C) represents an average of blood glucose levels in the blood over the previous 4 months. This test is a good indicator of long-term control of blood glucose levels. Some glucose molecules in the blood bind to hemoglobin, which is attached to red blood cells (RBCs). The more glucose available in the blood, the more glycosylated hemoglobin is formed. The glucose remains bound to the RBCs for their normal life span, which is approximately 120 days (4 months). Therefore, this test represents blood glucose levels over 4 months. Fasting prior to this test is not necessary. The normal Hgb A1C laboratory value is 4% to 6%.

FIG 29-5 Glucometer.

Urine Glucose Test

The urine glucose test detects glucose in a urine sample. Typically, glucose should not be present in urine. Glucosuria (presence of glucose in urine) indicates that the body is unable to utilize serum glucose for energy. As serum glucose levels rise to an abnormally high level, the kidneys excrete excess glucose in the urine. Therefore, glucosuria is an indirect indicator of hyperglycemia. Glucose in the urine can be detected from a random urine sample by using the dipstick method of testing. should let the laboratory technician know if she is taking any thyroid medications. Normal values for a T3 uptake test are 32% to 48.4%. Normal values for a T4 test are 6.1 to 12.2 g/dl. Normal values for TSH are 0.34 to 5.6 microinternational units/ml and a normal calcitonin value is less than 14 pg/ml for females and less than 19 pg/ml for males.

Thyroid Scan
A thyroid scan is a nuclear medicine study done to evaluate thyroid size, shape, position, and function. It is useful for evaluating thyroid nodules, goiter thyroiditis, or thyroid cancer. It is also helpful in differentiating masses in the neck, at the base of the tongue, and in the mediastinum. The patient must drink an oral dose of radioactive iodine or receive an IV dose of technetium. Uptake of these media by the thyroid gland and surrounding tissue reveals problems. Areas of increased uptake, called hot spots, are due to hyperfunctioning thyroid nodules and are not likely to be malignant. Areas of decreased uptake, or cold spots, are caused by hypofunctioning nodules, which are more likely to be malignant. However, determining for sure whether tissue is malignant requires tissue biopsy.

Glucometer Testing
Blood glucose levels can be tested in the physicians ofce but patients can also check their own blood glucose by themselves at home, school, or work using a glucometer. This instrument measures the concentration of glucose in the blood, usually testing peripheral blood. Diabetic patients test their blood glucose level several times throughout the day. Although testing is slightly different for each patient, most test their glucose levels in the morning when they are fasting, before meals, and again in the evening before bedtime. (See Figure 29-5.)

Thyroid Tests
Thyroid tests evaluate hormones related to thyroid function by blood specimen analysis. Such hormones include triiodothyronine (T3), thyroxine (T4), thyroid stimulating hormone (TSH), and calcitonin. The patient should not need to fast but

Radioactive Iodine Uptake

Radioactive iodine uptake (RAIU) is a nuclear medicine study used to evaluate thyroid function. It directly measures the ability of the thyroid gland to concentrate and retain

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circulating iodine for the synthesis of thyroid hormone. It is useful for diagnosing hypothyroidism and even more useful for diagnosing hyperthyroidism. In this test, a very small dose of oral radioactive iodine is given to the patient at specied intervals of time. Uptake values are measured in conjunction with measurements of circulating thyroid hormone levels to differentiate primary from secondary thyroid disease. Serial measurements are helpful in long-term management of thyroid disease and its treatment.

Chapter Summary

Major structures of the endocrine system include the pituitary gland, pineal gland, thyroid gland, parathyroid glands, thymus gland, adrenal glands, pancreas, and ovaries and testes. Functions of the endocrine system include secretion of hormones that act on other glands to initiate specic processes in the body that contribute to growth and development and maintaining homeostasis. Major hormones of the endocrine system include growth hormone, prolactin, antidiuretic hormone, folliclestimulating hormone, luteinizing hormone, estrogen, progesterone, testosterone, aldosterone, adrenalin, cortisol, insulin, glucagon, oxytocin, melatonin Common diseases of the endocrine system include diabetes mellitus (type I and type II), gestational diabetes, hypothyroidism, and hyperthyroidism. Common tests for endocrine system diseases and disorders are glucose testing (fasting and glucose tolerance) using blood and urine, glycosylated hemoglobin, glucometer testing, thyroid tests, thyroid scan, and radioactive iodine uptake.

c. sick-day guidelines for patients with diabetes to follow when they are ill (Include glucose testing, insulin administration, diet, uids, when to call the physician, and so on.) d. supplies for the patient with diabetes (Include syringes, lancets, glucometers, oral agents, and so forth as well as typical pricing, where they might be obtained, and so forth.) e. general dietary guidelines for patients with diabetes (Consider recommended systems, including exchange plans, carbohydrate counting, and tracking the glycemic index. Explain the systems and describe how the individual might plan meals for a typical day. Also discuss tips for shopping and reading labels.) 2. Divide into teams of three to ve students. Each team must create a skit in which the members demonstrate (by acting or role playing) the role and effect of the hormones listed below (as assigned by the instructor). a. insulin, glucagon, and glycogen b. calcium and parathyroid hormone c. aldosterone and antidiuretic hormone d. adrenocorticotropic hormone and cortisol e. thyroid stimulating hormone, thyroxine (T4), and triiodothyronine (T3)

Case Studies
1. Mrs. Popp makes an appointment for her 7-year-old daughter Rachel to see the doctor. Mrs. Popp states that Rachel is drinking much more water than usual and is also urinating more. She is wondering if the increased urination is normal due to the fact that Rachel is drinking so much more. How should the medical assistant respond? 2. Paul is a 40-year-old male who has had diabetes for the past 15 years. He currently follows a healthy diet and injects insulin as needed to control his blood glucose level. He notices that the physician orders an Hgb A1C test instead of his usual blood glucose level test and is wondering why there is a change in blood tests. What information should the medical assistant give Paul regarding his blood test?

Team Work Exercises

1. Divide into teams of three to ve students. Each team must create an informational pamphlet for patients on one of the following topics (as assigned by the instructor). Team members must research appropriate subjects to gather the information. Consider contacting community resources as well as using online resources. Be sure to list resources on the pamphlet so that patients can obtain further information as needed. The topics include: a. travel guidelines for patients with type I diabetes (Consider out-of-country travel, need for supplies, packing and storage issues, and so on.) b. exercise guidelines for patients with type I diabetes (Include type of exercises recommended, diet guidelines, insulin administration times and sites, and so on.)

Resources

The Endocrine Society: www.endo-society.org Information on and support for Cushing syndrome: www.CSRF.net Information on diabetes: www.diabetes.org Information on pituitary disorders: www.pituitary.org Society for Endocrinology: www.endocrinology.org

CHAPTER

Gastroenterology
Learning Objectives
Upon completion of this chapter, the student will be able to: dene, spell, and pronounce terminology related to the gastrointestinal (GI) system identify the role of the medical assistant in a gastroenterology ofce explain functions of the GI system identify structures of the GI system assist with examination and procedures of the GI system describe common GI diseases and disorders identify common signs and symptoms of GI disorders explain common laboratory tests related to GI disorders explain common diagnostic tests related to GI disorders.
Recognize and respond to verbal and nonverbal communication

30
Hemorrhoids Inammatory bowel disease Disorders of the Accessory Organs of Digestion Viral hepatitis Cholelithiasis and cholecystitis Acute pancreatitis Disorders of Nutrition Celiac disease Anorexia nervosa Bulimia Disorders That Commonly Cause Diarrhea Food poisoning E. coli infection Campylobacter infection Salmonella infection Cancers of the GI System Oral cancer Esophageal cancer Gastric cancer Colorectal cancer Liver cancer Pancreatic cancer

Clinical Duties
Prepare patients for procedures Prepare and maintain examination and treatment area Prepare patients for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries Dispose of biohazardous materials Instruct patient in the collection of fecal specimen

Legal Concepts
Document accurately

Procedures
Instructing a patient on collecting a stool specimen Performing an occult blood test Assisting with exible sigmoidoscopy Performing a cleansing enema

CAAHEP Competencies
Clinical Competencies Fundamental Principles
Dispose of biohazardous materials Practice standard precautions

Chapter Outline
Structures and Functions of the Gastrointestinal System
Structures of the GI System Alimentary canal Accessory organs of digestion Functions of the GI System Alimentary canal Accessory organs of digestion

Gastroenterology Procedures
Assisting with Examination Stool specimen collection Fecal occult blood test Flexible sigmoidoscopy Cleansing Enema GI System Tests Helicobacter Pylori Liver function test Upper GI x-ray Lower GI x-ray Gallbladder ultrasound

Specimen Collection
Instruct patients in the collection of a fecal specimen

Patient Care
Prepare and maintain examination and treatment areas Prepare patients for and assist with routine and specialty examinations Prepare patients for and assist with procedures, treatments, and minor ofce surgeries

Medical Terminology Related to the GI System Common GI System Diseases and Disorders
Disorders of the Upper GI Tract Gastroesophageal reux disease Hiatal hernia Peptic ulcer disease Gastritis Pyloric stenosis Disorders of the Lower GI Tract Abdominal hernia Appendicitis Diverticular disease

Chapter Summary Team Work Exercises Case Studies Resources

General Competencies Patient Instruction

Instruct individuals according to their needs

537

ABHES Competencies
Communication
Use appropriate medical terminology

Key Terms
absorption

Process of transferring nutrients from the digestive tract into the bloodstream
alimentary canal

Structures and Functions of the Gastrointestinal System

The gastrointestinal (GI) system consists of the alimentary canal and accessory organs of digestion. Together, these structures provide nutrients to all cells of the body.

Route of digestion that includes all structures from the mouth to the anus, excluding the accessory organs of digestion; also known as the digestive or gastrointestinal tract
bolus

Structures of the GI System

The structures of the GI system include the alimentary canal and the accessory organs of digestion.

Mass of masticated (chewed) food

cardiac sphincter

Circular muscle at the top of the stomach that allows food from the esophagus to enter the stomach
chyme

Alimentary Canal
The alimentary canal, also known as the digestive tract or gastrointestinal tract, is the route of digestion that includes all structures from the mouth to the anus, excluding the accessory organs of digestion. At the beginning of the alimentary canal is the mouth, including the tongue, teeth, and gums. The uvula is a small, nger-shaped portion of soft tissue that hangs from the upper part of the mouth at the back. Continuous with the mouth is the pharynx, which is shaped like a funnel. The pharynx begins at the back of the mouth and extends to the esophagus, a long, tubelike structure that connects the mouth to the stomach, passing through the diaphragm. At the beginning of the esophagus is a small, cartilaginous ap called the epiglottis, which hangs between the esophagus and the trachea. At the lower end of the esophagus is a muscular opening called the lower esophageal sphincter (LES), also called the cardiac sphincter because of its location near the heart. The LES separates the esophagus from the stomach. The abdominal cavity holds the stomach, small intestine, large intestine, rectum, and anus. This cavity is lined with a membrane called the peritoneum. The stomach, which is lined with rugae, is composed of three major areas: the fundus (upper portion), body (middle portion), and pylorus (lower portion). The pyloric sphincter, another circular muscle, lies between the lowest portion of the stomach and the small intestine. The small intestine is a coiled tube that measures about 20 ft and consists of the duodenum (upper portion), jejunum (middle portion), and ileum (end portion). The small intestine is lined with villi, which are tiny, ngerlike projections surrounded by capillaries and lymph vessels. The ileocecal valve connects the ileum with the large intestine at the cecum. The large intestine includes the cecum and the colon. The cecum is a small pouch at the beginning of the large intestine. The appendix is a small, tubelike appendage that hangs from the cecum in the right lower quadrant (RLQ) of the abdomen. The cecum connects to the colon, which consists of four portions: ascending colon, transverse colon, descending colon, and sigmoid colon. The last part of the alimentary canal, the rectum, begins at the sigmoid colon and ends at the anus. (See Figure 30-1.)

Mixture of partially digested food and saliva

defecation

Passage of feces from the bowels

deglutition

Swallowing
digestion

Chemical and physical breakdown of food in the gastrointestinal tract

enema

Introduction of a solution into the rectum to stimulate bowel activity

epiglottis

Uppermost cartilage of the larynx

excretion

Process of eliminating waste products of digestion

gastroenterologist

Physician who diagnoses and treats disorders of the gastrointestinal tract

gastroenterology

Study of the gastrointestinal tract

glucagon

Hormone that cleaves bonds in glycogen to release glucose

insulin

Hormone that binds to glucose allowing its transport from the bloodstream to the tissues
mastication

Process of chewing food

peristalsis

Wavelike muscular contractions that move food down the esophagus

rugae

Folds on the internal surface of the stomach

saliva

Oral secretions that moisten food for tasting, chewing, and swallowing
uvula

Soft tissue hanging from the upper mouth that prevents food from entering the nasal cavity
villi

Projections of the small intestines that absorb water and nutrients

CHAP TER 30

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Pancreas
The long, somewhat at pancreas lies posterior and inferior to the stomach. Within the pancreas lie specialized cells called the islets of Langerhans. There are two types of these cells: alpha and beta cells. The pancreas also contains the pancreatic duct, which connects with the hepatic duct at the duodenum of the large intestine.
Mouth and salivary glands Esophagus Bolus of food

Functions of the GI System

The organs of the GI system break down food into usable nutrients through mechanical and chemical processes that break the food down into smaller pieces so the body can absorb and utilize the nutrients for all cells. The major products of digestion are proteins, fats, vitamins, minerals, water, and glucose. Digestive enzymes called proteases and lipases break down proteins and fats. As food is digested, vitamins and minerals move into the bloodstream, which delivers water-soluble vitamins to the tissues and fat-soluble vitamins to the liver and muscle tissue for storage. Insulin is essential for enabling glucose to leave the bloodstream and enter the tissues. These products of digestion are necessary for many biochemical reactions in cells of all parts of the body. The GI system also performs excretion, the process of eliminating bulk waste (feces) from the anus. These processes of digestion and excretion are carried out by the organs of the alimentary canal and the accessory organs of digestion.

Right and left hepatic ducts Gallbladder Common bile duct Duodenum Ascending colon Ileum Cecum Anus

Liver Stomach Transverse colon Pancreas Descending colon Jejunum Sigmoid colon Rectum

Alimentary Canal
Digestion begins in the mouth as teeth mechanically break down food into smaller pieces by mastication (chewing). As food is chewed, or masticated, the salivary glands of the mouth secrete saliva to mix with the food. Saliva moistens food and contains ptyalin, a chemical that starts to break down starches. The tongue helps to form the food into a bolus, which is a rounded mass of masticated food that is ready for deglutition (swallowing). The tongue helps distinguish the taste of food. Taste buds on the surface of the tongue contain 50 to 100 taste cells, which perceive tastes of sweet, sour, salty, bitter, and umami (glutamate avor, such as monosodium glutamate [MSG]). Each taste bud has a pore that opens to the surface of the tongue so that molecules and ions taken into the mouth can reach the taste cells. Taste cells are modied epithelial cells with microvilli that extend into the gustatory pore where the molecules and ions enter the cell. The perception of various tastes are produced by specialized nerve bers that enter the taste cell and occupy the central portion of the cell. While it was once thought that taste buds on specic areas of the tongue sense one of the ve main tastes, new research shows that the ve avors can be perceived by taste cells on all areas of the tongue. The taste cells have a life span of approximately 12 days and regenerate new cells from the base of the bud. (See Figure 30-2.)

FIG 30-1 Gastrointestinal system.

Accessory Organs of Digestion

The accessory organs of digestion include the liver, gallbladder, and pancreas. Although these organs serve other functions for other body systems, they are referred to as accessory organs of digestion when discussing the GI system because they serve important functions in the digestive process.

Liver
The liver consists of two large lobes and lls the upper right and center of the abdominal cavity just below the diaphragm. It is the largest glandular organ of the body. The hepatic duct of the liver extends to the duodenum of the large intestine.

Gallbladder
The gallbladder is a 3- to 4-inch long sac on the interior surface of the liver. The gallbladder is connected to the common bile duct, which also connects to the duodenum.

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Taste pore

Nonkeratinized squamous epithelium

Light taste cell

Nerve

Basal cell

Dark taste cell

FIG 30-2 Structure of a taste bud with taste cells.

As a person swallows food, the uvula prevents the food from entering the nasal cavity. The epiglottis covers the trachea to prevent food from entering the respiratory tract. The bolus continues into the esophagus, where involuntary muscular contractions, called peristalsis, move the bolus downward into the stomach. The lower esophageal sphincter lets the bolus in and prevents backflow of gastric secretions up into the esophagus. The rugae, which are folds in the internal surface of the stomach, allow the stomach to expand to accommodate large quantities of food. The fundus and body of the stomach are mostly holding areas for the food. The majority of digestion happens in the lowest portion, the pylorus. Gastric secretions within the stomach are highly acidic, with a pH around 1.7. (Some people have an elevated stomach pH due to antacid use.) These secretions continue the breakdown of food to enable the absorption, which is the process by which nutrients move from the digestive tract into the bloodstream. At this point in the digestive process, the food is referred to as chyme, a more liquid material comprised of chewed food, saliva, and digestive juices. The pyloric sphincter allows the liquid material to be released from the stomach into the small intestine a little at a time. The villi of the small intestine increase its surface area, allowing greater absorption of water and nutrients into the blood. Most of this absorption occurs in the small intestine. (See Figure 30-3.) All other products of digestion not absorbed by the small intestine, deemed waste

Villus

Microvilli Absorptive cells (enterocytes)

Lymphatic nodule

Lacteal

Blood capillaries

F.P.O
Ed: pls provide new art

FIG 30-3 Villi of the small intestine.

CHAP TER 30

Gastroenterology

541

products, continue into the large intestine for water absorption and elimination of bulk waste. The function of the appendix, at the junction of the small and large intestine, is unknown. The large intestine secretes mucus to facilitate the passage of stool, the bulk waste product of digestion. No digestion occurs in the large intestine; however, it does facilitate absorption of water and some minerals. After this absorption, the large intestine facilitates the formation and elimination of stools by defecation (elimination of feces from the bowel).

Pancreatic enzymes and sodium bicarbonate are secreted into the duodenum to neutralize stomach acid. These pancreatic enzymes include:

trypsin, to break down proteins lipase, to break down fats amylase, to break down carbohydrates.

The specialized cells of the islets of Langerhans secrete insulin and glucagon, two hormones that regulate blood glucose levels.

Accessory Organs of Digestion

Although the liver, gallbladder, and pancreas are not part of the alimentary canal, these organs play vital roles in the digestion, absorption, storage, and chemical conversion of vital nutrients.

Liver
The liver is involved in digestion, absorption, storage, and excretion. Its contributions to the digestive process include:

manufacturer of bile, a fat emulsier, which it then sends to the gallbladder for storage production and storage of glycogen, which can be converted to glucose when needed by cells detoxication of drugs and alcohol, making them water soluble so they can be excreted by the kidneys storage of fat-soluble vitamins A, D, E, and K for use when needed by cells manufacture of blood lipids, such as cholesterol and other lipoproteins, that protect arterial walls from damage and transport fat-soluble substances, such as vitamins, to various tissues via the bloodstream destruction of old erythrocytes, recycling the iron from those blood cells, and sending it to muscles as well as back to bone marrow to make new erythrocytes and release of bilirubin, which gets excreted in feces use of dietary protein sources to manufacture blood-clotting proteins, such as prothrombin and brinogen, which aid in repair of an injured artery, vein, or capillary walls.

Insulin, is secreted by the beta cells of the islets of Langerhans in response to increased blood glucose levels after eating. Insulin binds to glucose molecules in the bloodstream, allowing them to diffuse into the tissues. Glucagon, is secreted by the alpha cells of the islets of Langerhans in response to low blood glucose levels. Glucagon releases a storage form of glucose called glycogen from the liver. (See Sweet mnemonic, page 542.) Release of glycogen occurs while sleeping and fasting. (See Figure 30-4.)

Because the pancreas secretes substances into the bloodstream (insulin and glucagon) and into the alimentary canal

Meal

Pancreas

Muscle Glucagon Insulin Liver

Gallbladder
The gallbladder acts as a storage pouch for bile. Bile, produced in the liver, is sent to the gallbladder for storage through the right and left hepatic ducts. When food that contains fat passes from the stomach to the duodenum, the gallbladder secretes the bile into the duodenum through the common bile duct to break down those fats.

Glycogen

Fat cells

Glucose molecules

Pancreas
The pancreas secretes substances into the duodenum through the pancreatic duct and directly into the bloodstream through capillaries of the islets of Langerhans.
Bloodstream

FIG 30-4 Blood glucose regulation by the accessory organs of digestion.

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Sweet mnemonic
To remember which comes rst, glucagon or glycogen, remember this rhyme: Glucagon acts upon. Glucagon acts upon glycogen to release glucose into the bloodstream.

(sodium bicarbonate and pancreatic enzymes), it is considered an exocrine (outside of the bloodstream) and endocrine (into the bloodstream) gland. For more information on the endocrine functions of the pancreas, see Chapter 29, Endocrinology, on page 519.)

Table 30.1 | Element

Word Elements
Meaning Example
anal (A-nal) appendicitis (a-pen-d-SI-ts) appendicolysis (a-pen-d-KOL--ss) cheek lip buccal (BUK-al) cheilitis (k-LI-ts) labionasal (la-be-o-NA-zal) bile vessel bile, gall gallbladder bile duct colon cholangioma (ko-lan-je-O-ma) choleresis (kol-er-E-ss) cholecystitis (ko-le-ss-TI-ts) choledocholithiasis (ko-led-o-ko-l-THI-a-ss) colopexy (KO-lo-pek-se) colonopathy (ko-lo-NOP-a-the)

Meaning

Combining Forms an/o append/o appendic/o bucc/o cheil/o labi/o cholangi/o chol/e cholecyst/o choledoch/o col/o colon/o anus appendix Relating to the anus or outer rectal opening Inammation of the appendix Surgery to free the appendix from adhesions Pertaining to the cheek Inammation of the lip Pertaining to the lips and nose Tumor of the bile duct Secretion of bile by the liver Inammation of the gallbladder Stone in the bile duct Fixation of a segment of the colon to the abdominal wall Any disease of the colon dent/o odont/o teeth dentition (den-TISH-un) orthodontist (or-tho-DON-tst) The type, number and arrangement of teeth Specialist concerned with positioning and alignment of teeth duoden/o enter/o esophag/o gastr/o gingiv/o gloss/o lingu/o hepat/o ile/o liver ileum duodenum intestine esophagus stomach gum(s) tongue duodenal (du-o-DE-nal) enterospasm (EN-ter-o-spazm) esophagocele (e-SOF-a-go-sel) gastrectasia (gas-trek-TA-ze-a) gingivitis (jn-j-VI-ts) glossopharyngeal (glos-o-fa-RIN-je-al) lingual (LING-gwal) hepatitis (hep-a-TI-ts) ileostomy (l-e-OS-to-me) Pertaining to the duodenum Intermittent painful contraction of the intestines Hernia of the esophagus Acute or chronic dilatation of the stomach Inammation of the gums Pertaining to the tongue and pharynx (throat) Pertaining to the tongue Inammation of the liver Surgery to create an opening from the ileum to the outside of the body (stoma) jejun/o or/o stomat/o pancreat/o pancreas jejunum mouth jejunorrhaphy (je-joo-NOR-a-fe) oral (OR-al) stomatitis (sto-ma-TI-ts) pancreatalgia (pan-kre-a-TAL-je-a) Surgical repair of the jejunum Pertaining to the mouth Inammation of the mouth Pain in the pancreas

CHAP TER 30

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543

Table 30.1 | Element

pharyng/o proct/o

Word Elementscontd
Meaning
pharynx (throat) anus, rectum

Example
pharyngotomy (far-n-GOT-o-me) proctologist (prok-TOL-o-jst)

Meaning
Incision into the pharynx Specialist in diseases and disorders of the colon, rectum, and anus

pylor/o rect/o sial/o sigmoid/o Prexes dia-

pylorus rectum saliva, salivary gland sigmoid colon

pylorodiosis (p-lo-ro-d-O-ss) rectocele (REK-to-sel) sialolith (s-AL-o-lth) sigmoidoscopy (sg-moy-DOS-ko-pe)

Dilation of the pylorus Hernia of the rectum Salivary stone Procedure to view the sigmoid colon

through, across

diarrhea (d-a-RE-a)

Abnormally frequent discharge or ow of watery fecal matter from the bowel

perisubsufxes -emesis -iasis -megaly -orexia -pepsia -phagia -prandial

around under, below

perihepatic (per--he-PAT-k) sublingual (sub-LING-gwal)

Around the liver Under the tongue

vomit abnormal condition enlargement appetite digestion swallowing, eating meal

hematemesis (hem-at-EM-e-ss) cholelithiasis (ko-le-l-THI-a-ss) hepatomegaly (hep-a-to-MEG-a-le) anorexia (an-o-REK-se-a) dyspepsia (ds-PEP-se-a) polyphagia (pol-e-FA-je-a) postprandial (post-PRAN-de-al)

Vomiting of blood Condition of gallstones Enlargement of the liver Loss of appetite Indigestion, bad digestion Eating large amounts of food, gluttony Following a meal

Table 30.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to the GI system with a pronunciation guide and brief denition for each. Term
appendicitis a-pen-d-SI-ts cholelithiasis ko-le-l-THI-a-ss colitis ko-LI-ts diarrhea d-a-RE-a dyspepsia ds-PEP-se-a

Denition
Inammation of the appendix

Term
dysphagia ds-FA-je-a atulence FLAT-u-lens gastroesophageal reux disease gas-tro-e-sof-a-JE-al RE-uks d-ZEZ

Denition
Painful or difcult swallowing

Presence of gallstones

Excessive gas in the stomach and intestines Common condition where acid from the stomach ows back into the esophagus, causing discomfort and, sometimes, erosion of the lining of the esophagus

Inamed colon

Passage of loose, watery stool from the rectum Poor or painful digestion

peritonitis per--to-NI-ts

Inammation of the serous membrane that lines the abdominal cavity

Continued

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Table 30.2 | Term

polyp POL-p pruritis proo-RI-tus

Pathologic Termscontd
Denition
Growth projecting from a mucous membrane Itching, tingling

Term
pyrosis p-RO-ss

Denition
Heartburn

Medical Terminology Related to the GI System

Table 30.3 |

Abbreviations

In gastroenterology, as in other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed here save time and effort in documentation and written communications. Abbreviation
ac ALT

Term
before meals alanine aminotransferase (liver enzyme test)

AST

aspartate aminotransferase (liver enzyme test)

Terms used the in the gastroenterology ofce will include the names of the organs associated with digestion, absorption, storage, and elimination of food. The medical assistant working in the gastroenterology setting will become familiar with pathologies related to the organs of the GI system. Working in these practice settings will allow the medical assistant to assist with diagnostic testing and therapeutic procedures for the GI system. To be effective in her role, a medical assistant must become well versed in the language and vocabulary that pertains to the gastrointestinal system. The following tables list common medical terminology related to the gastrointestinal system.

BaE, BE BM ERCP

barium enema bowel movement endoscopic retrograde cholangiopancreatography

Common GI System Diseases and Disorders

Diseases and disorders of the GI system can cause pain and malabsorption of nutrients, adversely affect growth or maintenance of tissues, and affect overall health. The medical assistant can offer the patient resources on healthy diets, medications, and foods to avoid that promote reduction of symptoms for their specic GI ailment. There are many diseases and disorders affecting the GI system. Here are some of the most common with a summary of each, along with their corresponding ICD-9-CM code.

GERD GI IBD IBS IVC LFT NG NPO, npo pc PO, po PR PUD SBO

gastroesophageal reux disease gastrointestinal inammatory bowel disease irritable bowel syndrome intravenous cholangiogram liver function test nasogastric nothing by mouth (Latinnulle per os) after meals by mouth per rectum peptic ulcer disease small bowel obstruction

Disorders of the Upper GI Tract

The organs of the upper GI tract include the oral cavity, esophagus, and stomach. Disorders of these organs can cause dysphagia (difculty swallowing) and pyrosis, commonly called heartburn. Patients may complain that eating is difcult and no longer enjoyable. Some of the most common diseases and disorders of the upper GI tract include gastroesophageal reux disease, hiatal hernia, peptic ulcer disease, gastritis, and pyloric stenosis.

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Gastroesophageal Reux Disease

ICD-9-CM code: 530.81 Gastroesophageal reflux disease (GERD), commonly known as heartburn, is one of the most common disorders of the GI tract. It involves the backow of acidic gastric contents into the esophagus causing pyrosis, also called heartburn. The tissues of the esophagus are not designed to deal with acidic gastric secretions. If prolonged exposure to these secretions occurs, the lining of the esophagus becomes irritated and causes symptoms. As many as 44% of Americans suffer from symptoms of GERD once per month and an estimated 7% to 10% have daily symptoms. Factors that contribute to GERD include weak esophageal peristalsis, delayed gastric emptying, pyloric stenosis (narrowing of the lower portion of the stomach), hiatal hernia, obesity, smoking, alcohol, and such medications as aspirin and other nonsteroidal anti-inammatory drugs (NSAIDs). GERD is also common in pregnant women, because the enlarging uterus exerts upward pressure on the stomach and other structures, and less-than-normal LES pressure allows the reux of gastric contents into the esophagus. Symptoms include heartburn, dysphagia, chronic cough, upper abdominal pain, and difculty breathing. Symptoms worsen about 1 hour after meals, when lying down, or if intra-abdominal pressure increases, such as with coughing, belching, or physical strain. Diagnosis is based on the patients history and clinical manifestations. Testing may include a barium swallow to detect erosion or abnormalities of the esophagus. An upper endoscopy enables visualization of the esophagus, LES, and stomach, testing of uid pH, and biopsy of tissue for analysis. Conservative, nonpharmacologic treatment measures include smoking cessation, weight loss, reducing or eliminating alcohol, avoiding large meals, avoiding high-fat foods or foods that reduce LES tone (such as caffeine, fat, and chocolate) 4 hours before bedtime, and elevating the head of the bed 6 in. Medication to treat GERD includes H2-receptor antagonists, such as famotidine (Pepcid), and proton pump inhibitors, such as esomeprazole (Nexium) and omeprazole (Prilosec). If conservative measures fail, symptoms can usually be managed effectively with drug therapy. Surgical management is reserved for severe symptoms that do not respond to other measures and includes narrowing of the LES via laparoscopy. Long-term complications may include esophagitis, dysphagia, and precancerous cellular changes in the esophageal lining.

muscle in the abdomen necessary for breathing. The incidence of hiatal hernias is greater in Western countries and increases with age, from 10% in those below the age of 40 to as high as 70% in those over 70 years of age. A hiatal hernia occurs when the part of the diaphragm around the base of the esophagus weakens and allows a portion of the stomach to slide upward into the thoracic cavity. The cause of hiatal hernias is not always clear but contributing factors include obesity, trauma, advanced age, and anything that increases intra-abdominal pressure. The key symptoms of hiatal hernia are the same as for GERD. Stomach uids, which are highly acidic with a pH of 1.7, are regurgitated upward into the lower esophagus, causing pyrosis. Other symptoms may include chest pain, dysphagia, and respiratory problems if aspiration occurs. Some patients may not exhibit common symptoms but may complain of such vague symptoms as a loss of appetite or malaise. Such patients may admit some feelings of nausea or vomiting if asked but may consider such incidents unrelated. Diagnostic studies include chest x-ray and barium study. Upper endoscopy may be done to conrm the diagnosis and check the pH of reuxed uid. Conservative management includes weight loss; eating smaller, more frequent meals; and avoiding foods that exacerbate symptoms. Medications used to treat GERD may also be used to treat the symptoms of hiatal hernia, including H2-receptor antagonists, such as famotidine (Pepcid). Cholinergic agents may be used to strengthen the LES. Antacids, such as aluminum hydroxide and magnesium hydroxide (Maalox, Mylanta) and calcium carbonate (Tums), are used to relieve the symptoms of heartburn associated with hiatal hernia. If conservative measures are not effective, surgical repair may be necessary. Prognosis is generally good unless further complications arise. Complications can include a strangulated hernia, in which the protrusion of the stomach is so tight that blood supply to the tissue is restricted and tissues begin to necrotize or die. Strangulated hernias require prompt surgical intervention to avoid the development of gangrene. (See Figure 30-5.)

Peptic Ulcer Disease

ICD-9-CM code: 531.90 (gastric), 532.90 (duodenal), 530.2 (esophageal) Ulceration occurs when an area of the protective mucous membrane lining breaks down leaving the area sensitive to the acidity of various digestive secretions. The three most common sites of ulceration are the lower esophagus, stomach, and duodenum. About 10% of Americans develop peptic ulcer disease (PUD) at some point in their lifetime and approximately 10% of emergency department patients who complain of abdominal pain are diagnosed with PUD. An estimated 50% of the worlds population is infected with

Hiatal Hernia
ICD-9-CM code: 553.3 A hernia is a protrusion of an organ or other tissue through a wall or structure that normally contains it. There are many different types and locations of hernias. A hiatal hernia is a protrusion of the stomach upward through the diaphragm, a

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Esophagus

Lower esophageal sphincter Hiatal hernia Diaphragm

Duodenum Pyloric sphincter

Stomach

Esophagus

Lower esophageal sphincter

Hiatal hernia Necrosis Diaphragm

Helicobacter pylori, the bacteria responsible for most cases of peptic ulcer, although the incidence of PUD in the developed world is decreasing. The majority of peptic ulcers result from H. pylori infection, which causes inammation and breakdown of the mucosal lining of the stomach. The next most common cause of ulcer formation is the use of nonsteroidal antiinammatory drugs (NSAIDs), which block the production of certain prostaglandins that protect the mucosal lining of the stomach from digestive acids. Alcohol is also a contributor because it promotes acid secretion, which in excess can lead to erosion of the gastric mucosa. Smoking and eating spicy foods were once suspected to cause ulcers but have not been found to cause peptic ulcers. Although diet and stress may play a minor role in some individuals, they are not major risk factors, as was commonly believed in the past. Symptoms of peptic ulcers include indigestion, heartburn, and epigastric pain. The most common location for a peptic ulcer is in the duodenum. Symptoms include heartburn, midepigastric pain, nausea, and vomiting, with symptoms peaking about 2 hours after eating. Information is obtained through the health history, physical examination, and barium studies. Tests that conrm the diagnosis include a blood test or a urea breath test that reveals the presence of H. pylori and endoscopy, which enables direct visualization of the upper GI tract and collection of gastric contents for analysis to determine pH and the presence of blood and H. pylori. The physician may also perform a tissue biopsy to rule out malignancy. The physician may prescribe antibiotics if tests conrm the presence of H. pylori. Other treatment measures include avoiding intake of irritating agents, such as alcohol, NSAIDs, and tobacco (which may irritate the condition even though it does not cause it) as well as such medications as H2-receptor antagonists, antacids, and proton pump inhibitors. PUD does not generally require signicant dietary changes; however, the patient should avoid any food that seems to exacerbate symptoms. Prognosis is good with early diagnosis. Potential complications include mild or severe bleeding and perforation, resulting in hemorrhage, peritonitis, and sepsis. (See Figure 30-6.)

Gastritis
Duodenum Pyloric sphincter FIG 30-5 Hiatal hernia. (A) Uncomplicated hiatal hernia. (B) Strangulated hiatal hernia. Stomach

ICD-9-CM code: 535.5 (use fth digit to denote hemorrhage or no hemorrhage) Gastritis is an acute or chronic inammation of the lining of the stomach. In acute gastritis, the gastric mucosa is red and inamed and can ulcerate and bleed. Chronic gastritis is found mostly in patients ages 50 and older. The most common cause of gastritis is infection with H. pylori, the same bacteria that causes peptic ulcer disease. Less common causes include irritants, such as alcohol,

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Stomach Esophagus

Front ofceBack ofce connection

Emesis in the Waiting Room

Gastric ulcer

Duodenum

Peptic ulcer

Duodenal ulcer

Because many patients waiting to see a physician are ill perhaps so ill that emesis (vomiting) is a possibility, the administrative medical assistant must be aware of this danger. In addition, she should have a working knowledge of blood and body secretions to protect herself and others from potentially infectious diseases. If the administrative medical assistant is aware of a patient who may be ill, she should communicate with the clinical medical assistant to get the patient into a treatment room as quickly as possible and provide him with an emesis basin. If a room is not available, she should provide the patient with the emesis basin in the waiting room or escort him to the restroom. If a patient does vomit in the waiting area, she should clean the area immediately using proper infection control techniques.

Stomach pH testing can conrm suspected hypochlorhydria. Treatment of acute gastritis includes antibiotic therapy if H. Pylori is the causative agent, B12 injections to correct vitamin deciency, and temporary administration of H2-receptor antagonists to decrease acid production while the gastric mucosa heals. (See Antacid overuse.) Supplemental hydrochloric acid can be administered to restore digestive function of the stomach. The prognosis for gastritis is good with proper treatment. The medical assistant should encourage patients with gastritis
FIG 30-6 Common ulceration sites.

Patient Education
tobacco, and NSAIDs, and chronic peptic ulcers. Because it is so common in older patients, it is thought to be due in part to hypochlorhydria, a decrease in the production of stomach acid. With age or disease (such as chronic peptic ulcers), normal production of stomach acid decreases, which leaves the stomach vulnerable to irritants and infection. In addition, the decrease in acid production causes atrophy of the mucosa of the stomach, which leads to decreased production of intrinsic factor, a stomach secretion that activates vitamin B12. This secondary effect of gastritis causes a vitamin B12 deciency. Patients may be asymptomatic or suffer from epigastric pain, nausea, vomiting, and hematemesis (vomiting of blood). (See Emesis in the waiting room.) Other symptoms include mild epigastric pain, anorexia, or intolerance to spicy and fatty foods. Diagnosis depends on the health history and endoscopy or barium studies, which reveal the presence of inammation.

Antacid Overuse
Many people take over-the-counter acid suppressants, also called antacids, to alleviate discomfort caused by overeating or eating spicy foods. However, stomach acid performs two important functions. It aids in the digestion of foods by breaking chemical bonds and inhibits the growth of bacteria. Bacteria cannot grow in an acidic environment, so stomach acid can kill potentially harmful bacteria before they cause infection. Recent studies also indicate that prolonged stomach acid suppression contributes to osteoporosis, because stomach acid is necessary to metabolize calcium. The medical assistant should advise patients to use overthe-counter acid suppressants sparingly to avoid poor digestion of food, decreased absorption of nutrients, and infection.

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to avoid alcohol, tobacco, and any foods that they have found to be irritating. Because the loss of gastric secretions leaves the patient at an increased risk for peptic ulcers and gastric carcinoma, the medical assistant should encourage patients to notify the physician if symptoms return.

Pyloric Stenosis
ICD-9-CM code: 537.0 (adult), 750.5 (congenital-infantile) In pyloric stenosis, a stenosis (narrowing of the pyloric sphincter) interferes with the emptying of the stomach into the duodenum. This condition may be present at birth. It affects about 3 of every 1,000 infants, usually within the rst 8 weeks of life. Boys are ve times more likely than girls to suffer from pyloric stenosis. It is very rarely acquired as an adult. In infants, a congenital hyperplasia of the mucosa and submucosa of the pylorus prevents the passage of food into the duodenum. Studies have shown that this congenital malformation could be inherited. In adults, the most common cause is scar tissue that develops around a healing gastric ulcer. The major sign of pyloric stenosis in infants is projectile vomiting, because food cannot pass from the stomach to the duodenum. Adult symptoms include distention of the stomach and forceful projectile vomiting after eating. Diagnosis of infants is conrmed by physical examination, which reveals a rm, nontender, mobile, hard pylorus on palpation. Palpation is most effective after the infant has vomited and when he is calm. History of forceful projectile vomiting and signs of dehydration, such as depressed fontanelles, dry mucous membranes, and decreased tearing, are also present. Adult diagnosis is conrmed by endoscopy, which shows narrowing of the pyloric sphincter. In infant and adult patients, blood tests reveal elevated electrolyte levels consistent with dehydration and acid-base imbalance. Treatment for infants includes laparoscopic division of the muscles of the pylorus to help the passage of food. Without surgical correction, the infant will not be able to eat enough to grow and thrive. Adults can be treated with the placement of a stent to open the passage. Adult patients may be able to control symptoms with diet modication or eating small, frequent meals; however, surgical correction is commonly required. Infants who undergo surgical correction have a good prognosis; most babies can feed 3 to 4 hours after surgery and will grow and gain weight normally. Adult prognosis is also good with diet modication and, in some cases, surgical correction.

tract commonly complain of diarrhea, constipation, or lower abdominal pain. Gas causing atulence, the accumulation and elimination of gas from the lower intestine, is another common complaint. The medical assistant can assist the physician in the diagnosis and treatment of disorders of the lower GI tract and provide patients strategies to reduce symptoms of chronic disorders. Common diseases and disorders of the lower GI tract include abdominal hernia, appendicitis, diverticular disease, hemorrhoids, and inammatory bowel disease.

Abdominal Hernia
ICD-9-CM code: 553.9 An abdominal hernia involves protrusion through the abdominal wall of one of the structures enclosed within it, including the intestine. An estimated 5 million people in the United States have an abdominal hernia. However, only a small percentage of these people seek treatment. Three common sites of abdominal hernias include:

umbilicus, which accounts for 10% to 20% of all hernias inguinal ligament, which accounts for 75% of all hernias and is 25 times more likely in men than women site of previous surgery, which accounts for approximately 5% of all hernias.

Disorders of the Lower GI Tract

The lower GI tract is responsible for absorption of nutrients, such as minerals, and water and the synthesis of vitamin K in the large intestine. Patients with disorders of the lower GI

An abdominal hernia can develop anywhere there is a weakness in the omentum, the musculature that lines the abdominal cavity. When this weakness results in an opening in the abdominal wall, the intestines can protrude through the opening. Contributing factors include anything that increases intra-abdominal pressure, such as heavy lifting. Umbilical hernias occur when the opening to the abdominal wall for the umbilical cord does not completely close at birth. Inguinal hernias occur when the inguinal canal, which usually closes shortly after birth, stays open, allowing abdominal structures to migrate into the canal. Rarely, women have an opening in the same region that can become herniated. Unlike the umbilical hernia, the inguinal hernia can occur in adulthood, especially at middle age and older, as a result of thinning of the tissue and loss of muscle tone in the inguinal region. Hernias at sites of previous surgeries occur because the surgical cutting of the muscle wall causes a weakness. (See Figure 30-7.) Symptoms of abdominal hernia vary, depending on the site and severity of the hernia. Patients may notice a bulge that can be reduced by pushing on it. A person with an inguinal hernia may notice sharp pain when straining or standing. Severe pain may indicate a strangulated hernia, in which the blood supply to the herniated tissue has been cut off. Diagnosis is usually based on physical examination ndings and a description of symptoms. Radiographic studies of abdominal structures may conrm the diagnosis. Treatment depends on the type and location of the hernia as well as

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Previous surgical sites Umbilicus

Inguinal ligament

Previous surgical site

may exhibit rebound tenderness to palpation at McBurneys point, a point 1 to 2 in. above and central to the right ilium and RLQ rebound tenderness. Other signs and symptoms may include fever, diarrhea, and constipation. In over half of all cases, the symptoms are less specic and pain and tenderness are more generalized. Diagnosis is based primarily on symptoms and physical examination ndings. A complete blood count (CBC) may reveal an elevated level of white blood cells (WBCs). However, radiologic tests are not helpful and exploratory surgery is usually necessary to conrm the diagnosis. The only treatment for appendicitis is surgical removal of the appendix and administration of antibiotics to prevent or resolve infection. Prognosis is good with surgery and full recovery is expected in most cases. If the appendix ruptures before surgery, peritonitis develops, causing peritoneal abscess, infection of the reproductive organs, septicemia, and shock. In these cases, prognosis is less certain and depends on the immediate intervention.

Diverticular Disease
DiverticulosisICD-9-CM code: 562.10 and 562.12 DiverticulitisICD-9-CM code: 562.11 and 562.13 Diverticular disease includes diverticulosis and diverticulitis. Diverticulosis is a disorder in which tiny, pouchlike herniations, called diverticula, develop in the wall of the distal portion of the large intestine. Diverticulitis is the development of inammation and infection of these diverticula. It is estimated that approximately half of the population has developed some degree of diverticulosis by age 60, although most people are not aware of it until they experience symptoms. Diverticula form in the intestinal wall when increased pressure causes small herniations around small vessels and other structures that transect the wall. Contributing factors include low-ber diet and chronic or recurrent constipation. Diverticulitis develops when the diverticula become clogged with feces, resulting in inammation and infection. Patients with diverticulosis are usually asymptomatic. Symptoms of diverticulitis include fever, nausea, bloodstreaked stools, and left lower quadrant (LLQ) abdominal pain. Diagnosis is generally based on a description of symptoms when the patient has developed diverticulitis. Tests that conrm the diagnosis include air contrast barium enema, radiographic studies, colonoscopy, and sigmoidoscopy, which reveal diverticula and small herniations of the intestinal wall. A complete blood count (CBC) will show an elevated WBC count. Diverticulosis is treated with dietary measures, including adequate uid and ber to prevent constipation and avoidance of foods containing small seeds and nuts that might lodge in the diverticula. Diverticulitis is treated with antibiotics, analgesics, and a liquid diet that allows the bowel to

FIG 30-7 Common abdominal hernia sites.

patient factors, such as age and general health status. Patients may wear a truss, which is a device that reduces and holds the herniated tissue in place. However, if the patient is considered a good surgical candidate, treatment generally involves surgical repair. If untreated, a hernia may worsen over time. Therefore, evaluation health care provider is recommended. Prognosis for a surgically repaired hernia is generally very good. A strangulated hernia is a medical emergency that requires prompt surgical intervention to prevent tissue necrosis, gangrene, and septicemia.

Appendicitis
ICD-9-CM code: 540 When the appendix becomes inamed, the result is the condition known as appendicitis. Appendicitis is most common in patients between ages 10 and 40 and is the second most common cause of acute abdominal pain and surgery in the United States. Occasionally, intestinal matter clogs the appendix, resulting in the inammation and infection. Less than half of the patients with appendicitis develop the classic symptoms of nausea, vomiting, and severe periumbilical pain, which eventually localizes to the right lower quadrant (RLQ). Patients

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rest. In cases of diverticular rupture (bowel perforation), the physician may perform surgery to resect the ruptured portion of the bowel. Additional measures include rest and stress reduction. Prognosis for diverticulosis is good unless diverticulitis develops. Mild cases of diverticulitis usually resolve without complications. Complications may include perforation, infection, obstruction, and hemorrhage. (See Foods that cause diverticular disease.)

Hemorrhoids
ICD-9-CM code: 455 Hemorrhoids are varicose veins of the anal area and may be inside the rectum or on the exterior of the anal opening. They are rarely serious, but hemorrhoids are common and can be uncomfortable. It is estimated that half of adults over the age of 50 suffer from hemorrhoids. Hemorrhoids result from constipation, which results in excessive straining during defecation, or other factors, such as pregnancy and obesity, that increase pressure on veins located in the anorectal area. Disorders that predispose people to the development of hemorrhoids include ulcerative colitis and Crohn disease. Signs and symptoms of hemorrhoids include small bulging areas in the anal region that may be painless. However, they can easily worsen with constipation and straining to defecate. Other symptoms include pain or tenderness as well as itching. Bleeding may occasionally be present after passing stool and is usually minor. Diagnosis is based on the health history, physical examination, and symptoms. In addition, proctoscopy, an examination of the rectum with a scope, evaluates the anal canal and rectum for internal hemorrhoids. Radiography may include a barium enema or virtual colonoscopy, which uses x-rays and computers to produce two- and three-dimensional

images of the colon that reveal vein distention and possible narrowing of the lumen of the colon due to engorgement of hemorrhoidal veins. Conservative measures are aimed at treating and preventing constipation by increasing intake of dietary uids and ber and using of stool softeners. (See Preventing constipation.) Symptoms can be treated by soaking in a warm bath and applying topical anesthetics and anti-inammatory creams. When these treatments are ineffective, a variety of measures may be used to destroy hemorrhoids, including sclerotherapy, cryotherapy, and ligation. When these measures are ineffective or when bleeding is severe, a hemorrhoidectomy is the best treatment measure.

Inammatory Bowel Disease

Crohn diseaseICD-9-CM code: 555.9 Ulcerative colitisICD-9-CM code: 556.9 Irritable bowel syndromeICD-9-CM code: 564.1 Several disorders fall under the category of inammatory bowel disease (IBD). These disorders include Crohn disease, ulcerative colitis, and irritable bowel syndrome (IBS). Although these disorders have some similarities, they also have some distinctive differences. In each case, diagnosis is based on presenting symptoms, barium enema, abdominal x-rays, lower endoscopy, and, possibly, tissue biopsy. Laboratory tests include CBC and stool studies. All three disorders are considered chronic in nature with no specic cure, yet all can be managed with a resulting normal or near-normal life expectancy. Even so, all three are considered risk factors for bowel cancer.

Crohn Disease
Crohn disease is inammation and edema deep into the lining of any part of the GI tract. It affects 7 in 100,000

Patient Education

Preventing Constipation
Patient Education
Conservative treatment for hemorrhoids includes treating constipation. The medical assistant should teach the patient with hemorrhoids about these measures to prevent or treat constipation: Drink plenty of nonalcoholic, noncaffeinated uids Eat a high-ber diet (including fresh fruits, vegetables, whole grains, and bran). Drink prune juice. Use bulk-forming, nonchemical laxatives, such as Metamucil. Stool softeners and chemical laxatives, although available over the counter, can be habit-forming with regular use. It is important to consult with a physician when using these products.

Foods That Cause Diverticular Disease

For a patient with diverticula, preventing inammation and infection (diverticulitis) is essential. The medical assistant should teach such a patient to avoid foods that can get stuck in the diverticula, including: nuts, such as peanuts, walnuts, almonds, and cashews seeds, such as pumpkin and sunower seeds tomatoes cucumbers strawberries kiwi fruit.

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patients in the United States. It is more prevalent in Caucasians and Jewish people and slightly more common in men than women. Most newly diagnosed patients are between the ages of 15 and 30 or 60 and 80. The specic cause of Crohn disease is unknown. However, factors that contribute to the disease include diet, genetics, infectious agents, allergies, and psychological components. There is some evidence that it may also be an autoimmune disorder. Symptoms include chronic diarrhea, fever, weight loss, fatigue, anorexia, abdominal pain, and cramping that may localize to the right lower quadrant (RLQ). Treatment aims at symptom management and includes administration of IV uid and parenteral nutrition, anticholinergics and opioids to control pain and reduce bowel motility, antimicrobials for infection, corticosteroids to reduce inammation, and surgery for perforations or to remove involved portions of the colon. Patients may also be referred to a support group or therapist. Potential complications of Crohn disease include bowel obstruction, malnutrition, adhesions, abscesses, fistulas, and fluid and electrolyte imbalance.

diarrhea along with other GI symptoms. IBS is the most common GI disorder in the United States, accounting for more than 10% of all medical ofce visits. About 1 in 5 American adults suffer from IBS, and young women are most commonly affected. The specic cause of IBS is unknown. Current theories include changes in motor or sensory nerves in the bowel, central nervous system changes, genetic factors, and hormonal inuences. Symptoms include alternating diarrhea and constipation, abdominal pain, bloating, gas, distention, cramping, and heartburn. These symptoms may be aggravated by emotional stress and trigger foods, such as chocolate, milk, and alcohol. Treatment of IBS includes avoidance of identied trigger foods, which may reduce the frequency of episodes. Antispasmodics may help reduce hypermotility. Antidiarrheal medications or laxatives may help control symptoms of diarrhea and constipation. Bulk ber, such as Metamucil, helps minimize diarrhea and constipation. Most patients can control symptoms of IBS through medication and diet modication (avoiding trigger foods).

Ulcerative Colitis
Ulcerative colitis is a chronic inammation of the innermost lining of the rectum and colon. This disease follows a pattern of episodes of acute symptoms alternating with periods of remission. It affects more than 500,000 Americans, usually young adults, and affects men and women equally. Incidence of the disease in people of Caucasian, Jewish, and European descent is ve times higher than in other groups. This type of IBD is commonly confused with Crohn disease. The specic cause of ulcerative colitis is unknown. Theories include heredity, antibiotic use, and autoimmune factors or environmental factors (such as urban or industrialized areas and northern climates). Symptoms include weight loss, fever, malaise, and up to 10 to 20 episodes of bloody, mucoid diarrhea per day with pain, cramping, and urgency to defecate. Treatment for ulcerative colitis includes a nutritious, lowber diet and avoidance of trigger foods, which vary from patient to patient. Anticholinergics and antidiarrheals reduce bowel motility. Other medications may include bulk Metamucil, NSAIDs, sulfasalazine, mesalamine, corticosteroids, sh oil, and analgesics. Treatment may also include surgery in cases of severe hemorrhage or perforation. About 25% to 40% of people with ulcerative colitis eventually require surgery. Complications of ulcerative colitis include infection and fulminant colitis, a severe form that causes severe pain, profuse diarrhea, hemorrhage, uid and electrolyte imbalances, and shock.

Disorders of the Accessory Organs of Digestion

The liver, gallbladder, and pancreas can also become diseased, cause pain, and disrupt digestion. The medical assistant can assist the physician in the diagnosis and treatment of disorders to the accessory organs of digestion by taking patient histories, scheduling laboratory and radiographic studies, and providing patient education. Common disorders of the accessory organs include viral hepatitis, cholelithiasis and cholecystitis, and acute pancreatitis.

Viral Hepatitis
ICD-9-CM code: 070.1 (hepatitis A), 070.30 (hepatitis B), 070.51 (hepatitis C, acute), 070.54 (hepatitis C, chronic), 070.52 (hepatitis D), 070.53 (hepatitis E) Viral hepatitis is a disorder characterized by inammatory cells in the liver. There are several types of viral hepatitis, including hepatitis A, B, C, D, and E. Diagnostic tests to determine the viral cause identify the presence of the antigen for each type of hepatitis.

Hepatitis A
Hepatitis A is caused by the hepatitis A virus (HAV), which is spread by the fecal-oral route. Risk factors for infection with HAV include living with an infected person, traveling to countries where hepatitis A is prevalent, and sharing body uids with an infected person through sex or drug use. One-third of all Americans have evidence of past infection with HAV. Symptoms of hepatitis A include jaundice, fatigue, abdominal pain, nausea, diarrhea, anorexia, and fever. Blood tests can conrm the presence of antibodies to hepatitis A.

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a disorder of the intestine characterized by alternating episodes of constipation and

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Administration of immune globulin may prevent infection before exposure or treat a recent exposure (less than 2 weeks before administration). Administration of the hepatitis A vaccine conveys long-term protection against infection. Prognosis for hepatitis A is good with treatment. The time between infection and the start of illness is approximately 28 days. Most people fully recover within 2 months. Approximately 15% of people experience relapsing symptoms for 6 months to 1 year after initial diagnosis.

Hepatitis D
Hepatitis D is caused by infection with the hepatitis D virus (HDV). However, this form of hepatitis is only present with a coexisting HBV infection. Because testing for HDV is not routine, there is no reliable data available on its prevalence in the population. Risk factors for contracting HDV include IV drug use, hemodialysis, sexual contact with an infected person, and working in a health care or public safety setting. Symptoms of hepatitis D include jaundice, fatigue, abdominal pain, anorexia, nausea, vomiting, joint pain, and dark urine. Blood tests reveal the presence of small and large delta antigens (HDAg-S and HDAg-L), which indicate the presence of HDV. The vaccine for hepatitis B also prevents infection with HDV. In addition, a booster of HBV immune globulin prevents infection or treats exposure at the time of diagnosis. There is no treatment for acute infection with HDV other than supportive care. Treatment for chronic hepatitis D includes administration of interferon-alfa, liver transplant, or both. Patients with hepatitis D may develop cirrhosis, and up to 20% will develop liver failure.

Hepatitis B
Hepatitis B is caused by infection with the hepatitis B virus (HBV), which is spread through blood or body uids. Risk factors for infection include travel to areas where HBV is common as well as IV drug use and multiple sex partners. An estimated 1.25 million Americans have chronic hepatitis B, and 20% to 30% acquired the infection during childhood. In the United States, people ages 20 to 49 are at the highest risk for the disease. Each year, approximately 5,000 Americans die from HBV infection. Worldwide, HBV is a major cause of chronic liver disease and liver cancer. Symptoms of hepatitis B include joint pain, clay-colored feces, dark urine, abdominal pain or tenderness, nausea, anorexia, fatigue, and yellowish skin and eyes. Patients with hepatitis B will test positive for the hepatitis B antigen (HBsAg) 1 to 2 months after exposure. The hepatitis B vaccine prevents infection with HBV. Antiviral drugs treat chronic HBV infection. Although most people recover from hepatitis B, complications may include liver cancer and liver failure.

Hepatitis E
Hepatitis E is caused by infection with the hepatitis E virus (HEV). HEV transmission occurs via the same route as HAV, the fecal-oral route (usually through contaminated food or water). Risk factors for contracting HEV include travel to developing countries and fecal contamination of water or food. Person-to-person transmission is uncommon. Outbreaks of hepatitis E occur after heavy rainfall that disrupts and contaminates water supplies. It is prevalent in developing countries, especially those with hot climates. Hepatitis E is rare in the United States. It is most common in people from ages 15 to 40. Symptoms of hepatitis E include jaundice, fatigue, abdominal pain, anorexia, nausea and vomiting, and dark urine. Patients with hepatitis E test positive for the hepatitis E antigen (HEV Ag).There is no treatment other than supportive care for hepatitis E. Hepatitis E mortality rates are low. It is usually selflimiting and patients recover fully within a few weeks.

Hepatitis C
Hepatitis C occurs in acute and chronic forms. It is caused by infection with the hepatitis C virus (HCV), which is spread via the blood. Risk factors for contracting HCV include IV drug use, blood transfusion or solid organ transplant before July 1992, transfusion of clotting factors before 1987, long-term dialysis, and liver disease. Approximately 3.9 million (1.8%) Americans are currently infected. In 2003, the CDC reported 30,000 new cases of hepatitis C in the United States. About 80% of people infected with HCV are asymptomatic. Symptoms of hepatitis C include jaundice, fatigue, abdominal pain, anorexia, nausea, fatigue, and dark urine. Tests used to conrm hepatitis C include the enzyme immunoassay (EIA) or the enhanced chemiluminescence immunoassay (CIA) test. The recombinant immunoblot assay (RIBA) test conrms positive results. There is no vaccine available for the prevention of HCV infection. Treatment for hepatitis C includes administration of interferon and ribavirin, which eliminates the virus in 50% to 80% of people. Drinking alcohol can exacerbate the disease. The mortality rate for hepatitis C is fairly low (1% to 5%). However, as many as 85% of patients with hepatitis C will develop chronic infection or chronic liver disease. Hepatitis C is the leading reason for liver transplants.

Cholelithiasis and Cholecystitis

CholelithiasisICD-9-CM code: 574.20 CholecystitisICD-9-CM code: 575.12 Cholelithiasis is a condition in which gallstones have developed and are present in the gallbladder, liver, biliary ducts, or all three locations. When inammation of the gallbladder occurs along with cholelithiasis, the condition is known as cholecystitis. Cholelithiasis affects 20 million people in the United States, with up to 3% becoming symptomatic with cholecystitis. It occurs in both genders but most commonly affects women of childbearing age. Incidence increases with age. The ethnic groups most commonly affected include those of fair-skinned northern European descent, Native

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Americans, and Hispanics. Less than 50% of people with cholelithiasis become symptomatic with acute cholecystitis. The cause of cholelithiasis is not fully understood. Risk factors include a high-calorie, high-fat diet, obesity, oral contraceptive use, pancreatitis, and alcoholic cirrhosis. Gallstones most commonly develop from insoluble cholesterol but also from bile salts. The most common cause of cholecystitis is biliary duct obstruction by gallstones or crystallized bile sludge. The resulting increased pressure creates inammation within the gallbladder. Other causes include infection, injury to the gallbladder, or underlying diseases such as diabetes. People with cholelithiasis are commonly asymptomatic and may not realize that they have gallstones. If stones or sludge obstructs bile ducts, biliary colic ensues with symptoms of epigastric pain, commonly radiating into the right upper quadrant (RUQ), right shoulder, and back. Other symptoms include belching, bloating, fatty food intolerance, nausea, vomiting, muscle guarding, fever, tachycardia, jaundice, light-colored stools, dark urine, and pruritus, a tingling sensation that causes itching. Diagnostic tests are unnecessary for cholelithiasis unless patients become symptomatic. Gallstones are commonly noted incidentally during a computed tomography (CT) scan or other tests done for other reasons. Diagnosis of cholecystitis is based on symptoms, an ultrasound that reveals wall thickening of more than 2 to 4 mm, distention, or uid from perforation or exudates. Other tests may include oral cholecystogram, plain abdominal x-ray, or IV cholangiogram. Laboratory tests may reveal increased WBCs and, if obstruction is present, increased serum bilirubin. If patients are asymptomatic, no treatment is indicated. However, diet should be modied to decrease fat intake. Nonsurgical treatment options that attempt to dissolve or disintegrate stones have shown limited success and are seldom used. Elective surgery may be advised for people at high risk for complications, including those with cirrhosis and portal hypertension. If a patient becomes acutely ill with cholecystitis, he may be hospitalized, placed on nothing-bymouth status, and undergo nasogastric (NG) tube insertion. Other treatment may include antibiotics, antiemetics, analgesics, IV uids, and electrolyte monitoring. The most denitive treatment for cholecystitis is cholecystectomy, which is the surgical removal of the gallbladder. For patients who develop cholecystitis, prognosis is good with appropriate treatment. Complications of cholecystitis include biliary pancreatitis, perforation, and sepsis. Chronic cholecystitis may be a precursor to cancer of the gallbladder. The mortality rate for emergent cholecystectomy is 3% to 5%.

alcohol abuse in men than women. Black Americans are more likely than whites to develop pancreatitis. Congenital cystic brosis increases the risk of developing acute pancreatitis. Acute pancreatitis is caused by pancreatic enzymes that normally remain inactive while in the pancreas and leave the pancreas through the pancreatic duct to the duodenum to digest food. In pancreatitis, the enzymes become activated while still in the pancreas and begin to digest pancreatic tissue. Chronic abuse of alcohol or an obstruction of the pancreatic duct by gallstones are the most common causes of pancreatitis. Less common causes include exposure to drugs such as diuretics and pentamidine (an antiprotozoal medication). Symptoms of acute pancreatitis include sudden onset of epigastric pain, nausea, and vomiting. Serum analysis shows elevated pancreatic enzymes. Treatment consists of no food or drink and administration of IV uids and electrolytes. Pain relievers and antiemetics are also administered intravenously. Feeding the patient too soon will result in a relapse of inammation. The degree of pancreatic inammation can vary from mild to severe. In most patients it will resolve within a few days or weeks. However, in 5% of patients it may be so severe that multiple organ system failure, shock, and death occur. Assessment of the severity of pancreatitis is based on the evaluation of several factors. (See APACHE II.) These factors, along with liver function and abnormalities seen on a computed tomography (CT) scan, are used to determine prognosis.

Disorders of Nutrition
Nutritional disorders can arise from a food intolerance and an inability to absorb nutrients, as in celiac disease, or emotional disorders that compromise healthy eating habits, as

APACHE II
The acute physiology and chronic health evaluation II (APACHE II) system evaluates several factors to arrive at a numerical score. This score is compared to a severity scale that indicates the degree of pancreatitis. The factors evaluated include: body temperature heart rate mean arterial pressure respiratory rate serum creatinine and sodium levels arterial pH white blood cell count Glasgow coma scale age.

Acute Pancreatitis
ICD-9-CM code: 577.0 Acute pancreatitis is an inammation of the pancreas. It is most common in men over age 55, possibly due to a higher rate of

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in anorexia nervosa and bulimia. Strict dietary guidelines for patients with celiac disease can help them eat foods that are tolerated and ensure adequate nutrition. Nutritional disorders that are related to body dysmorphia, in which poor eating habits result from the patient thinking she is too fat, must be treated with physical and psychological therapies to restore the body. The medical assistant can assist the physician in treating a patient with a nutritional disorder by providing the patient with nutritional information and emotional support.

Celiac Disease
ICD-9-CM code: 579.0 Celiac disease, also called sprue or gluten enteropathy, involves an intolerance to the gluten found in wheat, wheat products, oats, and barley. The intolerance to these foods causes damage to the mucosal lining of the small intestine, which hinders nutrient absorption. Celiac disease is twice as common in women as in men and affects 1 in every 133 people in the United States. Although the exact cause of celiac disease is unknown, it may be the result of an immune response. Symptoms include abdominal distention, gas, anorexia, cramping, and steatorrhea, which is diarrhea of greasy, pale, foul-smelling stools. Other symptoms may include aphthous ulcers (small ulcers of the mouth), fatigue, and bone or joint pain. Eventually, symptoms of malnutrition related to malabsorption appear. Blood tests reveal elevated WBC count, platelet count, and IgA level as well as increased prothrombin time and albumin level. Radiographic studies of the upper gastrointestinal system and small intestine may reveal inammation of the mucosal lining. Denitive diagnosis is determined though tissue biopsy and improvement of symptoms while eating a gluten-free diet. A strict gluten-free diet is the major treatment for celiac disease. However, if symptoms persist despite a change in diet, the physician may prescribe corticosteroid medication to suppress inammation of the small intestines. Patients generally recover by strictly adhering to dietary guidelines. Complications may include osteoporosis, infertility, depression, and, later, development of abdominal cancer.

body image), obsession with food, and a compulsion to be thin. Malnutrition and weight loss may be mild or severe. Menstrual periods cease as body fat drops below normal. Diagnosis is based on health history, weight loss to lower than 15% of ideal body weight, and such behaviors as eating pattern, refusal to maintain normal weight, and an intense fear of gaining weight. An electrocardiogram (ECG) may reveal arrhythmias due to electrolyte imbalance. A team approach is vital to effective management of anorexia nervosa. Members of the team may include physicians, nurses, psychiatric-mental health professionals, and nutritionists. A primary goal is to restore normal body weight and healthy eating behaviors as well as a normalized body image. Underlying psychological issues must be addressed to prevent recurrence or worsening of symptoms. In severe cases, patients may be hospitalized for uid, electrolyte, and nutritional replacement. Prognosis is variable and depends on the adequacy and timeliness of interventions as well as the individuals acceptance of psychological therapy. Complications include heart failure, osteoporosis, and loss of muscle mass and strength. The mortality rate of 5% to 20% is higher than for any other psychiatric illness.

Bulimia
ICD-9-CM code: 307.51 Bulimia is a physical and psychiatric disorder. It involves a combination of obsessive eating of large quantities of food and purging behaviors. Bulimia most commonly affects women (80% of all cases) with 1% to 2% of all young women in America suffering from it. The underlying causes of bulimia are similar to those for anorexia nervosa, including such psychological issues as a feeling of lack of control. There may also be issues of depression, conict, anger, denial, and perfectionism. Binge and purge episodes are commonly triggered by emotional distress. The key characteristic of bulimia is an identied pattern of binge eating (eating large quantities of food at one time) followed by purging through self-induced vomiting, excessive laxative and diuretic use, and extreme exercise. Esophagitis and gingivitis may develop and teeth may begin to erode due to frequent exposure to stomach acids. Eyes may display small broken vessels from the stress of self-induced vomiting. Weight may be normal but commonly uctuates. Diagnostic criteria include a pattern of binging and purging more than twice per week for at least 3 months. Patients may lose muscle mass and suffer effects of low electrolyte levels, such as cardiac arrhythmias. In addition to psychological therapy, treatment for bulimia includes administration of antidepressants. Nutritional counseling and referral to a support group may also be helpful. Prognosis is variable and depends on the adequacy and timeliness of treatment interventions as well as the individuals

Anorexia Nervosa
ICD-9-CM code: 307.1 Anorexia nervosa is a physical and psychiatric disorder. It involves a combination of an intense fear of weight gain and severe, self-imposed restriction of food intake. Anorexia nervosa affects 0.5% to 1% of Americans, most commonly highly intelligent young women who are high achievers. The exact cause of anorexia nervosa is not well understood. There is a psychological component and there may be a genetic one as well. Characteristics of anorexia nervosa include self-imposed starvation, dysmorphia (a distorted

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acceptance of psychological therapy. Complications include heart failure and life-threatening hemorrhage caused by the rupture of esophageal vessels, the esophageal wall, or even the stomach.

Disorders That Commonly Cause Diarrhea

The causes of food poisoning and infection with Escherichia coli, Campylobacter, or Salmonella vary, yet all have the common key sign of diarrhea. Because health care providers begin the diagnostic process by considering a possible list of diagnoses, the physician will consider these disorders when a patient complains of diarrhea. Although the physician may use a variety of methods to conrm a diagnosis, in most cases, she will order analysis and culture of a stool specimen. All of these disorders put patients at risk for dehydration, which may become profound in some cases. Thus, measures to prevent or treat dehydration are a high priority. The medical assistant may need to instruct the patient on the proper technique for collecting a stool sample. She will also receive that sample from the patient and must adhere to OSHA guidelines regarding safety for storage and transport of body uids.

Food Poisoning
ICD-9-CM code: 005.9 Food poisoning is a common term for a number of illnesses. Another common term for this type of illness is dysentery. People of any age may be affected. Food poisoning is caused by the ingestion of food that has spoiled or is contaminated by bacteria, toxins, insecticides, lead, mercury, and other substances. Common bacterial causes include Campylobacter, Salmonella, and E. coli. Other causes include viral and parasitic infections. The major sign of food poisoning is diarrhea, which starts 2 to 6 hours after eating the offending food. Other signs and symptoms include abdominal cramping, vomiting, fever, weakness, and headache. The term food poisoning and its associated ICD-9-CM code is used to diagnose a condition when the signs and symptoms point to a food-borne illness but laboratory results identifying the offending organism are not yet available. Diagnostic tests include testing emesis and blood for the suspected pathogen. Treatment depends on the infecting organism but generally includes rest and fluids. Prognosis is generally good with a full recovery being the most common outcome.

dangerous strain of E. coli named O157:H7, which refers to chemical compounds found on the bacteriums surface. It produces toxins that can cause severe damage to the intestinal lining and bloody diarrhea. There are approximately 71,000 cases of E. coli infection per year in the United States. The most common source of E. coli O157:H7 is cattle; however, other mammals, domestic and wild, may also harbor it. People are usually infected by ingesting undercooked or raw hamburger as well as salami, alfalfa sprouts, lettuce, unpasteurized milk, apple juice, apple cider, and contaminated well water. Those swimming in contaminated water may also become infected. Those with mild infection may be asymptomatic. Symptoms of severe infection typically begin 2 to 5 days after exposure and include bloody diarrhea and abdominal cramps, nausea, and fatigue. Other symptoms may include low-grade fever and vomiting. Diagnosis is determined by symptoms and a stool culture. Conservative treatment for E. coli infection, including rest and oral uids, is usually sufcient. In severe cases, hospitalization is needed for IV rehydration and treatment of complications. Symptoms usually resolve within 8 days. Patients whose primary symptom is diarrhea usually recover completely. Those with more serious infections may suffer kidney impairment or failure and associated complications.

Campylobacter Infection
ICD-9-CM code: 005.8 Infection with the bacteria of the genus Campylobacter results in intestinal illness. According to the Centers for Disease Control and Prevention (CDC), nearly 212 million people are affected each year by bacterial diarrheal illness caused by Campylobacter. Persons most commonly affected are children under the age of 5 and young adults. There are several strains of the Campylobacter bacteria; however, C. jejuni is responsible for most cases of intestinal illness. It is spread by ingestion of contaminated food, most commonly undercooked poultry or drippings from raw poultry and contaminated water or raw milk. It may also be transmitted via infected animals and human feces. Those infected with Campylobacter may be asymptomatic but usually develop diarrhea (possibly bloody), abdominal cramps and pain, fatigue, and fever. Symptoms usually appear within 2 to 5 days of exposure. Other symptoms may include nausea and vomiting. Diagnosis is generally based on symptoms and culture of a stool specimen. Conservative treatment is usually sufcient and includes rest and uids. Most people recover fully after a week or so. However, those with a weakened immune system may develop septicemia. There are approximately 100 deaths each year from Campylobacter infection.

E. Coli Infection
ICD-9-CM code: 041.4 There are numerous strains of E. coli, many of which are harmless. Other strains are a common cause of intestinal and urinary tract infections. In 1982, the CDC identied a

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Salmonella Infection
ICD-9-CM code: 003.0 Salmonellosis is an intestinal infection caused by the Salmonella organism. Numerous types of this bacteria cause infections in animals and people. However, the species S. typhimurium and S. enteritidis are most common in the United States. An antibiotic-resistant strain known as S. typhimurium denitive type (DT) 104 is the next most common strain in the United States. Infections with Salmonella account for 1 billion dollars in direct and indirect health care costs. Outbreaks usually occur in small, contained segments of the general population or there may be large outbreaks in hospitals, restaurants, or facilities for children or the elderly. In North America and Europe, most outbreaks are reported, with approximately 40,000 cases being reported to the CDC annually. Infection is spread via contaminated reptiles and mammals, undercooked poultry and beef, eggs, and the contaminated feces of those who are infected. Other sources may include unwashed fruits and alfalfa sprouts grown in contaminated soil. Those infected with Salmonella develop symptoms within 12 to 72 hours and report fever, headache, diarrhea, and abdominal cramps. Other symptoms may include nausea, vomiting, and anorexia. Those most severely affected typically include the very young, the very old, and those with chronic illness or a weakened immune system. Diagnosis is based on symptoms and a stool culture. Treatment includes rest and uid replacement. (See Treating dehydration.) Antimicrobials are usually not needed. Severe cases may require hospitalization.

The illness usually lasts 4 to 7 days and most people recover fully without treatment. However, in some cases, severe diarrhea may result in dehydration and the need for hospitalization. A possible complication is septicemia. It is estimated that nearly 112 million people are infected annually, with 1,000 related deaths.

Cancers of the GI System

Cancer may develop anywhere in the GI system, although most malignancies occur in the mouth, esophagus, stomach, and colon as well as the pancreas and liver. Incidence varies with the type of cancer. Causes are variable, although tobacco use is a major contributor for nearly all types. Some forms of cancer commonly invade nearby structures by the time of diagnosis. Prognosis is generally poor in these cases. Diagnostics may include a variety of radiologic and laboratory tests. However, in most cases, tissue biopsy is needed to conrm diagnosis. Treatment nearly always involves surgical excision or resection if the cancer is still localized. However, once metastasis has occurred, surgery may only provide palliative value. Many patients also elect to undergo chemotherapy or radiation therapy for curative or palliative reasons. If patients with liver cancer qualify, they may undergo a transplant, cryoablation, or ethanol injection. With advanced malignancy of all kinds, palliative care is focused on pain relief, comfort, and maximizing function and quality of life.

Oral Cancer
ICD-9-CM code: 145.9 (mouth, unspecied) Oral cancer includes cancerous tissue changes of any oral structure, including the lips, tongue, gums, inner cheek, or mouth oor. Oral cancer makes up 8% of all forms of malignancy, with more than 30,000 new cases diagnosed each year. It is twice as common in men as in women, and most prevalent in those over age 40. However, an elevated incidence is also seen among young men who use chewing tobacco. Risk factors include use of chewing tobacco (80% of cases), alcohol use, poor oral hygiene, jagged teeth, and poorly tting dentures. The most common symptom of oral cancer is the development of white, patchy lesions or mouth ulcers called leukoplakia. These lesions fail to heal. Such lesions are usually nontender until late in the disease process. Other symptoms include dysphagia, bleeding, referred pain to the ear or jaw, and weight loss. Diagnosis is based on physical examination ndings and tissue biopsy. Staging is done via contrast-enhanced CT scan, which may also identify bone and cartilage invasion. Treatment depends on whether the cancer is localized or has spread. Surgery to remove cancerous tissue is common and may include lymph node dissection. Radiation therapy and chemotherapy are commonly used to destroy the remaining

Patient Education

Treating Dehydration
To help a patient prevent or treat dehydration, the medical assistant should encourage liberal intake of recommended uids and avoidance of uids that exacerbate dehydration.

Recommended Fluids
water fruit juice (diluted to reduce stomach irritation) electrolyte sports drinks (diluted to reduce stomach irritation) Jell-O popsicles broth.

Fluids to Avoid
caffeinated beverages alcoholic beverages.

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cancer cells after surgical resection. In some cases, hyperthermia (heat therapy) is used as well. Oral cancers tend to spread quickly and invade bone and liver and lung tissues. As a result, the 5-year survival rate for oral cancer is only 50%. More than 8,000 people in the United States die from oral cancer each year.

Esophageal Cancer
ICD-9-CM code: 150.9 Esophageal cancer develops in tissue cells in the lower esophageal lining. Such cancer is nearly always squamous cell carcinoma (SCC) but may be adenocarcinoma as well. SCC rates are highest in populations of Iran, Asia, and Africa. Adenocarcinoma rates are highest in Caucasians. Those most commonly affected are males over age 55. Risk factors for SCC and adenocarcinoma include alcohol and tobacco use, obesity, swallowing caustic substances, poor nutrition, and GERD. Underlying disorders, such as stricture (narrowing of the esophagus) and achalasia (persistent contraction of the esophagus), are also contributing factors. Early symptoms include dysphagia, weight loss, substernal pain, the sensation of pressure or burning, and hoarseness of the voice. Diagnosis is based on symptoms as well as x-rays, which reveal a mass, and barium swallow and tissue biopsy via upper endoscopy, which differentiate cancerous and benign lesions. Esophageal cancer is usually treated with surgery, chemotherapy, or radiation, depending on the stage of the cancer and the patients general heath. Surgery involves an esophagectomy (removal of the esophagus) or esophagogastrectomy (removal of the lower esophagus and upper stomach). Prognosis depends on how early the cancer is detected. There is a 30% rate of metastasis to the liver, bone, or lungs. If metastasis occurs, the prognosis becomes less favorable.

Diagnosis is based on symptoms, health history, and contrast barium study and gastroscopy, which provide a visualization of the tumor. A CT scan may be done to detect metastasis and stage tumors. Treatment of gastric cancer depends on staging. Surgery includes a partial or total gastrectomy, radiation, or chemotherapy. In half of all patients with gastric cancer, metastasis has occurred by the time of diagnosis. Recurrence after remission is common, with an overall 5-year survival rate of only 20%.

Colorectal Cancer
ICD-9-CM code: 154 Colorectal cancer is one of the most common types of cancer. It affects the large intestine and rectal area. Colorectal cancer is the second leading cause of cancer-related deaths in the United States, with nearly 150,000 new cases diagnosed each year. More than 90% of cases occur in persons over age 50. Risk factors include a history of inammatory bowel disease (IBD) and family history of colorectal cancer. Lifestyle factors may include sedentary lifestyle; a low-ber, high-fat diet; obesity; and alcohol and tobacco use. Patients are commonly asymptomatic in the early stage. Potential symptoms include a change in bowel elimination pattern, blood in the stools, abdominal pain, pallor, anemia, and intestinal obstruction. Diagnostic tests include fecal occult blood test to detect blood in stools and a barium enema and lower endoscopy with tissue biopsy to visualize a mass and obtain tissue for analysis. Treatment for colorectal cancer depends on the location and stage and includes surgery, chemotherapy, or radiation therapy. Newer forms of treatment also include medications that help to shrink cancerous tumors or inhibit blood ow to tumors. Among those who experience early detection, the survival rate is 90%. However, in 61% of cases, metastasis has occurred by the time of diagnosis. More than 50,000 people die each year from colorectal cancer.

Gastric Cancer
ICD-9-CM code: 151.9 Gastric cancer occurs in tissue cells of the stomach wall. Populations with the highest rates of gastric cancer include Japanese and African American men over the age of 50. Risk factors for the development of gastric cancer include Barretts syndrome (replacement of the squamous epithelium of the esophagus with columnar epithelium from chronic exposure to stomach acid), infection with H. pylori early in life, genetics, and diet. High-risk diets include those high in complex carbohydrates but low in fresh fruits, vegetables, and ber. People with gastric cancer are commonly asymptomatic. As the cancer advances, symptoms include weight loss, abdominal pain, nausea, vomiting, fatigue, dysphagia, feelings of fullness, anorexia, or abdominal mass. Melena (black, tarry stools caused by the digestion of blood in the gastrointestinal tract) can also be an indication of gastric cancer.

Liver Cancer
ICD-9-CM code: 155.0 Cancer of the liver is usually secondary to metastasis from other sites. Primary liver cancer is uncommon. Liver cancer is the number-one cause of cancer death in Africa and Asia and the fth most common cancer worldwide. It is becoming more common in the United States due to the prevalence of hepatitis B and C. Contributing factors include previous infection with hepatitis B or C. Particularly in patients with a history of chronic hepatitis B or C, the immune system attacks hepatocytes (liver cells) in an attempt to combat the virus. The repeated attack on liver cells can cause mutations in the cells and the formation of cancer. Hepatitis B and C infections contribute to 20% of all cases of liver cancer. Cirrhosis,

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resulting from alcohol abuse and exposure to toxins, contributes to 80% of liver cancer cases. Symptoms of liver cancer are similar to those of chronic liver disease and include abdominal pain, hepatomegaly, weight loss, poor appetite, ascites, splenomegaly, and jaundice. Liver function tests reveal elevated alpha-fetoprotein (AFP) over 500 g/L. Other diagnostic tests include CT or MRI scans, which reveal the presence of tumors. Biopsy for histological analysis may be done but is considered risky. Treatment of liver cancer commonly includes surgery to remove the tumor. Occasionally, the physician may consider liver transplantation. About 100 transplants occur annually for this reason. Other mainstays of treatment include chemotherapy and radiation therapy. Liver cancer commonly metastasizes to the bones, lungs, brain, peritoneum, and adrenal glands. If metastasis is present, prognosis is poor.

Gastroenterology Procedures
Gastroenterology is the study of the GI system, including all structures from the mouth to the anus. A physician who specializes in the diagnosis and treatment of diseases and disorders of the GI tract and accessory organs is called a gastroenterologist. The role of the medical assistant in the gastroenterologists office is to obtain vital signs and a health history and to assist with procedures. The medical assistant must have knowledge and understanding of the structure and function of the GI system. A thorough and complete history of the patients symptoms is necessary for the physician to make a diagnosis, including eating habits, bowel habits, and family history. The medical assistant may be expected to administer an enema, a procedure in which fluid is introduced into the rectum to stimulate bowel activity and cause emptying of the lower intestines. She will also be expected to provide patient instruction for further testing and health maintenance. The gastroenterologists office may have a standard form prepared for the medical assistant to fill in during the patient interview. (See Common GI interview questions.)

Pancreatic Cancer
ICD-9-CM code: 157.9 (part unspecied) Pancreatic cancer is a malignant tumor of the pancreas, 95% of which are adenocarcinomas, a tumor of the endocrine glands of the pancreas. The remaining 5% are tumors of the exocrine glands of the pancreas and are called serous cystadenomas. Pancreatic cancer, specically adenocarcinoma, is the fourth most common cause of cancer-related death in the United States, with 32,000 deaths per year. It is most common in men ages 40 to 60. Risk factors include family history of pancreatic cancer, high fat and meat diet, cigarette smoking, and a history of chronic pancreatitis or diabetes. Pancreatic cancer is commonly asymptomatic in the early stages and commonly goes undetected until it is advanced. Occasionally, pancreatic masses are detected when the patient is undergoing radiologic procedures for other purposes. Symptoms include abdominal pain, nausea, vomiting, weight loss, anorexia, jaundice, steatorrhea, hepatomegaly, weakness, fatigue, and diarrhea. Diagnosis is based on health history and physical examination ndings as well as abdominal ultrasound, CT scan, endoscopic retrograde pancreatography (ERCP), and a MRI scan, which enable visual conrmation of tumors. Blood testing includes liver function tests that may reveal elevated bilirubin and alkaline phosphatase, indicating bile duct obstruction (common in pancreatic cancer). A biopsy is required for denitive diagnosis. Surgery is generally useful only when pancreatic cancer is detected early or when the surgery is done for palliative purposes. Radiation and chemotherapy are commonly used. Although serous cystadenomas respond favorably to chemotherapy, the prognosis for pancreatic cancer from adenocarcinomas is very poor. Patients who elect to undergo high-risk surgery known as the Whipple procedure have a 5-year survival rate of only 10% to 25%. For those who do not have this surgery, the survival rate is just over 3%.

Assisting with Examination

The medical assistant working in the gastroenterologists ofce will assist with various procedures. Because such procedures are commonly invasive and require that the patient disrobe, the medical assistant should attempt to ease the patients anxiety by conveying a professional demeanor and attending to the patients modesty and comfort. Such procedures include stool specimen collection with a fecal occult blood test, exible sigmoidoscopy, and cleansing enema.

Common GI interview questions

The patient interview will vary depending on the medical specialty and the individual patient. Here are some common interview questions used during a gastrointestinal (GI) examination conducted at a gastroenterologists ofce: Describe your typical daily meals. How often do you have a bowel movement? Do you ever experience diarrhea or constipation? Do you ever experience difculty chewing or swallowing food? Do you ever experience heartburn? Do have pain before, during, or after eating? Does anyone in your family have stomach problems? Describe any stress you may have in your life.

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Stool Specimen Collection

A stool specimen is commonly difcult for a patient to collect, so thorough patient instruction is essential. To enable accurate detection of bacteria, viruses, ova, or parasites in stool, the collection must not be contaminated. Specically, urine will destroy microorganisms within the sample, so the patient must avoid allowing urine to enter the stool sample. The patient must use the sterile container and proper technique to avoid contamination. Proper patient education is vital to obtaining a useful sample. The medical assistant should instruct the patient to bring the stool sample to the ofce. She should then forward the sample to the laboratory for analysis. She must properly label the sample and refrigerate it if there is a delay in transport to the laboratory. (See Procedure 30-1: Instructing the patient on collecting a stool specimen.)

Fecal Occult Blood Test

A fecal occult blood test, sometimes referred to as a stool card, screens for hidden blood in a patients stool. Because blood should not be present in any part of the colon, rectum, or anus, its presence may indicate disease. Two days before
PROCEDURE 30-1

collecting the specimens, the patient must refrain from eating red meat or any food that contains red dyes and avoid intake of aspirin and aspirin products, vitamin C, and iron supplements. Intake of these things may lead to false-positive test results. The patient should also increase ber in his diet to promote a bowel movement. Patient instruction is essential for proper collection of the specimens. Although instructions are listed on the test cards, the medical assistant should instruct the patient on the collection procedure to promote understanding. She should also be sure to tell the patient that the stool specimens should not be collected during menstruation or if bleeding hemorrhoids are present. The patient collects a stool sample and smears a small amount on the test card three different times, after which he must bring the test cards to the ofce for evaluation or mail them. (See Figure 30-8.) If mailed, U.S. Postal regulations permit the cards to be mailed in the mailing pouch provided, not a standard envelope. If the patient brings the cards in, the medical assistant should conrm with the patient that he followed the dietary, vitamin, and medication restrictions during the collection of the samples before she performs the test. (See Procedure 30-2: Performing an occult blood test, page 560.)

Instructing a patient on collecting a stool specimen

Task Instruct a patient on how to collect a stool specimen. Conditions Specimen container with lid Laboratory request form Patients medical record Pen Plastic wrap Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully instruct a patient on collecting an adequate stool specimen for laboratory analysis. Performance Standards 1. Assemble the items next to the patient to show the patient the sample container. 2. Identify the patient and explain the physicians orders for a stool sample. 3. Instruct the patient to defecate onto the plastic wrap to avoid toilet water from mixing with the sample. 4. Instruct the patient to obtain 3 to 4 tablespoons of stool (to ensure a quantity sufcient for laboratory testing) from the plastic wrap and place it in the specimen container. 5. Explain to the patient that he should be sure to avoid getting any toilet paper or urine in the container because these items could interfere with test results. 6. Tell the patient to write his name and the date and time on the container to ensure proper identication and seal the container. 7. Tell the patient to bring the sample in the closed container to the ofce for laboratory testing. 8. To prevent the growth of bacteria that could interfere with test results, instruct the patient to keep the sample refrigerated if he cannot transport it to the ofce within 2 hours. 9. Ask the patient if he understands the instructions and answer any questions he may have to ensure patient understanding and promote accurate collection procedures. 10. Document in the patients medical record all patient education performed as well as the patients understanding of the procedure to ensure a complete, accurate medical record.
Date 05/26/08; 9:45 a..m. Verbal and written instructions for stool collection given to patient, pt. understands, states he will bring sample to the office tomorrow morning. ------------------------ C. Chapin, CMA

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SAMPLE

SAMPLE

SAMPLE

FIG 30-8 Fecal occult blood test cards.

Because the chances of a good prognosis increase with early detection, yearly exible sigmoidoscopy is recommended for all adults after age 50. When scheduling a patient for a exible sigmoidoscopy, the medical assistant must give the patient instructions on how to prepare for the examination. Those instructions should include having a light, low-residue dinner the day before the procedure or a clear liquid diet the entire day before the procedure, as directed by the physician. The physician may also indicate that the patient should have an enema the night before or the morning of the procedure. (See Cleansing enema at home.) The medical assistant may assist the physician with a exible sigmoidoscopy. During the procedure, she should be sure to promote the patients privacy and comfort. (See Procedure 30-3: Assisting with exible sigmoidoscopy.)

Cleansing Enema Flexible Sigmoidoscopy

A exible sigmoidoscopy is a procedure that uses a specialized exible scope, called a sigmoidoscope, to view the sigmoid colon and obtain biopsies of tissues that may be diseased. The examination helps diagnose cancer of the colon, polyps, tumors, ulcerations, and bleeding. Polyps are areas of swelling of the mucous membrane of the colon and can cause bleeding. Although they may be benign, they can become malignant later. Therefore, removal is best to prevent malignancy.
PROCEDURE 30-2

Although it is not a common procedure, sometimes the medical assistant will have to perform a cleansing enema to adequately prepare a patient for sigmoidoscopy. Patient home preparation for the sigmoidoscopy should clean out the colon. However, if the physician begins the rectal examination and finds that the colon is not sufficiently cleansed, a cleansing enema can be performed in the office prior to the sigmoidoscopy. (See Procedure 30-4: Performing a cleansing enema, page 562.)

Performing an occult blood test

Task Perform an occult blood test on a stool specimen. Conditions Nonsterile disposable gloves Hemoccult slides with stool samples (stool cards) provided by the patient Developer Timer or clock Biohazard bag Patients medical record Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully test a stool specimen for occult blood. Performance Standards 1. Wash your hands and apply gloves to ensure infection control. 2. Open the test side of the hemoccult paper slide. 3. Place two drops of developer onto the sections of the reagent paper. To avoid contaminating the slide, be sure to avoid touching the paper with the dropper. 4. Immediately begin timing for 1 minute. At 30 seconds, watch the slide for color changes around the edges of the stool sample. 5. Place an additional drop of developer between the positive and negative control areas to ensure that the controls are in good condition. 6. At 60 seconds, compare the test areas with the control area. 7. Record the results in the patients medical record. 8. Dispose of the cards and sample container in the biohazard bag to ensure infection control.
Date 10/16/08; 9:30 a..m. Hemoccult slides 1. pos, 2. pos, 3. neg, -------- W. Jones, CMA

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Patient Education

GI System Tests
Physicians commonly order laboratory tests to diagnose the cause of a patients intestinal complaint. If laboratory tests are inconclusive, more invasive testing may be required, including barium studies of the upper and lower GI tract and ultrasounds of the gallbladder and internal visceral organs.

Cleansing Enema at Home

In order to evacuate the bowel of feces, the physician will commonly order a cleansing enema for the patient. Most patients have never given themselves an enema and may be uncomfortable and unsure about the procedure. Thus, the medical assistant can teach the patient how to carry out this procedure at home. First, the medical assistant should advise the patient to buy a Fleet enema kit at the local pharmacy or give the patient the enema kit in the ofce. She should instruct the patient to follow the directions on the kit and emphasize these points: Take your time and have privacy for the procedure. Use an old towel to lie on to avoid ruining bedding. Warm the enema solution under running water, not in the microwave, to avoid overheating the solution. Apply a small amount of lubricant to the tip of the nozzle before insertion to make insertion easier. Lie on your left side, relax, and retain the solution for 5 to 10 minutes, as directed on the package. Then go to the toilet to evacuate the bowels.

Helicobacter Pylori
The presence of Helicobacter pylori in the stomach is the most common cause of ulcers. The physician who suspects H. pylori as the cause of gastric distress can order a blood test that will detect the presence of antibodies to H. pylori. If the blood test is inconclusive and the physician still suspects H. pylori, she can order a gastric biopsy to culture and grow the bacteria. The physician will order the less invasive blood test rst to avoid unnecessary patient discomfort.

Liver Function Test

A liver function test (LFT) is a blood test that determines the livers ability to perform its many complex functions. Enzyme levels found in serum, including aspartate aminotransferase (AST) and alanine aminotransferase (ALT), indicate damage to liver cells, biliary tract obstruction, and dysfunction. When liver cells die due to liver disease, these enzymes are released into the bloodstream. Elevated AST and ALT levels can

PROCEDURE 30-3

Assisting with exible sigmoidoscopy

Task Assist the physician and the patient during sigmoidoscopy. Conditions Nonsterile disposable gloves Flexible sigmoidoscope Water-soluble lubricant Sterile specimen container with preservative 4'' 4'' gauze squares Tissue wipes Drape Biopsy forceps Biohazard container Patients medical record Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist the physician in a exible sigmoidoscopy examination. Performance Standards 1. Wash or sanitize your hands to promote infection control. 2. Assemble supplies, making sure supplies are situated for easy access by the physician. Check the light source on the sigmoidoscope to ensure that it is working. 3. Greet and identify the patient and explain the examination procedure to ensure that the procedure is performed on the correct patient and that the patient will cooperate. 4. Ask the patient if he needs to empty his bladder prior to the examination. An empty bladder reduces pressure, making the examination more tolerable. 5. Give the patient a gown and drape and ask him to remove all clothing from the waist down. Instruct him to put the gown on with the opening in the back and sit on the examination table with the drape over his lap. 6. Knock before re-entering the room to ensure patient privacy while disrobing. 7. When the physician is ready to proceed, position the patient in the Sims (left lateral) position to provide access to the rectum. 8. Drape the patient so that the corner of the drape can be lifted to expose the anus to provide warmth and privacy.
Continued

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PROCEDURE 30-3contd

9. Ask the patient if he is comfortable. Ask him to breathe slowly and deeply to help him relax and encourage him to relax the muscles of the anus and rectum. 10. Lubricate the physicians gloved hand for ease of examination just before the digital rectal examination. 11. To ease insertion of the sigmoidoscope, lubricate the end of it before handing it to the physician. 12. Assist the physician with suction as required. 13. Ask the patient if he is comfortable to comfort and reassure him. 14. Assist the physician with collection of a biopsy as needed. Hand the biopsy forceps to the physician and hold the specimen container to receive specimens. Do not touch the inside of the container to avoid contaminating it. 15. Place the cover on the specimen container and place the container on the counter for transport to the laboratory. 16. When the examination is complete, apply clean gloves and clean the patients anal area with tissues to remove excess lubricant. 17. Remove your gloves and wash your hands to ensure infection control.

18. Assist the patient to a sitting position and allow him to rest to prevent postural hypotension and fainting. Ask him if he feels faint or dizzy. If he does, allow him to sit and observe him until he feels better to ensure patient safety. 19. Assist the patient off the examination table and allow him to dress and use the restroom so that the patient can expel air that was used to inate the colon during the procedure. 20. Prepare the laboratory requisition form and accompanying specimens to ensure their proper labeling. 21. Clean the examination room to ensure cleanliness for the next patient. 22. Document the procedure in the patients medical record.
Date 09/26/08; 9:45 a..m. Sigmoidoscopy with 1 bx of lesion on anterior wall at 7 inches, sent to lab. Pad placed over anal area for light bleeding. Patient instructed to call the office if bleeding continues. F ollow-up when lab results receieved. ---------------------------------------------------------------- S. Gonzales, CMA

PROCEDURE 30-4

Performing a cleansing enema

Task Perform a cleansing enema. Conditions Disposable nonsterile gloves Prepackaged disposable enema Water-soluble lubricant Mayo tray Towel Drape Tissues Patients medical record Pen Standard In the time specied and within the scoring parameters determined by the instructor, the student will successfully administer a cleansing enema. Performance Standards 1. Wash your hands to promote infection control and assemble supplies. 2. Explain the procedure to the patient to promote patient cooperation and understanding. (Note: Use an anatomical model or chart to explain the procedure to the patient if necessary.) 3. Ask the patient to disrobe from the waist down and put on a gown with the opening towards the back. Provide a drape and ask him to sit on the examination table with the drape across his lap. 4. Assist the patient into the Sims position (lying on his left side and bringing his right knee up towards the waist) to provide access to the rectum. 5. Remove the cover of the enema container and inspect the container to ensure that it is clean and there are no defects in the plastic that could cause discomfort. 6. Warm the enema solution to body temperature in warm water at the sink to make it easier for the patient to retain the solution. 7. Apply a small amount of lubricant to the tip of the container to ease entrance into the rectum. 8. Adjust the drape sheet to expose the buttocks.

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PROCEDURE 30-4contd

9. With one hand, separate the buttocks to expose the anus. Hold the enema bottle with the other hand and insert it into the anus. Point the tip of the bottle toward the patients abdomen to follow the direction of the rectum. 10. Advise the patient to breathe deeply and slowly and to relax his abdomen to enable instillation of the solution. 11. Squeeze the bottle slowly to promote relaxation and enable the patient to retain the solution and express all of the solution into the patients body. 12. Tell the patient that you will withdraw the enema tip and then do so slowly so that the patient is able to retain the uid. 13. Provide the patient with a tissue to hold against the anus to prevent leaking and ask him to retain the liquid as long as possible to promote cleansing of the bowel. 14. Discard the enema container and tissues in a biohazardous waste container because these items are contaminated with body uids.

15. Allow the patient to lie quietly for 5 to 10 minutes and then direct him to the restroom. Ask him to allow you to check the results before ushing them to ensure adequate cleansing. If the results seem inadequate, consult with the physician and repeat the procedure if necessary. 16. While the patient is in the restroom, clean the examination room in preparation for the examination or sigmoidoscopy. 17. Wash your hands to ensure infection control. 18. Document the procedure in the patients medical record.
Date 10/07/08; 11:45 a..m. Administered cleansing enema (fleet), Pt. tolerated procedure, good results, Pt. ready for sigmoidoscopy. ---------------------------------------------------- S. Gonzales, CMA

indicate liver dysfunction. Levels of ammonia and bilirubin found in blood are also commonly elevated in patients with liver dysfunction. The liver is also responsible for the synthesis of many blood-clotting factors; quantitative analysis of these substances can be used to assess liver damage. In addition to the blood test, the physician will observe the patient for liver dysfunction by the appearance of jaundice, a yellow discoloration of the skin due to an inability of the liver to eliminate bilirubin from the bloodstream. Further testing may include a liver biopsy if the LFT indicates dysfunction. (See Statin drugs and the liver, page 564.)

Upper GI X-ray
Because none of the structures of the GI tract are visible on x-ray, an upper GI x-ray involves the use of a contrast medium to help visualize organs. The medical assistant commonly schedules the procedures and sometimes assists during the procedure. The upper GI x-ray, also known as UGI, views the throat, esophagus, and stomach. The examination takes 15 to 20 minutes. During the procedure, the patient must drink barium, a radiopaque substance, to increase visualization of these structures. Many physicians now use a substance similar to Alka-Seltzer combined with a small amount of water prior to the barium to introduce air into the stomach. Doing so aids the visualization of the stomach and is referred to as a double contrast. As the patient drinks the barium, the radiologist or technician takes the x-rays. The radiologist observes a moving

picture of the ow of the liquid and takes radiologic lms for a permanent record. The radiologist will dictate ndings observed during the procedure. This test aids diagnosis of gastroesophageal reux disease (GERD), hiatal hernias, dilated esophageal veins called varices, strictures, and tumors. This procedure as well as other GI radiologic procedures is performed in radiologic ofces and outpatient departments of hospitals. The medical assistant should prepare the patient for the procedure by telling him to eat nothing after midnight the night before the test (npo) and to take no medications for GERD. She should be sure to explain that medications for GERD will not allow the physician to see how liquid ows down the esophagus and whether it goes into the stomach or is reuxed back to the esophagus. The medical assistant can provide cathartics, if ordered, for the patient after the examination to help the patient excrete the barium.

Lower GI X-ray
A lower GI x-ray involves visualization of the large intestine by rectal instillation of barium sulfate. The technician instills barium into the rectum and then insufates air into the colon to help the physician visualize the colonic mucosa. During the examination, the patient will feel a strong urge to defecate. The medical assistant can advise the patient to breathe through his mouth slowly and deeply. When the examination is over, the patient can use the toilet. The examination takes approximately 45 minutes and helps

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Patient Education

Gallbladder Ultrasound
Gallbladder ultrasound, also called gallbladder sonography, involves the use of sound waves with a frequency of 20,000 cycles per second. The ultrasound machine sends these sound waves into the abdomen in the area of the gallbladder to produce an image of internal body structures. Because gallstones are much denser than the gallbladder and adjacent organs, they are easy to see in the image produced. A gallbladder ultrasound can be conducted in a hospital or medical ofce setting. This procedure replaces the older gallbladder x-ray that required fasting for 12 hours and ingestion of several contrast media tablets the evening before the test. Although the gallbladder ultrasound requires the patient to fast for 12 hours before the test, it requires no contrast media. The medical assistant should tell the patient to fast for 12 hours before a morning appointment or have a fatfree liquid breakfast and no lunch for an afternoon appointment.

Statin Drugs and the Liver

One of the many functions of the liver is to manufacture cholesterol and send it to the bloodstream. HMG-CoA reductase inhibitors, commonly called statins, are used to lower cholesterol in patients who are at risk for cardiovascular disease. However, because statins inhibit production of enzymes that help make cholesterol, these drugs may cause irreversible damage to the liver. Patients taking these drugs, such as atorvastatin (Lipitor), must undergo liver function tests to help prevent damage to the liver. The medical assistant must be sure to provide proper patient education about dietary changes and increased exercise before the administration of lipid-lowering drugs to help avoid serious liver damage. The medical assistant can help her patient lower cholesterol without medications by encouraging him to: Increase dietary ber, such as oats, barley, legumes, and fruit. These brous foods can bind to cholesterol and bile in the intestinal tract and decrease their absorption. Increase physical activity, which has been proven to lower levels of low-density lipoprotein (LDL)the bad cholesteroland raise levels of high-density lipoprotein (HDL)the good cholesterol. Substitute soy for animal sources of protein, which has been proven to signicantly lower serum cholesterol. Consume alcohol in moderation. Drinking excessive amounts of alcohol is associated with liver stress and will elevate cholesterol. If overweight, lose weight to decrease blood cholesterol.

Chapter Summary

diagnose polyps, diverticula, colorectal cancer, inammatory bowel disease, and obstructions. This procedure is performed primarily in a hospital setting. To prepare the patient for a lower GI x-ray, the medical assistant should tell him not to eat dairy products and to follow a liquid diet for 24 hours before the examination. The patient must also take a bowel preparation the night before the test. The medical assistant can advise the patient to drink the bowel preparation and remain home for the evening to enable evacuation of the bowels. The medical assistant should also tell the patient to administer a home enema on the morning of the test and verify that the contents are clear. She should advise the patient to drink plenty of uids for 48 hours after the procedure to promote full evacuation of residual barium.

Structures of the GI system include the oral cavity, esophagus, stomach, and small and large intestines. The accessory organs of digestion include the liver, gallbladder, and pancreas. The functions of the GI system include the digestion, absorption, and elimination of food ingested. Medical assistants must be well versed in the language and vocabulary that pertain to the GI system. In addition to knowing common combining forms, they should be familiar with common abbreviations and pathological terms. Some of the most common disorders of the GI system include GERD, gastritis, peptic ulcer disease, IBS, hepatitis, cholecystitis (gallstones), and various cancers of the GI tract. Medical assistants prepare patients by assisting them as needed with undressing and positioning. They also assist the physician with examinations and procedures. Treatments for GI disorders vary and include medication, dietary changes, and surgery as well as psychotherapy for eating disorders. Diagnostic procedures include stool analysis, sigmoidoscopy, and such radiographic procedures as upper and lower GI x-ray and gallbladder ultrasound. Patient education is vital in diagnosing, treating, and managing disorders of the GI system.

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Team Work Exercises

1. Divide into teams of three to ve students. Each team must create poster illustrations or three-dimensional models of the GI system, including appropriate labels. The class or instructor can evaluate these posters to pick a winner based on accuracy, use of humor, creativity, or other criteria. 2. Divide into teams of three to ve students. Each team must create a patient education pamphlet about one of the cancers of the GI system described in this chapter. Pamphlets should include: a. incidence of cancer b. early detection testing c. risk factors, such as behaviors, nutrition, genetics, and so forth d. treatments available, including medical and alternative and complementary treatments e. prognosis. Teams must provide copies of their pamphlet to the rest of the class as well as friends and family members (who are not medically trained). Each team member must ask the friend or family member questions about the information presented and note areas of confusion or lack of understanding. The teams should discuss their ndings with each other and the class.

most likely source of his discomfort? What test will the physician likely order? 2. Gretchen Holmes is a medical assistant working in the scheduling department of a gastroenterologists ofce. A patient calls and states that she works in a restaurant where there has been an outbreak of hepatitis A. The patient wants to make an appointment within the next month. What should Gretchen tell this patient?

Resources

Case Studies
1. David Frenczik comes to the medical ofce complaining of pain in the epigastric region of his abdomen during the middle of the night. He states that he wakes with heartburn and discomfort almost every night. What is the

Dahlman, D., and Bland, J.: Why Doesnt My Doctor Know This? Conquering Irritable Bowel Syndrome, Inammatory Bowel Disease, Crohn Disease, and Colitis. Garden City, NY: Morgan James, 2008. Digestive Wellness (compact disc). American Media International, 2609 Tucker St. Extension, Burlington, NC 27215. Johnson, L.R.: Gastrointestinal Physiology, 7th ed. St. Louis: Mosby, 2006. Patient information on GI health: www.mayoclinic.com/ health/digestive-system/DG99999 Patient information on GI cancer: www.caring4cancer.com Patient information videos on GI health: www .everydayhealth.com/Publicsite/Healthology/VideoTopic.aspx? category=gi Sullivan, R. J., et al.: Digestion and Nutrition. New York: Chelsea House, 2006.

CHAPTER

Urology and the Male Reproductive System

Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell terms related to urology and reproduction identify key structures of the urinary and male reproductive systems describe the functions of the urinary and male reproductive systems describe the role of the medical assistant in urology identify common urological and male reproductive diseases and disorders list the main structures in the urinary and male reproductive systems identify patient education regarding diseases and disorders of the urinary and male reproductive systems list commonly used word elements related to the urinary and male reproductive systems give at least 10 examples of how new terms related to the urinary and male reproductive systems may be created by combining prexes, sufxes, and combining forms describe the medical assistants role in assisting with urological procedures list common tests done for urinary system diseases and disorders. General Competencies Patient Instruction
Provide instruction for health maintenance and disease prevention

31
Pyelonephritis Glomerulonephritis Bladder cancer Renal cancer Wilms tumor Hydronephrosis Polycystic kidney disease Renal calculi Acute renal failure Chronic renal failure Male Reproductive System Diseases and Disorders Benign prostatic hypertrophy Prostate cancer Testicular cancer Epididymitis Balanoposthitis Prostatitis Sexually transmitted diseases Erectile dysfunction

ABHES Competencies
Clinical Duties
Interview and record patient history Prepare patients for procedures Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries Collect and process specimens

Procedures
Teaching a patient to perform TSE Performing urinary catheterization

Chapter Outline
Structures and Functions of the Urinary and Male Reproductive Systems
Structures of the Urinary System Kidneys Nephrons Ureters, urinary bladder, and urethra Functions of the Urinary System Kidneys Nephrons Ureters, urinary bladder, and urethra Structures of the Male Reproductive System Functions of the Male Reproductive System

Urology and Male Reproductive Procedures

Assisting with Examination Catheterization Renal Computed Tomography Scan Intravenous Pyelography Cystoscopy Voiding Cystourethrography Creatinine Blood Urea Nitrogen Renal Angiography Vasectomy

CAAHEP Competencies
Clinical Competencies Patient Care
Prepare patients for and assist with routine and specialty examinations Prepare patients for and assist with procedures, treatments, and minor ofce surgeries

Medical Terminology Related to the Urinary and Male Reproductive Systems Common Urological and Male Reproductive Diseases and Disorders
Urinary System Diseases and Disorders Bacterial cystitis and urethritis

Chapter Summary Team Work Exercises Case Studies Resources

567

Key Terms
anuria

Absence of urine production

cystoscopy

Structures and Functions of the Urinary and Male Reproductive Systems

The urinary system consists of the kidneys, ureters, bladder, and urethra. It facilitates ltration of the blood, excretion of wastes, and regulation of uid, electrolytes, acids, and bases. Structures of the male reproductive system include the penis, urethra, testes, and scrotum as well as a series of ducts and glands. These structures play an important role in reproduction.

Visual examination of the bladder

dysuria

Painful or difcult urination

ltrate

Mixture of water, electrolytes, urea, and other small molecules rst ltered in the glomerulus
frequency

Need for frequent urination

hemodialysis

Articial means of removing urea, wastes, toxins, and excess uid from the blood
lithotripsy

Structures of the Urinary System

The structures of the urinary system include two kidneys, two ureters, the bladder, and the urethra. (See Figure 31-1.)

Treatment that uses shock or sound waves to crush stones in the kidneys or urinary tract
micturition reex

Kidneys
The key organs of the urinary system are the kidneys, which are located in the back of the abdominal cavity in the retroperitoneal space to either side of the vertebral column. The right kidney is slightly lower than the left. Each kidney is surrounded by a renal capsule made up of connective tissue and a thick layer of fat. The renal artery, vein, nerves, and ureter exit the kidneys on the medial side at the hilum. Both kidneys are highly vascular organs made up of an outer cortex and an inner medulla. Within the medulla are several oval-shaped renal pyramids, which point inward. Cupping the tip of each renal pyramid is a calyx. The area where all of the calyces join is called the renal pelvis. The renal pelvis narrows and joins the ureter.

Bladder reex that creates the urge to urinate

oliguria

Deciency of urine production

peritoneal dialysis

Dialysis in which the lining of the peritoneal cavity is used as the dialyzing membrane
renal colic

Pain that radiates from the ank into the abdomen or groin area
stent

Device that holds tissue in place and maintains an opening

urgency

Sudden, nearly uncontrollable need to urinate

urinalysis

Nephrons
Located primarily within the outer cortex are the nephrons. There are more than one million nephrons in each kidney. Each one is a microscopic, yet complex structure composed of an arteriole, venule, glomerulus (capillary cluster within the Bowman capsule), proximal tubule, loop of Henle, distal tubule, and capillary bed. (See Figure 31-2.)

Laboratory analysis of urine

urine culture

Growth and study of microorganisms isolated from a urine specimen

urinary catheterization

Procedure that involves insertion of a sterile drainage tube into the bladder to drain or withdraw urine
vasectomy

Ureters, Urinary Bladder, and Urethra

The ureters are long, narrow tubes that connect the renal pelvis of the kidneys to the urinary bladder. The bladder is a exible, muscular container for urine. The lining of the ureters and the bladder is uniquely designed to be exible in accommodating varying amounts of uid. At the base of the bladder is the exit into the urethra, a tube that varies in length, depending on the patients sex. The male urethra is approximately 20 cm long and the female urethra is approximately 4 cm long.

Procedure that involves removal of a segment of the vas deferens to achieve male sterilization

CHAP TER 31

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Right kidney

Left kidney

Ureter Ureter

Bladder

Urethra

FIG 31-1 The urinary system.

Functions of the Urinary System

Each structure of the urinary system is uniquely designed and suited to its purpose. The urinary systems main functions are to lter and excrete the waste products of digestion and metabolism from the body, help to regulate blood pressure, and maintain an optimal level of uid and electrolytes within the body.

optimal acid-base balance by retaining or excreting buffers and acids as needed.

Nephrons
The nephron has long been called the functional unit of the kidney because it is where most of the action takes place. To begin the ltration process, blood passes from a tiny arteriole into the glomerulus. The walls of the glomerulus and Bowman capsule are designed to permit optimal ltration of water, electrolytes, urea, and other small molecules. A large amount of this uid (approximately 180 L) called ltrate, is created each day. However, as it moves on through the proximal tubule, loop of Henle, and distal tubule, a majority (99%) of the water and useful solutes are reabsorbed and additional wastes are excreted. After the kidneys make nal adjustments in the composition of the uid, it is called urine. The kidneys produce and excrete an average of 1 to 2 L of urine each day.

Kidneys
The thick layer of fat in the renal capsule, which surrounds each kidney, acts as a shock absorber to cushion and protect the kidneys so that they may perform a key function of the urinary system. The highly vascular nature of the kidneys lends itself to this function, which is the ltration of blood for the elimination of wastes, excess uids, and the regulation of electrolytes. In fact, over 20% of the blood pumped by the heart each minute passes through the kidneys. When urine is formed, it drains into the calyces, which funnel the urine inward through the renal pelvis narrows and into the ureter, which, in turn, drains urine from the kidney to the urinary bladder. In addition to ltering uid and wastes from the body, the kidneys play active roles in maintaining blood pressure and blood pH (acidity or alkalinity). They help regulate blood pressure by retaining or excreting more uid and electrolytes (especially sodium). They help maintain an

Ureters, Urinary Bladder, and Urethra

Urine drains from the kidneys to the bladder via the two long, narrow ureters. In the bladder, urine accumulates until the volume reaches a level that stimulates stretch receptors. These receptors initiate the micturition reex, which is the urge to urinate. A person may temporarily ignore this urge. However, eventually, the increased level stimulates the

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Nephron

Kidney

FIG 31-2 The kidney and nephron.

stretch receptors again and the urge to urinate will be even stronger. The urethra functions as a passageway for nal urine elimination and emptying of the bladder. It serves a dual role in the male as a passageway for urine and for sperm mixed with seminal uid when ejaculation occurs.

Structures of the Male Reproductive System

The male reproductive system shares some structures with other body systems, including the penis and urethra, shared by the urinary system, and the testes, shared by the endocrine system. Other structures within the male reproductive system include the prostate gland, the scrotum, and a series of ducts and glands. (See Figure 31-3.) The scrotum is composed of two internal compartments surrounded by loose connective tissue and a smooth muscle layer. A second muscle group, called the cremasters, extends from the abdomen into the scrotum. Within the compartment of the scrotum are the testes. The testes are oval-shaped organs composed of an outer capsule made up

of thick, white connective tissue. The inner part is divided into 200 to 300 lobules, which contain the seminiferous tubules. From the testes to the urethra, a series of ducts connect to each other, beginning with the seminiferous tubules, then the rete testis, efferent ductules, epididymis, vas deferens, and, nally, the ejaculatory duct, which joins with the urethra. The urethra begins at the exit of the bladder and passes through the penis, ending at its tip. The penis is composed of three sections of erectile tissue and a distal, rounded end, which is the glans penis. A fold of skin commonly called the foreskin covers the glans penis. In many cultures, a procedure called circumcision is commonly practiced. In this procedure part or all of the foreskin is removed.

Functions of the Male Reproductive System

A primary function of the male reproductive system is reproduction. Sperm cells vital to this process are created and stored within the testes. They are sensitive to heat and

CHAP TER 31

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571

Vas deferens

Urethra

Penis

Scrotum

Testis

Prostate gland

FIG 31-3 The male reproductive system.

contracts to keep semen from entering the bladder and to keep urine from exiting the bladder. During arousal, the erectile tissue of the penis becomes engorged with blood and the penis becomes firm and erect to facilitate sexual intercourse and ejaculation. The state of erection ends with ejaculation or when sexual arousal diminishes. Secretions from a variety of sources contribute to the seminal uid. Mucus secretions from the bulbourethral glands and the inner urethral wall lubricate the urethra and neutralize its normally acidic environment. Seminal vesicles secrete fructose and other nutrients for sperm cells as well as prostaglandin, which stimulates smooth muscle contractions in the female reproductive tract, which is thought to help move sperm through that environment. The prostate gland secretes prostatic uid that ows through a number of ducts to the urethra and contributes an alkaline pH to help further neutralize the environment. A neutral environment is important to sperm motility because sperm need an environment that has a pH between 6.0 and 6.5 for optimal activity. Vaginal pH, by comparison, is normally between 3.5 and 4.0.

must live within an environment that is slightly less than normal body temperature. Therefore, prior to birth, the testes in the male fetus normally descend from the lower abdomen into the scrotum. The structures of the scrotum are designed to maintain an optimal temperature for spermatogenesis. In a cold environment, the smooth muscle of the scrotum and the cremaster muscles contract, bringing the scrotum and testes closer to the body to keep them warmer. In a warm environment, the same muscles relax and allow the scrotum and testes to descend away from the body to keep them cooler. Spermatogenesis takes place within the seminiferous tubules of the testes. When the spermatocytes have reached a sufcient stage of maturity, they exit the testes through a series of ducts and leave the body during ejaculation. The urethra serves a dual purpose as the exit passageway for urine and semen. However, both do not exit at the same time. During sexual activity, the internal urinary sphincter

Medical Terminology Related to the Urinary and Male Reproductive Systems

Urinary and reproductive disorders are common problems that lead people to seek medical care. Whether they work in family practice offices, urgent care centers, urology clinics, or other areas, medical assistants play an important role in the provision of health care to these patients. To be effective in their role, medical assistants must become well versed in the language and vocabulary that pertain to the urinary and male reproductive systems. The following tables list common medical terminology related to these systems.

Table 31.1 |

Word Elements

This table contains combining forms, prexes, and sufxes related to the urinary and male reproductive systems, along with examples of terms that use the word element, a pronunciation guide, and a denition for each. Element
Combining Forms bacteri/o balan/o bacteria glans penis bacteriuria (bak-te-re-U-re-a) balanitis (bal-a-NI-ts) Bacteria in the urine Inammation of the glans penis

Meaning

Example

Meaning

Continued

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Table 31.1 | Element

Word Elementscontd
Meaning Example
cystoscopy (ss-TOS-ko-pe) glomerulopathy (glo-mer-u-LOP-a-the) hematuria (he-ma-TU-re-a) hemolysis (he-MOL--ss) nephrolithiasis (nef-ro-lth-I-a-ss) nephrologist (ne-FROL-o-jst) renal (RE-nal) night decient testes nocturia (nok-TU-re-a) oliguria (ol-g-U-re-a) orchopathy (or-KO-pa-the) orchiectomy (or-ke-EK-to-me) orchidopexy (or-k-do-PEK-se) testomegaly (tes-to-MEG-a-le) peritoneum prostate renal pelvis pus sperm peritoneal (per--to-NE-al) prostatoplasty (pros-ta-to-PLAS-te) pyelonephritis (p-e-lo-ne-FRI-ts) pyuria (p-U-re-a) spermatogenesis (sper-mat-o-JEN-e-ss) aspermia (a-SPER-me-a) urethropexy (u-RE-thro-peks-e) urology (u-ROL-o-je) urinometer (u-r-NOM-e-ter) vasotomy (vas-OT-o-me)

Meaning

Combining Forms cyst/o glomerul/o hemat/o hem/o lith/o nephr/o ren/o noct/o olig/o orch/o orchi/o orchid/o test/o peritone/o prostat/o pyel/o py/o spermat/o sperm/o urethr/o ur/o urin/o vas/o Prexes anantidyspolyoligopretransSufxes -ary -cele -cidal pertaining to herniation killing, destroying urinary (U-r-nar-e) cystocele (SIS-to-sel) bacteriocidal (bak-ter-e-o-SI-dal) Pertaining to urine (or the urinary tract) Herniation of the bladder Killing bacteria without, absence of against painful, difcult many, much deciency before through, across anuria (an-U-re-a) antibacterial (an-t-b ak-TE-re-al) dysuria (ds-U-re-a) polyuria (pol-e-U-re-a) oligospermia (ol--go-SPER-me-a) prerenal (pre-RE-nal) transurethral (trans-u-RE-thral) Absence of urine (production) Pertaining to against bacteria Painful or difcult urination Much urination Condition of decienct sperm Pertaining to before the kidneys Pertaining to through or across the urethra vessel urethra urine stone kidney urinary bladder glomerulus blood Visual examination of the bladder Disease of the glomerulus Blood in the urine Destruction of blood Abnormal condition of kidney stones Specialist in the study of the kidneys Pertaining to the kidneys Urination at night Deciency of urine (production) Disease of the testes Surgical removal of the testes Surgical xation of the testes Enlargement of the testes Pertaining to the peritoneum Surgical repair of the prostate Inammation of the renal pelvis Pus in the urine Producing sperm Condition of no sperm Surgical xation of the urethra Study of disorders of the urinary tract Instrument for measuring urine Incision into a vessel

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Table 31.1 | Element

Sufxes -cyte -dynia -ectomy -gram -megaly -pathy -pexy -spasm -tic -tripsy -uria

Word Elementscontd
Meaning Example
spermatocyte (sper-MAT-o-st) urodynia (u-ro-DIN-e-a) prostatectomy (pros-ta-TEK-to-me) pyelogram (PI-e-lo-gram) prostatomegaly (pros-ta-to-MEG-a-le) nephropathy (ne-FROP-a-the) cystopexy (SIS-to-pek-se) urethrospasm (u-RE-thro-spazm) nephrotic (ne-FROT-k) lithotripsy (LITH-o-trp-se) oliguria (ol-g-U-re-a)

Meaning

cell pain surgical removal record enlargement disease surgical xation spasm pertaining to crushing urine

Sperm cell Painful urination Surgical removal of the prostate Radiological record of the kidneys Enlarged prostate Disease of the kidneys Surgical xation of the bladder Contraction of the urethra Pertaining to the kidneys Crushing of a stone Deciency of urine

Table 31.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to the urinary and male reproductive systems with a brief denition for each. Term
acute renal failure a-KUT RE-nal FAL-yer bacterial cystitis bak-TE-re-al ss-TI-ts balanoposthitis bal-a-no-pos-THI-ts benign prostatic hypertrophy be-NIN pros-TAT-k h-PER-tro-fe chronic renal failure KRON-k RE-nal FAL-yer Chlamydia trachomatis kla-MID-e-a tra-KO-ma-ts cryptorchidism krpt-OR-kd-zm diuresis d-u-RE-ss end-stage renal disease END STAG RE-nal d-ZEZ Abnormal secretion of large amounts of urine Enlargement of the prostate gland caused by noncancerous cellular proliferation; also called benign prostatic hyperplasia Progressive loss of the kidneys effectiveness in excreting waste products and regulating uid and electrolytes; also called chronic kidney disease Organism that causes many diseases, including genital infections in men and women

Denition
Sharp rise in the serum creatinine level of 25% or more that may last days or weeks or develop into chronic renal failure Inammation of the bladder due to bacterial infection; also called bladder infection Inammation of the glans penis beneath the foreskin

Condition in which the testicles fail to descend into the scrotum

Termination of the kidneys ability to regulate uid and electrolytes and excrete wastes, ending in death unless transplantation occurs

Continued

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Table 31.2 | Term

enuresis en-u-RE-ss epididymitis ep--dd--MI-ts

Pathologic Termscontd
Denition
Involuntary urination during sleep; also called bed wetting

Inammation of the epididymis

erectile dysfunction e-REK-tl ds-FUNK-shun fecal incontinence FE-kal n-KONT-n-ens glomerulonephritis glo-mer-u-lo-ne-FRI-ts glucosuria gloo-ko-SU-re-a gonorrhea gon-o-RE-a herpes simplex virus type 2 HER-pez SIM-plex VI-rus human papilloma virus HU-man pap--LO-ma VI-rus hydronephrosis h-dro-nef-RO-ss interstitial cystitis n-ter-STISH-al ss-TI-ts interstitial nephritis n-ter-STISH-al nef-RI-ts nephritic syndrome ne-FRIT-k SIN-drom nephrolithiasis nef-ro-lth-I-a-ss nephropathy ne-FROP-a-the nocturia nok-TU-re-a oliguria ol-g-U-re-a orchitis or-KI-ts overow incontinence O-ver-o n-KONT-n-ens phimosis f-MO-ss

Inability of a man to attain an erection adequate enough to achieve a satisfactory sexual experience; also called impotence Loss of control over bowel function

Form of nephritis in which the glomeruli are primarily affected

Glucose in the urine; also called glycosuria

Sexually transmitted infection caused by Neisseria gonorrhoeae

Virus that causes repeated eruptions of painful vesicles on the genitals and other mucosal surfaces and on the skin Genital wart virus that is specic to humans and is a common viral sexually transmitted disease Stretching of the renal pelvis as a result of obstruction to urinary outow

Chronic condition of inammation of the bladder lining

Pathologic changes in renal tissue that destroy nephrons and impair kidney function

Condition marked by increased glomerular permeability to proteins, resulting in massive proteinuria, edema, hypoalbuminemia, hyperlipidemia, and hypercoagulability Presence of kidney stones

Disease of the kidneys

Excessive need to urinate at night after going to bed

Deciency of urine production with an output less than 400 ml/day

Inammation of the testicle, usually caused by bacterial or viral infection; also called orchiditis Ineffective emptying of the bladder caused by nerve damage or other disorders, leading to urine leakage Stenosis of the foreskin opening so that it cannot be retracted back over the glans penis

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Table 31.2 | Term

Pathologic Termscontd
Denition
Any of several hereditary disorders in which cysts form in the kidneys and other organs, eventually destroying kidney tissue and function Inammation of the prostate gland

polycystic kidney disease pol-e-SIS-tk KID-ne d-ZEZ prostatitis pros-ta-TI-ts pyelonephritis p-e-lo-ne-FRI-ts sexually transmitted disease SEKS-u-al-e TRANS-mt-ed d-ZEZ spermatocele sper-MAT-o-sel stress incontinence STRES n-KONT-n-ens syphilis SIF--ls total urinary incontinence TO-tal U-r-nar-e n-KONT-n-ens uremia u-RE-me-a urethritis u-re-THRI-ts urinary retention U-r-nar-e r-TEN-shun varicocele VAR--ko-sel Wilms tumor VILMS TU-mor

Inammation of the kidney and renal pelvis, usually due to bacterial infection that has ascended from the urinary bladder Any disease that may be acquired as a result of sexual intercourse or other intimate contact with an infected individual; also called venereal disease Type of cyst that develops when the tubes that transport sperm become blocked

Involuntary urine leakage with physical stress, such as a cough or sneeze

Multistage infection typically transmitted through sexual contact caused by the spirochete Treponema pallidum Continuous and unpredictable loss of urine

Accumulation in the blood of metabolic by-products such as urea; also called azotemia Inammation of the urethra

Retention of urine in the bladder due to an inability to urinate

Presence of enlarged varicose veins within the scrotum

Rapidly developing cancerous tumor of the kidney that usually occurs in children; also called nephroblastoma

Table 31.3 |

Abbreviations

In urology, as in other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed here save time and effort in documentation and written communications. Abbreviation
ARF BPH

Term
acute renal failure benign prostatic hypertrophy; also called benign prostatic hyperplasia

Abbreviation
CRF

Term
chronic renal failure; also called chronic kidney disease

DRE ED ESRD GFR

digital rectal examination erectile dysfunction end-stage renal disease glomerular ltration rate

BUN CKD

blood urea nitrogen chronic kidney disease; also called chronic renal failure

Continued

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Table 31.3 |

Abbreviationscontd
Term
human papillomavirus herpes simplex virus intravenous pyelogram kidney, ureter, bladder parts hydrogen (acidity or alkalinity of a substance)

Abbreviation
HPV HSV IVP KUB pH

Abbreviation
PSA RP STD TSE TURP UA UTI

Term
prostatic-specic antigen retrograde pyelogram sexually transmitted disease testicular self-examination transurethral resection of the prostate urinalysis urinary tract infection

PKD

polycystic kidney disease

Common Urological and Male Reproductive Diseases and Disorders

There are innumerable diseases and disorders of the urinary and male reproductive systems. Some of the most common urological disorders include inammatory disorders, such as bacterial cystitis; disorders of obstruction, such as hydronephrosis; nephrotic syndrome; polycystic kidney disease; chronic renal failure; and various cancers of the urinary system. Common male reproductive disorders include benign prostatic hypertrophy, prostate or testicular cancers, sexually transmitted diseases, and erectile dysfunction.

Urinary System Diseases and Disorders

Bacterial Cystitis and Urethritis
CystitisICD-9-CM code: 595.9 (unspecied) UrethritisICD-9-CM code: 597.80 (unspecied) Bacterial cystitis is an inammation of the bladder. Urethritis is an inammation of the urethra. These conditions commonly coexist and together constitute a urinary tract infection (UTI), sometimes referred to as a bladder infection. UTIs are more common in women than men because women have a short urethra (about 11/2 (long), which allows microorganisms to ascend the urethra into the bladder more easily. Because of the males longer urethra, men have fewer UTIs than women. However, they have a higher incidence of urethritis, which is the most common type of sexually transmitted disease (STD) in men. Cystitis and other forms of UTIs are most commonly caused by bacterial invasion. The most common organisms involved are Escherichia coli, Enterobacter, Klebsiella, Proteus, and Pseudomonas. Other causes include such STDs as Chlamydia trachomatis, Neisseria gonorrhoeae, and herpes

simplex as well as other viruses, parasites, and fungi. Contributors to the development of cystitis and urethritis include poor hygiene and sexual activity, both of which increase the likelihood of microorganisms ascending into the urinary tract. Common symptoms of bladder inammation include urgency (need to urinate urgently), frequency (need to urinate frequently), and dysuria (pain, burning, or other discomfort during urination). Other symptoms may include fever, malaise, bladder spasms, pelvic or low back pain, and cloudy, pink, or foul-smelling urine. When urethritis is caused by an STD, urethral discharge may also be present. Diagnosis of UTI is usually based on the results of a urinalysis (laboratory analysis of the urine), which reveals bacteria and increased numbers of white and red blood cells. A urine culture, in which a laboratory examines the growth of microorganisms in a urine specimen under a microscope, may identify the causative organism. A culture of urethral discharge may also identify whether an STD is involved. Treatment of UTI depends on the underlying cause. In the case of bacterial infection, the physician will prescribe antibiotics. Other treatment includes phenazopyridine (Pyridium), which is a urinary tract analgesic; general analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs); and uids to help ush the urinary tract. To help treat UTIs and to help prevent reoccurrence, the medical assistant should encourage the patient to empty her bladder soon after sexual intercourse, drink plenty of uids (6 to 8 glasses of water each day), and drink uids that acidify the urine and inhibit bacterial growth, such as cranberry juice. Other measures include wiping from front to back after defecation, avoiding tight-tting clothing (which harbors moisture), and conducting routine daily hygiene. (See Treating and preventing UTI.) Prognosis for UTI is good with timely diagnosis and treatment. (See Quick urinalysis.) Complications develop

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Patient Education

Treating and Preventing UTI

The medical assistant teaching a patient with a urinary tract infection (UTI) about treatment and prevention should be sure to include these points. Take medications as prescribed by your physician. Take prescribed anti-infective medication until it is gone. Do not stop taking it as soon as you feel better.

Treatment
If you think you may have a UTI, see your health care provider, who will take a brief health history, collect a urine specimen, and, possibly, conduct a physical examination. Drink lots of healthy uids, such as water and juice, to help remain well hydrated and ush the urinary tract. Be sure to drink cranberry juice, which helps make your urine more acidic and, therefore, less hospitable to bacteria.

Prevention
Continue drinking lots of uids daily unless told otherwise by your physician. Urinate soon after sexual intercourse. Wipe from front to back after bowel movements. Avoid wearing tight-tting undergarments that harbor moisture. Follow additional advice of your physician.

Front ofceBack ofce connection

Quick Urinalysis
In many medical ofces, if a patient complains of symptoms that could be caused by a UTI (pelvic or back pain, dysuria, urinary frequency, and so forth), the administrative medical assistant will instruct the patient to collect a urine specimen as soon as she checks in. Doing so enables the clinical medical assistant to conduct a quick urinalysis while the patient awaits examination. Because the results are available for the physician to review at the time of examination, he can make a more timely diagnosis and initiate early treatment. When the administrative and clinical medical assistants can provide specimen collection instructions and equipment to the patient, the physician is able to meet the highest standard of care.

most common offender is E. coli. Other causes include tumors, kidney stones, and severe prostate enlargement or other obstructions that impede urine ow and create inammation, causing an environment conducive to bacterial growth. Signs and symptoms of pyelonephritis include sudden onset of fever, chills, nausea, and ank pain. These signs and symptoms are commonly preceded by signs of bladder infection. Diagnosis is based on the patients signs and symptoms and the result of urinalysis and urine culture, which reveal the presence of bacteria, casts, WBCs, and RBCs. Radiologic studies reveal enlarged, swollen kidneys. Treatment includes IV, IM, or oral antibiotics as well as analgesics and uids. Prognosis is usually good with early intervention, although chronic infection may lead to kidney damage.

Glomerulonephritis
ICD-9-CM code: 580 (acute), 582 (chronic) Acute glomerulonephritis is the inflammation of the glomeruli within the kidneys. Chronic glomerulonephritis is a noninfectious disease that progresses slowly and leads to permanent kidney damage and kidney failure. The cause of glomerulonephritis is unclear. However, it most commonly follows 1 to 2 weeks after an upper respiratory infection caused by some strains of streptococci. Signs and symptoms of glomerulonephritis include hematuria (bloody urine), which may not be apparent to the naked eye or it may be signicant enough to turn the urine a dark rust-brown or red color. Urine may also appear foamy. Other manifestations include ank pain, general malaise, anorexia, and low-grade fever. Individuals with chronic glomerulonephritis are commonly asymptomatic. Eventually, they

when bacterial organisms enter other parts of the urinary tract, causing nephritis, pyelonephritis, prostatitis, and other types of infections.

Pyelonephritis
ICD-9-CM code: 590.80 Pyelonephritis is the inammation of the renal pelvis and connective tissues. It can affect one or both kidneys. Pyelonephritis is more common in women than men because their shorter urethra makes it easier for bacteria to be introduced into the bladder. Pyelonephritis is most commonly caused by bacterial infection from pathogens that ascend the urinary tract. The

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begin to experience hypertension, hematuria, proteinuria, oliguria, azotemia (buildup of urea in the blood), malaise, nausea, vomiting, dyspnea, pruritus, and edema as renal failure progresses. Diagnostic tests for acute and chronic glomerulonephritis are the same. Urinalysis may indicate blood, WBCs, casts, protein, or other abnormalities. Blood tests indicate elevated blood urea nitrogen (BUN), increased erythrocyte sedimentation rate (ESR), and decreased serum protein. Radiological studies may reveal kidney enlargement. Treatment of acute glomerulonephritis may include antibiotics if streptococcal infection is still present. With both disorders, treatment measures aim to control hypertension and prevent or delay renal failure. The physician may also recommend dietary restriction of protein, sodium, and uids. Patients with chronic glomerulonephritis may ultimately require dialysis or kidney transplantation.

Bladder Cancer
ICD-9-CM code: 239.4 Bladder cancer is the most common form of urinary tract cancer. Most tumors develop in the bladder lining, while more invasive tumors develop in the muscle. Transitional cell carcinoma is most common in industrialized countries and squamous cell carcinomas caused by parasitic infestations are most common in developing countries. Bladder cancer is the sixth most common type of cancer and is most common in industrialized countries such as the United States, Canada, and France. Over 50,000 Americans are diagnosed with it each year and more than 12,000 die. The incidence increases with age, especially over age 55. It is three times more common in men and is more common in the Caucasian population. The cause of bladder cancer is unknown. However, there are many contributors and risk factors, including exposure to tobacco smoke, radiation, arsenic, and other carcinogens; advanced age; chronic bladder inammation; high-fat diet; genetics; male gender; and a history of Schistosoma haematobium parasitic infection. Persons at increased risk due to workplace exposures include truck drivers, machinists, printers, painters, hair dressers, and those working in the rubber, metal, leather, textile, and chemical industries. The most common symptom of bladder cancer is hematuria (blood in the urine). Bladder cancer is generally painless and may not be obvious in early stages. Other symptoms may include urinary frequency and dysuria. Diagnosis is based on urinalysis and diagnostic imaging. Urinalysis rules out infection and identies the presence of blood and abnormal cells. Intravenous pyelogram (IVP) enables better examination of all structures within the urinary tract. Cystoscopy allows visual examination of the inner bladder wall and the opportunity to take a tissue sample for biopsy, which is used to conrm the diagnosis. The physician will stage the cancer

according to the tumor, node, metastasis (TNM) system. Other diagnostic tests used to determine the extent or stage of the cancer may include computed tomography (CT) scan, magnetic resonance imaging (MRI), bone scan, and ultrasound. Newer tests identify tumor markers, which are substances released by tumors. These tests are still under investigation. Treatment varies for each patient, depending on cancer type, stage, and other health factors. Interventions include surgery, radiation, chemotherapy, immunotherapy, or a combination. Surgery may be as simple as transurethral excision of a small lesion or as complex as the surgical removal of the entire bladder, nearby lymph nodes, some of the reproductive organs or structures, and surrounding tissue. Prognosis for bladder cancer is guarded. The 5-year survival rate for supercial bladder cancer is 85%. However, those with more invasive forms have a poorer prognosis and those with identied metastasis have a 5-year survival rate of just 5%. Because there is a high rate of recurrence, follow-up examinations, including cytology (study of tissue cells) and cystoscopy, are recommended every 3 months for 2 years and then every 6 months for another 2 years. Complications of bladder cancer and its treatment include anemia, urinary incontinence, and metastasis to other organs.

Renal Cancer
ICD-9-CM code: 189.0 Renal cancer is cancer of the kidneys. It includes renal cell carcinoma and renal pelvis carcinoma. It also includes Wilms tumor, which is a common type of kidney cancer that develops in young children. An estimated 32,000 Americans are diagnosed with renal cancer each year and an estimated 12,000 people die from renal cancer each year. It most commonly affects elderly individuals between ages 50 and 70 and affects men more than women. The specic cause of renal cancer is not clear. However, there are a number of known risk factors, including being age 60 or over, male, or African American; using tobacco (especially pipes and cigars); being obese; having hypertension; or undergoing exposure to such toxins as solvents, asbestos, and radiation. Individuals with a history of bladder cancer and those who undergo long-term dialysis are also at increased risk. Patients with renal cancer are commonly asymptomatic in the early stages. In later stages, the patient may experience hematuria, back pain, weight loss, fatigue, and intermittent fever. The diagnostic process begins with routine blood and urine tests, which help the physician determine current kidney function and provide baseline data to help measure the patients response to therapy. A complete health history and physical examination reveal signs and symptoms associated

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with renal cancer. Such radiologic studies as IVP, ultrasound, CT, and MRI can create detailed images of the kidneys and bladder and may detect unusual masses. Tissue biopsy, sometimes required for denitive diagnosis, reveals cancer cells. Treatment of renal cancer includes partial or total nephrectomy via laparoscopy or more traditional surgery. When surgery is not possible, another treatment option is arterial embolization, in which the surgeon injects material to clog the main vessel leading to the kidney. This clog robs the tumor of nutrients and oxygen and relieves pain and bleeding. Radiation therapy may target and kill cancer cells and relieve the pain of metastatic cancer. Other forms of treatment include immunotherapy and chemotherapy. Prognosis for those with renal cancer is variable and depends on the stage at the time of diagnosis. In general, the 5-year survival rate is 55%. However, those with stage 1 cancer have a 5-year survival rate of 94%. Those with stage 2 cancer have a 5-year survival rate of 65% to 75%. Those with stage 3 have a 5-year survival rate between 40% and 70%. The prognosis for those with stage 4 cancer is poor, with a 5-year survival rate of only 10%.

surrounding tissue. Prognosis for Wilms tumor has improved substantially in recent decades and survival is currently around 90%. Outcome is best when only one kidney is involved.

Hydronephrosis
ICD-9-CM code: 591 Hydronephrosis is not a disease but a condition. Bilateral hydronephrosis affects both kidneys. It occurs in infants, children, men, and women. Hydronephrosis is caused by obstructed urinary outow in which tissues of the renal pelvis are stretched due to pressure from urine accumulation. Thus, it may be caused by anything that obstructs urine outow. It occurs in infants and children due to congenital defects. It occurs in adults due to a variety of obstructive causes, including complications of pregnancy in women and prostate enlargement in men. Obstruction may be complete or partial, unilateral (one-sided) or bilateral. Common causes of obstruction in unilateral hydronephrosis include kidney stones, blood clots, tumors, ureteral strictures or other malformations, and parasitic infestations. Causes of bilateral hydronephrosis include benign prostatic hypertrophy (BPH), neurogenic bladder, pregnancy, bladder cancer, urinary tract inammation, and congenital malformations. Patients with hydronephrosis are commonly asymptomatic unless kidney stones are the cause. In the case of kidney stones, patients complain of severe loin or ank pain that sometimes radiates into the lower abdomen or groin. If kidney failure develops, symptoms associated with kidney failure are present. Radiologic tests, which may include ultrasound, IVP, and, occasionally, MRI, reveal dilation of the renal pelvis and obstruction. Blood tests may reveal creatinine and electrolyte imbalances. Urine pH may become more alkaline. In cases of complete obstruction, the kidney may be palpable on physical examination due to enlargement. Treatment of hydronephrosis is aimed at the underlying cause, with an emphasis on restoring urine flow. The physician may order renal function studies to monitor kidney function. In the case of kidney stones, the physician may perform lithotripsy, a procedure in which shock waves or sound waves crush stones in the kidneys or urinary tract. The physician may also prescribe surgery to remove lodged stones or tumors or to place a stent (device used to hold tissue in place and maintain an opening) for urine drainage. Treatment for obstruction in the bladder outlet includes insertion of a urinary or suprapubic catheter or prostate surgery. Treatment of obstruction caused by an enlarged prostate gland usually involves prostate surgery. If removal of the obstruction occurs in a timely manner, hydronephrosis resolves spontaneously. If restoration of

Wilms Tumor
ICD-9-CM code: 189.0 Wilms tumor, also known as nephroblastoma, is a rapidly growing type of kidney cancer that most commonly affects children between the ages of 1 and 5. Usually only one kidney is cancerous. Wilms tumor develops from immature kidney cells that multiply and grow in an abnormal manner. There is a genetic component in some cases and the condition is commonly associated with other genetic anomalies (abnormalities). Patients with Wilms tumor may be asymptomatic in the early stages. An abdominal mass is a common nding that may be detected by the parent when bathing or dressing the child or by the physician upon physical examination. Signs and symptoms include hematuria, weight loss, constipation, nausea, vomiting and abdominal pain, fever, anorexia, and malaise. Diagnosis is based on physical examination, family medical history, tests of urine and blood, and diagnostic imaging. MRI, CT scan, and ultrasound are used to locate and create visual images of the tumor or other structural abnormalities. Treatment of Wilms tumor includes surgery, chemotherapy, bone marrow transplant, and radiation therapy. As with most types of cancer, the physician will order analysis of tissue cells for staging in order to determine the most appropriate course of treatment. Surgery usually includes partial or complete nephrectomy (surgical removal of the kidney) and may include removal of local lymph nodes and other

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urinary ow does not occur, kidney tissues dilate and atrophy and chronic renal failure may occur.

Polycystic Kidney Disease

Congenital PKDICD-9-CM code: 753.13 Autosomal dominant PKDICD-9-CM code: 753.13 Autosomal recessive PKDICD-9-CM code: 753.14 Polycystic kidney disease (PKD) is a group of hereditary, progressive disorders in which cysts (small sacs of uid) form in the kidneys, eventually destroying them. Other organs may be affected, including the liver, heart, pancreas, and brain. One form of PKD usually appears early in childhood and is more severe than another form, which develops later in life. Polycystic kidney disease is the most common life-threatening hereditary disease in the United States, affecting approximately 600,000 persons. Approximately 12.5 million are affected worldwide. Incidence is higher in men, African Americans, and persons with sickle-cell disease. PKD disorders are inherited. Autosomal recessive polycystic kidney disease (ARPKD) is more rare and deadly than autosomal dominant polycystic kidney disease (ADPKD). Children of parents with PKD have a 50% chance of getting the disease. Onset of ADPKD is usually in middle age. Signs and symptoms of ARPKD are commonly present at birth or become apparent in early infancy. The most common signs of PKD include hypertension, hematuria, frequent kidney infections, and back or side pain. Diagnosis usually occurs after the individual begins to experience symptoms. Ultrasound and CT scan create images of the kidneys and detect the presence of cysts. Genetic testing helps denitively diagnose PKD. There is no cure for PKD. Treatment includes measures to improve comfort and may include kidney dialysis and kidney transplant. Many adults with PKD may be able to lead a normal or near-normal life. However, complications can occur, including hypertension, cerebral aneurysm, and renal failure. About half of those with ADPKD will develop end-stage renal disease (ESRD) by the age of 60.

is gout, which causes abnormal metabolism of uric acid. Other contributors include hyperparathyroidism and Crohn disease. Hyperparathyroidism affects serum calcium levels, increasing the likelihood of calcium stones. Crohn disease causes malabsorption of bile salts and fat, increasing likelihood of calcium oxalate kidney stones. Dietary contributors include excessive intake of calcium, vitamin D, oxalates, and alkali. Patients with renal calculi are commonly asymptomatic when stones remain in the kidneys. However, when a stone moves into and obstructs a ureter, the patient experiences sudden onset of intermittent, severe pain caused by spasm of the involved ureter. The pain, which commonly radiates downward from the ank into the abdomen or groin area, is known as renal colic. Other symptoms include chills, fever, hematuria, and urinary frequency. Preliminary diagnosis is based on the patients signs and symptoms and the presence of blood in the urine. The presence of renal stones is confirmed by such radiologic tests as CT scan, ultrasound, IVP, MRI, and abdominal x-rays. Conservative treatment of renal calculi includes opiate analgesics for pain, uids, and smooth muscle relaxants, with the goal of enabling the patient to pass the stone in his urine. However, if the stone is too large or if the ureter is completely blocked, the physician may order surgery to remove the stone. Lithotripsy, another treatment option, involves the use of ultrasound to disintegrate the stone. (See Figure 31-4.) Most patients are able to pass kidney stones without permanent damage. However, complete obstruction may result in hydronephrosis and potential failure of the involved kidney. Risk of recurrence is estimated at 50%.

Acute Renal Failure

ICD-9-CM code: 584 Acute renal failure (ARF) is an acute rise in the serum creatinine level of 25% or more and decreased GFR. It may last days or weeks or may develop into chronic renal disease. Approximately 3 million persons develop communityacquired ARF, meaning that it developed prior to hospitalization. A larger number of hospitalized patients develop hospital-acquired ARF. Highest rates are among those admitted to critical care and are related to advanced age, severity of illness, volume depletion, and exposure to nephrotoxic substances such as medications. Men and women are affected equally. ARF occurs when the kidneys rapidly lose function due to some type of damage. As a result, the body retains waste products such as urea and creatinine that are normally excreted. There are many causes of ARF, which are categorized as prerenal, renal, and postrenal, depending on the physical location of the problem. Prerenal failure involves inadequate blood ow to the kidneys. Causes include hypotension caused by

Renal Calculi
ICD-9-CM code: 592 Renal calculi, also called kidney stones, are composed of mineral salts and cause problems when they obstruct portions of the kidneys or, more likely, a ureter. An estimated 2% to 5% of Americans develop kidney stones at some time in their lives. Caucasian males between the ages of 40 and 70 are most commonly affected. Persons with gout, hypercalcemia, hyperparathyroidism, or inammatory bowel disease are at increased risk. The cause of renal calculi is not fully understood in every case. One cause is hypercalciuria, an inherited condition in which excessive calcium is excreted into the urine. Another

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Kidney Kidney stones Monitor ECG

Ureter Water bags Kidney stone BEFORE TREATMENT

Water column

Shock-wave generator Ellipsoidal reflector

Smaller pieces pass out of body in urine

AFTER TREATMENT

FIG 31-4 Lithotripsy.

hemorrhage, severe burns, shock or severe dehydration, liver failure, and renal vein thrombosis secondary to nephrotic syndrome. In renal failure, injury to the kidney, glomeruli, or tubules occurs. Causes of renal failure include pyelonephritis, some medications or toxins, and diseases that may damage the kidneys, such as sickle-cell disease, systemic lupus erythematosus, and multiple myeloma. In postrenal failure, an obstruction to urine outow occurs. Causes include prostatic enlargement, kidney stones, and prostate cancer. Common symptoms of ARF include oliguria (decient urine production) or anuria (absence of urine production), generalized edema, altered mental status, tremors, anorexia, metallic taste in the mouth, easy bruising or bleeding, ank pain, fatigue, hypertension, and seizures. Diagnosis is based on elevated creatinine or blood urea nitrogen (BUN) values in an ill, oliguric patient. Abdominal or kidney ultrasound is the most common radiological test but others may include x-ray, CT scan, or MRI, which rule out obstruction. Treatment of ARF is aimed at identication and treatment of the underlying cause. In many cases, the condition resolves

spontaneously after the underlying cause is alleviated, such as removal, destruction, or passage of a kidney stone. Treatment also includes careful monitoring of uid intake and output and electrolytes and administration of diuretic medications. The physician may also order diet modications to increase carbohydrates and limit protein, sodium, and potassium intake, while ensuring adequate calories and nutrients. In some cases, temporary dialysis is also necessary. There are two forms of dialysis: hemodialysis and peritoneal dialysis. Hemodialysis involves sending a patients blood through tubes within a dialysis machine comprised of selectively permeable membranes. Just outside of the tubes is dialysis uid which is somewhat similar in composition to human blood without the blood cells or waste products. Wastes along with excess uid and electrolytes move from the blood across the membrane into the dialysis uid and the machine returns the clean blood to the patients body. Peritoneal dialysis is similar to hemodialysis except that the lining of the patients peritoneal cavity (abdomen) is used as the dialyzing membrane. In this process, a nurse infuses

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dialysis uid through a tube inserted in the patients abdomen. Wastes then diffuse from the patients blood vessels beneath the peritoneum, across the membrane, and into the dialysis uid. After a specied period of time, usually 1 to 2 hours, the nurse removes the uid. Renal failure requires careful treatment and is potentially life-threatening. The mortality rate for hospital-acquired ARF is as high as 70% but is much lower for other groups. Infants and children with ARF have a 25% mortality rate. Some individuals may develop chronic renal failure, requiring ongoing dialysis or a kidney transplant. However, most individuals recover within several weeks or months.

Glomerular ltration rate (GFR) is considered the most reliable indicator of renal function and is used to track the disease. Normal GFR varies by age and ranges from 116 ml/minute for patients around age 20 to 75 ml/minute for those age 70 or older. The National Kidney Foundation has categorized the severity of chronic kidney disease into ve stages:

Chronic Renal Failure

ICD-9-CM code: 585 Chronic renal failure (CRF), also called chronic kidney disease (CKD), is dened as the progressive loss of the kidneys effectiveness in excreting waste products and regulating uid and electrolytes. An estimated 20 million individuals in the United States suffer from some degree of CRF and numbers are on the rise. The number of individuals with renal failure severe enough to require chronic dialysis or transplantation in 1999 was 340,000. However, it is estimated that by the year 2010, the number will be over 650,000. The United States has the highest rates of end-stage renal disease (ESRD), with the highest rates in the African American population. Japan follows in second place. At increased risk are elderly patients and patients with diabetes or hypertension. Chronic renal failure develops slowly over a period of years and may result from any number of diseases that cause kidney damage. The most common causes are diabetes and hypertension, which cause at least two-thirds of all cases. Other causes include polycystic kidney disease, glomerulonephritis, analgesic nephropathy (damage caused by long-term use of analgesics, such as NSAIDs and acetaminophen), and various types of urine outow obstruction. Risk factors include a family history of diabetes or renal failure. Also at increased risk are elderly persons and African American, Hispanic, Native American, and Pacic Islander populations. Progression of CRF is commonly so gradual that symptoms are not evident until 90% of kidney function is lost. Symptoms are related to the development of uremia, which is the presence of increased nitrogenous waste products, especially urea, in the blood. Initial symptoms include nausea, vomiting, weight loss, fatigue, malaise, generalized pruritus, headache, and frequent hiccups. Later symptoms include oliguria, nocturia, easy bleeding or bruising, lethargy, diminished sensation in the extremities, muscle twitching, and seizures. Other symptoms might include polydipsia, pallor, hypertension, agitation, and changes in skin tone (darker or lighter). According to the National Kidney Foundation, diagnosis is determined by checking blood pressure, urine albumin, and serum creatinine, all three of which will be elevated.

stage 1kidney damage with normal or increased GFR of greater than 90 ml/minute stage 2GFR of 60 to 89 ml/minute stage 3GFR of 30 to 59 ml/minute stage 4GFR of 15 to 29 ml/minute stage 5kidney failure with GFR less than 15 ml/minute or the patient is on dialysis.

Other findings may include progressively increasing creatinine and BUN levels with decreasing creatinine clearance as well as proteinuria and hyperkalemia. Other ndings may include hypertension, polyneuropathy, uid retention, metabolic acidosis, and abnormally small kidneys noted via x-ray, ultrasound, MRI, or CT scan. Treatment of CRF is aimed at symptom management, slowing disease progression, and reducing the risk of complications. In addition, careful management of related disorders, such as heart failure, chronic UTI, kidney stones, and anemia, is essential. The physician will also prescribe dietary changes, usually including restriction of uid, protein, and electrolytes. For individuals with end-stage renal disease, the physician will prescribe long-term dialysis and may consider kidney transplantation. The mortality rate is highest among those with CRF severe enough to require chronic dialysis. The 5-year survival rate for this population is approximately 35%. It is even lower, at 25%, for those with underlying diabetes. Death is usually related to cardiovascular disease.

Male Reproductive System Diseases and Disorders

Benign Prostatic Hypertrophy
ICD-9-CM code: 600.2 Benign prostatic hypertrophy (BPH), also called benign prostatic hyperplasia, is a noncancerous growth and enlargement of the prostate gland in men. It is rare in younger men but becomes increasingly common as men age because the prostate gland increases in size with age. Incidence of symptomatic BPH is greatest in men over age 40 and is estimated at 50% for men over age 50. This rises proportionally to 80% for men over age 80. However, only a quarter of these men, approximately 300,000 per year, will seek treatment. The cause of BPH is not fully understood; however, BPH develops in men who have elevated estrogen levels compared with relatively low testosterone levels. A substance known as

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dihydrotestosterone (DHT) may be a factor. DHT is synthesized from testosterone but is much more potent and plays an important role in prostate growth. As the prostate gland enlarges, it compresses the lumen, or passage, of the urethra, making it increasingly difcult for the patient to pass urine. Incomplete emptying of the bladder increases the risk of infection and other inammatory changes to urinary tract structures. Common symptoms of BPH are related to urethral obstruction and difculty emptying the bladder. As a result, individuals usually complain of urgency, frequency, hesitancy, and nocturia. Patients may also notice a decrease in the force and consistency of the urinary stream. Urinary retention causes some individuals to become prone to urinary tract infections, kidney problems, and incontinence. Diagnosis of BPH is based on the patients description of signs and symptoms and conrmed by digital rectal examination (DRE), which reveals an enlarged prostate that is rubbery in texture. (A swollen, tender prostate indicates prostatitis, and a hard or nodular prostate may indicate cancer.) A prostate-specic antigen (PSA) blood test reveals an elevated level of prostate-specic antigen in 30% to 50% of individuals with BPH. Other diagnostic tests include rectal ultrasound, urine ow study, IVP, and cystoscopy, which help identify the degree of prostate enlargement and impedance of urine ow and differentiate benign prostatic enlargement from prostate cancer. In some cases, initial treatment for BPH involves stabilization of kidney function by discontinuing anticholinergic drugs, treating infection, and emptying the bladder via catheterization. Further treatment for BPH aims to shrink or remove all or part of the prostate gland. In some men, the drug nasteride (Proscar) helps shrink the prostate gland. Other medications, such as terazosin (Hytrin), doxazosin (Cardura), and tamsulosin (Flomax), may act to improve urine ow and more complete emptying of the bladder in some patients. Transurethral microwave procedures employ the use of microwaves to destroy prostate tissue. Such procedures can usually be done in the medical ofce without general anesthesia. In a procedure called transurethral needle ablation (TUNA), low-level radiofrequency energy burns away part of the prostate. More invasive forms of surgery remove prostate tissue, including transurethral resection of the prostate (TURP), in which a surgeon inserts tiny surgical instruments via the urinary tract and uses them to remove prostate tissue. There are no external incisions or scars with this form of surgery. A urinary catheter must be in place postoperatively for 1 to 5 days to enable bladder irrigation and monitor urine output. Other options for surgery include laparoscopic prostatectomy, open prostatectomy, and radical prostatectomy. They are all more invasive and are generally reserved for patients with prostate cancer. They also require hospitalization and a longer recovery time.

Prognosis for BPH is generally good with adequate diagnosis and treatment. Around 5% to 10% of patients may experience some postoperative problems with sexual function and incontinence. In cases of extreme, prolonged obstruction, the ureters may dilate and hydronephrosis may develop. (See After prostate surgery, page 584.)

Prostate Cancer
ICD-9-CM code: 185 Prostate cancer is a malignant tumor of the prostate gland that occurs when prostate cells grow abnormally and uncontrollably. It is one of the most common forms of cancer in America. It affects 1 in 6 men, with nearly onequarter of a million men diagnosed each year and nearly 30,000 deaths. It is rare in young men but much more common in older age groups, with over 65% of prostate cancer diagnosed in those over age 65. The specific cause of prostate cancer is not clear. However, hormones such as testosterone are thought to play a role. Risk factors include advanced age, family history, genetics, and dietary factors. In addition, African American men are more likely to have prostate cancer; however, Caucasian men are twice as likely to die from the disease. Patients are commonly asymptomatic in the early stages of prostate cancer. As symptoms develop, the patient may notice urinary frequency, urgency, and hesitancy; nocturia; dysuria; erectile dysfunction; painful ejaculation; hematuria; and blood in the semen. As the cancer spreads to bones and surrounding structures, the patient may complain of pain or stiffness in the lower back, hips, or upper thighs. There is some controversy regarding the necessity of screening for prostate cancer. However, the American Cancer Society recommends that men over age 45 or 50 (depending on risk factors) undergo annual screening. Two common screening methods include digital rectal examination (DRE) and the prostate-specic antigen (PSA) test. To perform DRE, a health care provider palpates the prostate gland with a gloved, lubricated nger inserted rectally and notes irregularities in prostate gland shape, size, or texture. The PSA test detects the presence of a specic protein in the blood that is commonly elevated in the presence of prostate cancer, BPH, or prostatitis. If results of either test are abnormal, the physician will order a prostate tissue biopsy, which conrms the diagnosis if cancer cells are detected. Treatment of prostate cancer depends on the age of the patient, aggressiveness of the cancer, and personal preference. After consultation with specialists, including a urologist, radiation oncologist, and medical oncologist, the health care team will design a treatment plan. Such a plan may include surgery, radiation, and chemotherapy. Orchiectomy (surgical removal of one or both testes) and drug therapy may reduce testosterone levels, which reduces the risk of metastasis and the aggressiveness of the cancer.

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Patient Education

After Prostate Surgery

The medical assistant caring for a patient recovering from prostate surgery should emphasize to the patient that he should follow the physicians recommendations, which are tailored specically to the patient. She should be sure to review these general guidelines: Be sure to rest frequently and avoid strenuous activity for the rst few weeks even if you are having no pain. Drink lots of water to ush the bladder. Avoid driving or operating machinery for the time period specied by your physician. Avoid straining with bowel movements. Use these measures to avoid constipation: Drink plenty of nonalcoholic, noncaffeinated uids, including prune juice. Eat a high-ber diet, including fresh fruits, vegetables, whole grains, and bran. Use bulk-forming, nonchemical laxatives, such as Metamucil. Be sure to consult with a physician before using stool softeners and chemical laxatives because, although they are available over the counter, they can be habit forming with regular use. Avoid heavy lifting. You may experience urinary frequency, urgency, or discomfort with urination initially. These symptoms should lessen over the next 8 to 10 weeks. You may experience some difculty controlling urination initially; however, such difculty should lessen over time, If you notice a mild increase in blood in your urine, you should rest and drink uids. This increase is probably due to a loosening in the scab at the surgical site. If rest and uids do not help or if you are concerned, call your physician. Although many men worry about sexual function after prostate surgery, in most cases sexual function returns fully with time.

Prognosis for prostate cancer is variable, depending on the cancer stage, Gleason score (microscopic appearance of cells), and PSA level. Overall, the 5-year survival rate for all types of prostate cancer is just over 70% and the 10-year survival rate is around 55%. For those whose cancer has already spread at the time of diagnosis, the 5-year survival rate is only 30%.

Testicular Cancer
ICD-9-CM code: 186.9 Testicular cancer is a malignancy of the testicle that occurs when cells grow abnormally and uncontrollably. It usually affects only one testicle and is the most common form of cancer in young males between the ages of 18 and 32, and the incidence is increasing. Approximately 7600 Americans are diagnosed and 400 die each year. Incidence is higher in Caucasians than other groups. The specic cause of testicular cancer is unclear. Risk factors include a history of cryptorchidism (undescended testicle), infection with HIV or AIDs, age between 15 and 34, Caucasian race, and a family history of testicular cancer. Patients with testicular cancer may be asymptomatic in the early stages. Signs and symptoms include a lump or enlargement in the testicle, which may or may not be painful; a dull ache within the groin or abdomen; a feeling of heaviness within the scrotum; scrotal edema; testicular or scrotal pain or discomfort; breast enlargement; fatigue; and malaise.

Diagnosis is generally made after the patient has noticed a lump or other abnormality and then seeks medical care. A physician may also note a lump during a regular health examination. Testicular ultrasound is highly effective in identifying testicular cancer. It helps the physician examine shape, size, and density of the testicles as well as any other masses. A solid mass is a sign of a malignant tumor, because most other testicular conditions involve the presence of fluid. If findings are suspicious, tissue biopsy confirms the diagnosis. Blood tests to detect alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG), two proteins called tumor markers, in blood may indicate the presence of a testicular tumor. A CT scan may be done to help stage the cancer and identify whether it has spread to other organs. Treatment for testicular cancer depends on the type of cancer identified and whether it has spread. Surgical intervention usually includes orchiectomy and removal of local lymph nodes. Treatment also includes radiation therapy, chemotherapy, and, sometimes, bone marrow transplantation. Prognosis for testicular cancer is good when it is diagnosed early, but declines as the cancer becomes more advanced. (See Concerns about testicular cancer.) Overall, there is a 95% rate of successful treatment. Because cancer is usually limited to one testicle, men are usually able to retain normal sexual function and fertility. (See Procedure 31-1: Teaching a patient to perform TSE.)

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Patient Education

Concerns About Testicular Cancer

The medical assistant should encourage male patients to perform monthly testicular self-examination (TSE). Performing the TSE enables the patient to become familiar with how these tissues normally feel. By doing monthly examinations, the patient will notice changes early. The medical assistant should instruct the patient to report to the physician any changes that persist for more than 2 weeks so that he can evaluate the changes. In addition, the medical assistant should inform the male patient that other disorders besides cancer may explain testicular changes, including: benign masses, such as hernias, inammation, uid, and cysts inammation of structures, such as the epididymis varicocele, which is the presence of enlarged veins (varicose veins) within the scrotum orchitis, which is inammation of the testicle caused by bacterial or viral infection spermatocele, a type of cyst that develops when the tubes that transport sperm become blocked.

PROCEDURE 31-1

Teaching a patient to perform TSE

Task Teach a male patient to perform a testicular selfexamination (TSE). Conditions TSE pamphlet Examination model TSE shower card Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully teach a male patient to perform a testicular self-examination. Performance Standards 1. Greet and identify your patient to prevent errors. Introduce yourself and explain the procedure to ease patient anxiety. 2. Wash or sanitize your hands to ensure infection control and assemble supplies. 3. To motivate the patient, explain the rationale for regular performance of TSE, including: a. Testicular cancer commonly goes undetected in the early stages because many patients experience no discomfort. b. Regular monthly exam allows him to note any changes in a timely manner. c. Examinations should begin during puberty. d. Examination is easiest during a warm bath or shower. 4. Using the examination model, demonstrate examination of the testes: a. Hold the scrotum in the palms of the hand and feel one testicle. b. Apply gentle pressure while rolling it between the ngers. c. Note any hard, painless lumps. 5. Using the examination model, demonstrate examination of the epididymis: a. Locate the circular-shaped cord behind the testis. b. Feel for any hard lumps. 6. Using the examination model, demonstrate examination of the vas deferens: a. Locate the rm, movable, smooth tube that runs upward from the epididymis. b. Feel for any hard lumps. 7. Repeat the demonstration of examination on the other side to reinforce learning. 8. Have the patient demonstrate TSE using the model to reinforce learning and enable correction or clarication as needed. 9. Give the patient a TSE pamphlet, which provides the patient with a source of information he can refer to as needed. and shower card. Instruct him to hang the card in his shower to remind him to perform monthly TSE, establish a regular routine of TSE performance, and keep instructions at hand. 10. Record TSE education in the patients medical record to ensures a complete, accurate medical record.
Date 03/17/08; 10:30 a.m. TSE teaching done. Patient given pamphlet and shower card. -------------------------------------------------------------S. Gonzales, CMA

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Epididymitis
ICD-9-CM code: 604.90 Epididymitis is the inammation or infection of the epididymis, a duct on the surface of the testicle. It affects over half a million men between ages 19 and 35 each year. Epididymitis is commonly caused by a sexually transmitted disease. Causative organisms typically include Neisseria gonorrhoeae and Chlamydia trachomatis. Other organisms include Staphylococcus and E. coli. Epididymitis can also result as a complication of a urinary tract infection, prostatitis, and injury associated with surgery or the chronic presence of a urinary catheter. Signs and symptoms of epididymitis include abdominal or ank pain or more localized pain in the testicle or scrotum. Other manifestations may include edema, dysuria, urinary frequency and urgency, urinary retention, fever, chills, discharge, and symptoms of urethritis. Diagnosis is based on physical examination ndings and the results of urinalysis and urine culture, which reveal the presence of bacteria and WBCs. Blood tests may also indicate an elevated WBC count. In some cases, regular or colorcoded Doppler ultrasound reveals a thickened, enlarged epididymis and increased Doppler wave pulsation. While a potential complication of epididymitis is sterility, prognosis is usually good with timely diagnosis and treatment.

recommend circumcision for those patients with phimosis to prevent recurrence.

Prostatitis
ICD-9-CM code: 601.0 (acute), 601.1 (chronic) Prostatitis is the acute or chronic inammation of the prostate gland, a small organ located below the bladder and similar in shape and size to a walnut. It is most common in men over the age of 50. Prostatitis is categorized according to whether it is acute; chronic; includes conditions known previously as prostatodynia, chronic pelvic pain syndrome, and nonbacterial prostatitis or whether the individual is symptomatic or not. Prostatitis usually develops secondary to bacterial growth after the development of a UTI. Causative organisms include N. gonorrhoeae, E. coli, Staphylococcus, Pseudomonas, or Streptococcus. Signs and symptoms include fever, chills, urethral discharge, dysuria, malaise, myalgias (muscle aches), and perineal discomfort. Upon examination, the prostate gland is tender and enlarged. Culture of prostatic secretions help identify the causative organism so that appropriate antibiotics can be selected. Treatment includes an extended course of antibiotics, opiate analgesics, and antispasmodics to relieve discomfort. Prognosis is very good for acute prostatitis. The prognosis for chronic prostatitis is less certain because complications may occur, including urethritis, epididymitis, and cystitis.

Balanoposthitis
ICD-9-CM code: 607.1 Balanoposthitis, also called balanitis, is the inammation of the glans penis and foreskin covering the glans penis. General incidence is unclear. However, one study found that 11% of male genitourinary clinic attendees had this disorder. Balanoposthitis is most commonly caused by fungal infection but bacterial pathogens may also be involved. Organisms include the Candida species as well as Bacteroides, Gardnerella, and beta-hemolytic streptococci. They proliferate in the presence of smegma (a thick, cheesy, odoriferous secretion). The result is localized inammation and edema. It develops most commonly in uncircumcised men with poor hygiene. Signs and symptoms of balanoposthitis include tenderness, itching, redness, edema, and ulceration of the glans penis and foreskin; and meatal stenosis and phimosis (stenosis of the foreskin opening so that it cannot be pushed back over the glans penis). Diagnosis is usually based on physical examination ndings. Laboratory studies may include culture of urethral discharge and microscopic evaluation to identify the pathogen involved. Treatment depends on the cause and usually includes daily retraction and cleaning of the foreskin and application of antibiotic or antifungal cream. The physician may also prescribe oral antibiotics. The physician may also

Sexually Transmitted Diseases

ChlamydiaICD-9-CM code: 079.98 GonorrheaICD-9-CM code: 098.0 Genital herpes, HSV-2ICD-9-CM code: 054.10 HPVICD-9-CM code: 078.1 Genital syphilisICD-9-CM code: 091.0 (primary) Secondary syphilisICD-9-CM code: 091.1 (unspecied) Latent syphilisICD-9-CM code: 097.1 (unspecied) Sexually transmitted diseases (STDs) are a group of diseases transmitted through sexual intercourse or other intimate contact with infected individuals. Viruses that most commonly cause STDs include human papillomavirus (HPV), herpes simplex virus (HSV), and hepatitis A, B, and C. The HPV virus is actually a group of more than 100 tumor viruses that can cause tissue growths on the surface of skin and mucous membranes and in some cases are responsible for cervical cancer in women. Other organisms that often cause STDs include Chlamydia trachomatis and Neisseria gonorrhoeae. In nearly all cases, infection is spread through direct contact with lesions or other body fluids. Some types of STDs, such as syphilis, are becoming less common, but others have become epidemic. HPV has become the most common STD in the United States today, with more than 50% of all sexually active men and women becoming infected at some

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time. An estimated 20 million Americans between the ages of 15 and 49 are currently infected and over 6 million become newly infected each year. Young inner-city teens are most at risk for contracting gonorrhea, and nearly 400,000 cases are reported annually in the United States. An estimated 90 million people worldwide are infected with the genital herpes virus. Symptoms of STDs vary with the organism involved. In some cases, patients are asymptomatic. In general, symptoms of bacterial STDs include urethral or vaginal discharge, dysuria, and pelvic pain. Symptoms of herpes simplex include local pain, itching, burning, dysuria, and a rash of small vesicles or pustules. Individuals with HPV infection are commonly asymptomatic unless they notice tissue growths, sometimes called warts, in the anogenital area. In many cases, HPV is only detected through an abnormal result from a routine Pap test. Diagnosis of an STD is usually based on culture of vaginal or urethral discharge, examination of lesions, and the patients description of symptoms. Antibiotics are used to treat bacterial STDs. Treatment of viral STDs is more challenging. In some cases, antiviral medication helps minimize viral shedding and lessens symptoms; however, a complete cure is usually not possible. Patients should refrain from sexual contact with others until treatment is complete. Sexual contacts should be identied for culture and treatment if necessary. Prognosis for bacterial STDs is good with timely diagnosis and treatment. Prognosis for viral STDs is generally good with adequate self-care measures; however, because a cure is usually not possible, complications may occur. Some STDs can be passed to infants at birth, resulting in blindness or respiratory problems. HPV is the most common cause of cervical cancer in women.

Erectile Dysfunction
ICD-9-CM code: 607.84 (organic origin), 302.72 (inhibited sexual excitement) The term erectile dysfunction (ED), also called impotence, is a general term that describes a number of disorders, all of which impact the ability of a man to attain an erection adequate enough to achieve a satisfactory sexual experience. Episodic ED occurs at some time to most men and is not considered problematic from a medical standpoint. As men age, some changes in erectile function are common, including loss of rigidity, need for more stimulation, less intense orgasm, and need for increased recovery time between erections. However, when problems with ED become chronic or reoccur frequently, they can be a sign of a physical or emotional problem. Men who experience ED that lasts longer than 2 months are encouraged to see their health care provider. ED is most common in men over the age of 65 but can occur at any age. Incidence is higher in men who smoke

or abuse alcohol or other drugs and those with diabetes and cardiovascular disease. Causes of ED fall into two categories: physical and psychological. Common physical causes include disorders that affect nerve function, such as diabetes, spinal cord injury, and multiple sclerosis. Other disorders that may cause ED are cardiovascular disease or hormonal problems. ED may also be caused by adverse effects of medication, surgical complications, and drug and alcohol abuse. Psychological causes include fatigue, depression, stress, anxiety, and negative feelings toward or lack of interest in the sexual partner. The main symptom of ED is difculty developing or maintaining a full erection throughout intercourse. In order to diagnose ED, the physician must gather a health history, including a description of symptom onset and pattern and information about other medical conditions, medications, and recent physical and emotional events. Blood tests check hormone levels, such as testosterone, and help rule out underlying disorders, such as diabetes. The physician may adjust current medications to determine whether they are a factor. Ultrasonography can evaluate circulation. Neurological evaluation checks for nerve damage. Other tests include cavernosography to visualize the corpus cavernosum and cavernosometry to measure vascular pressure in the penis. Treatment of ED depends on the underlying cause. Psychological causes are treated with counseling and, in some cases, medication. When ED is caused by medications, a change in dose or switch to another medication may resolve the problem. Treatment of physical causes is tailored to the individual disorder. There are numerous medications on the market for the treatment of ED, including sildenal (Viagra), tadalal (Cialis), and vardenal (Levitra). These drugs relax smooth muscle in the penis, enabling greater blood ow, which results in increased quality of an erection when physical and psychological stimulation occur. Other treatments include testosterone replacement therapy, surgery, penile implants, and needle-injection therapy. Prognosis for ED is variable. In many cases, it may resolve completely with appropriate treatment. In other cases, it may not fully resolve but can be lessened. (See Teaching about ED, page 588.)

Urology and Male Reproductive Procedures

Urology is a medical specialty that focuses on the study and treatment of diseases and disorders of the urinary and male reproductive systems. A physician who specializes in this area of medicine is a urologist. Many patients who have urological disorders initially see family practice physicians who then refer them to a urologist.

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Patient Education

Teaching About ED
Erectile dysfunction (ED) is a personal subject and many men feel embarrassed about discussing it. However, the medical assistant should encourage male patients to discuss their concerns with the physician. When teaching about ED and treatment, the medical assistant should be sure to include these points: Many forms of treatment for ED are available. Discuss your concerns with the physician to identify a treatment plan that is right for you. Many unapproved treatments are promoted on television and the Internet. However, many of them do not work and some can actually harm you. Therefore, please talk with your physician prior to trying any of them. Even approved treatment methods are not right for everyone. Therefore, you should never use someone elses prescription medication. For example, if you have had a stroke, heart attack, or heart rhythm problem within the past 6 months, some medications could harm you. Never take sildenal (Viagra), tadalal (Cialis), or vardenal (Levitra) with nitrate medications such as nitroglycerine because you could experience heart and blood pressure problems. It may take time to experience the full benet of some medications, so do not be disappointed if you do not experience optimal results with the rst dose. Because the key to a mutually satisfying sexual relationship with your partner is communication, discuss your concerns with your partner and seek counseling if needed.

should include data regarding allergies, symptoms, and medications. In most urology ofces, the medical assistant will routinely ask the patient to collect a urine specimen each time the patient checks in. Therefore, the medical assistant should become well versed in instructing patients how to obtain a clean-catch, midstream specimen. She should then assist the patient as needed with undressing and positioning. For physical examination of the urinary tract, female patients should be placed on the examination table in the dorsal recumbent position. If the physician is male, then a female assistant should remain in the room. Male patients are seated on the examination table. In both cases, unless a urine specimen is to be obtained by catheterization, the medical assistant should encourage patients to empty their bladders before the examination. The medical assistant provides patient privacy and assists the physician as needed with the examination and performs ordered diagnostic tests. When examining a male patient, the physician uses inspection and palpation to examine the foreskin (if the patient is not circumcised), glans, penis, and scrotum for abnormal tenderness or masses. The physician may ask the medical assistant to dim the lights if he uses a transilluminator. The physician will typically perform a hernia check as well as a rectal examination, which allows the physician to palpate the prostate gland, noting the presence of enlargement, asymmetry, nodules, or other abnormalities.

Catheterization
Urinary catheterization is a procedure in which a sterile drainage tube is introduced into the bladder through the urethra to drain or withdraw urine. There are distinct advantages and disadvantages to obtaining a urine specimen by urinary catheterization. Disadvantages include invasiveness and the risk of introducing microorganisms into the urinary tract of the patient, in addition to the potential embarrassment experienced by the patient. However, advantages include the ability to obtain a more reliable specimen, particularly when the patient has some form of disability that might interfere with her ability to collect a clean-catch specimen properly. In any case, the medical assistant who performs the catheterization should use measures to protect the privacy and dignity of the patient and follow aseptic technique to protect the quality of the specimen obtained and protect the patient from infection. Medical assistants should perform catheterizations only under a physicians order and only if she has been specically trained in this procedure. Catheters are available in a variety of brands, types, and sizes. Medical ofces and hospitals commonly stock size 14 to 20 for adults and size 8 to 10 for children. In the rare event that an adult suffers from urethral stenosis, the medical assistant may need to use a childs size. Although the physician will occasionally specify the type of catheter to use, the medical assistant will more commonly

The medical assistant will help the urologist with examinations as well as procedures, diagnostic tests, and patient education. Urinalysis, urine culture, and 24-hour urine specimens are essential components in diagnosing urological diseases and disorders. Methods for collecting urine specimens include the clean-catch, midstream method or catheterization, depending on the necessity for a sterile specimen, the patients ability to comply with the physical demands of collecting a clean-catch specimen, and the physicians preference. (For more information on urine collection and analysis, see Chapter 44, Urinalysis, on page 923.)

Assisting with Examination

The medical assistant prepares patients for examination by checking vital signs and obtaining a health history, which

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use her discretion to determine the appropriate catheter. Therefore, the medical assistant must choose carefully and take into consideration the patients age, size, and gender and the rationale for the catheterization. If the purpose is simply to empty the patients bladder, as when a patient is suffering from urinary retention, she should choose a straight catheter, sometimes called an in-and-out catheter. Some medical ofces stock sterile catheterization kits that contain needed supplies. In such kits, the plastic supply container doubles as a urine collection tray. These kits usually contain a medium-size pair of sterile gloves; povidoneiodine swabs; water-soluble lubricant; a specimen container, lid, and label; and two drapes, one of which is fenestrated (has a small window in it). The kit may or may not include the catheter itself. If the patient is female and the sole purpose of the catheterization is to obtain a urine specimen, then the medical assistant may use a minicatheter, also called a fem-cath. If the catheter must remain in place for a period of time, the medical assistant should choose an indwelling catheter. These catheters have a port for injecting a small amount of sterile water to inate a small balloon near the tip of the catheter. The balloon helps secure the catheter in the patients bladder, although the external catheter tubing should always be secured to the patients leg with a catheter strap for the patients safety and comfort. Some patients may have difficulty lying supine for catheterization, especially if they are elderly or have such medical conditions as severe arthritis or heart failure. In such cases, a male patient can be positioned in a semiFowler position if necessary. However, such a position will not work with female patients, because it makes it impossible for the medical assistant to locate and visualize the patients urethra. For the female patient unable to lie supine, the medical assistant can assist the patient into the side-lying position. If the medical assistant stands behind the patient, she will have good view and access to the patients urethra. However, this technique does require a second assistant to help support the patients upper leg. Whenever the patient is a male with an enlarged prostate, a coud catheter is a good option. It is slightly more rigid, has a slight curve near the tip, which is more rounded in shape. (See Figure 31-5.) It was designed specifically for such patients and more easily slips by the enlarged prostate to enable successful catheter insertion. (See Procedure 31-2: Performing urinary catheterization, page 590.) Many urology tests aid in the diagnosis of urinary and reproductive disorders. Some of the most common tests include renal computed tomography, intravenous pyelography, cystoscopy, cystourethrography, creatinine, blood urea nitrogen, and renal angiography.

FIG 31-5 Catheters. (A) Indwelling. (B) Straight. (C) Coud catheter.

Renal Computed Tomography Scan

A renal computed tomography (CT) scan is a painless radiological procedure in which multiple x-ray beams and detectors rotate around the patient to produce three-dimensional cross-sectional views of the kidneys. This procedure provides more detail than standard x-rays and is useful in identifying lesions, abscesses, uid accumulation, kidney stones, obstructions, and tumors. It can also aid in needle placement for a kidney biopsy. The scan may or may not include administration of a contrast dye, a radioactive substance administered intravenously or orally that causes the tissue being studied to show up more clearly. Patients who are or may be pregnant; those allergic to contrast dye, iodine, or shellsh; or those sensitive

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PROCEDURE 31-2

Performing Urinary Catheterization

Task Perform urinary catheterization on a patient. Conditions Light source Laboratory slip Ink pen Nonsterile waterproof underpad Sterile urethral catheterization kit containing: Straight catheter Drapes Tray Gloves Lubricant Povidone-iodine swabs or cotton balls and povidoneiodine solution Specimen container and label Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform catheterization on a patient to empty the bladder or collect a urine specimen. Performance Standards 1. Wash or sanitize your hands to ensure infection control and assemble supplies. 2. Greet and identify your patient to prevent errors. Introduce yourself and explain the procedure to ease patient anxiety. 3. Ask the patient about allergy to iodine. If the patient is allergic, omit the povidone-iodine from this procedure to prevent an allergic reaction. 4. Instruct the patient to remove clothing below the waist, including undergarments, to facilitate efcient performance of the procedure. The patient may keep socks on if desired to help stay warm. Assist the patient as needed. 5. Assist the patient into the dorsal recumbent position and drape the patient for warmth and privacy, leaving the genital area exposed to help facilitate visualization of the urethra in female patients. (Note: Other than a pillow for the head, the patient should lie completely flat.) 6. For the female patient who is unable to lie completely at or abduct her hips, consider an alternative sidelying position, which requires a second assistant to support the patients upper leg. This position is more comfortable for these patients and increases the medical assistants success in locating the female urethra and successfully completing the procedure.

Place the patient in a at, dorsal recumbent position and apply drapes for warmth and privacy.

7. Adjust the light source on the genital area. If an adjustable lamp is not available, have an assistant hold a ashlight. Good lighting is critical in identifying the urethra. 8. Place the nonsterile waterproof underpad under the patients buttocks to absorb excess moisture. 9. To reduce the risk of infection to the patient and ensure a good-quality urine specimen, provide perineal hygiene as needed, including: a. Apply nonsterile gloves. b. Wash the perineal area with warm water and soap. c. Dry the perineal area with a towel. d. Remove and dispose of gloves. e. Wash your hands. 10. Open the catheter kit on a clean, dry, uncluttered surface using sterile technique to ensure infection control. Using a Mayo stand or other small wheeled table is optimal because it provides an efcient, movable work surface. 11. Keep the plastic bag that contained the kit nearby to use as a waste receptacle to enable efcient disposal of waste during the procedure. 12. Remove the sterile gloves from the kit and put them on to arrange sterile supplies within the kit without contaminating them. 13. If the physicians order does not include a specimen, remove the specimen container, lid, and label and set them aside to avoid cluttering the work space with unnecessary items. 14. If the order does request a specimen, place the label aside and put the specimen container and lid on a sterile surface within easy reach.

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PROCEDURE 31-2contd

15. Open the sterile lubricant package. Grasp the catheter and apply the lubricant to the distal 1 to 2 of the catheter to ease catheter insertion and minimize patient discomfort. Place the catheter back inside the urine collection tray. Dispose of the lubricant wrapper. 16. Open the povidone-iodine swab packet and pull the swabs most of the way from their package. If the kit contains cotton balls, rather than swabs, place them in the sterile container and pour the povidone-iodine solution over them. Preparing all items ahead of time increases efciency and decreases anxiety, stress, and the risk of contamination during the procedure. 17. Grasp the sterile drape so that two of the corners are wrapped around your hands to avoid contaminating your sterile gloves. Place the drape with the waterproof side down just under the patients buttocks to provide a sterile area near the genital areas to place supplies and help ensure infection control. Ask the patient to lift her buttocks slightly if possible to facilitate this process. 18. Grasp the fenestrated drape and allow it to unfold without touching a nonsterile surface. Place it over the patients genital area so that the genitals are visible through the window. (Note: Some providers prefer not to use a drape for female patients because the fenestrated drape may shift during the procedure and become a hindrance.)

19. Move the sterile tray by holding the inside with ngers extended outward against the sides and place it on the sterile drape near the clients buttocks to place needed items close at hand. 20. If the order requests a specimen, place the specimen container upright next to the urine collection tray on the sterile drape. Female patients 21. With your nondominant hand, separate the inner labia as widely as possible so that the urethral meatus is visible. This hand is now considered contaminated and must remain in place until the catheter is fully inserted. 22. With your dominant hand, grasp the povidone-iodine swabs (or soaked cotton balls) and wipe from top to bottom on one side of the inner labia. 23. Grasp another swab (or cotton ball) and wipe from top-to-bottom on the other side of the inner labia. 24. Grasp another swab (or cotton ball) and wipe from top-to-bottom over the urinary meatus. Cleaning the area in this way reduces the presence of microorganisms and the risk of infection to the patient and increases the quality of the urine specimen.

F.P.O

F.P.O

Wrap the corners of the sterile drape around your sterile gloved hands as you position the drape.

Separate the inner labia as widely as possible in order to view the urethral meatus. Continued

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PROCEDURE 31-2contd

Separate the inner labia as you cleanse with povidone-iodine swabs.

25. Grasp the catheter approximately 3 from its tip and position the other end in the collection tray. 26. Ask the client to cough or bear down to make the urethral opening more visible and relax the external sphincter, making catheter insertion easier. 27. Hold the catheter at a slight upward angle (pointing toward the patients umbilicus) to help the catheter slide into the urethra, rather than the vagina. Insert the lubricated tip into the urethra approximately 2 or until urine begins to ow into the collection tray. Release the labia with your nondominant hand and grasp the catheter, being sure not to let go of it because the catheter will quickly slide out if it is not secure. Male patients 28. With your nondominant hand, grasp the penis gently yet rmly and use gentle traction in an upward direction to straighten the urethra, making insertion easier. This hand is now contaminated and must remain in place until the catheter is fully inserted. 29. With your dominant hand, grasp the povidone-iodine swabs (or soaked cotton balls) and wipe in a circular pattern from the meatus outward. Repeat this step two more times to reduce the presence of microorganisms and the risk of infection to the patient and increase the quality of the urine specimen. 30. Grasp the catheter approximately 3 from its tip and position the other end in the collection tray. 31. Ask the client to cough or bear down to make the urethral opening more visible and relax the external sphincter, making catheter insertion easier.

Insert the catheter at a slight upward angle.

32. Insert the lubricated tip of the catheter into the urethra until urine begins to ow into the collection tray. (Note: For some men, you may need to insert nearly all of the catheter.)

Continue inserting the catheter until urine begins to ow.

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PROCEDURE 31-2contd

33. Release the penis with your nondominant hand and grasp the catheter to hold it securely for the remainder of the procedure because the catheter will quickly slide out if it is not secure. All patients 34. If the order requires a specimen, follow these steps: a. Use your dominant hand to temporarily crimp the catheter. b. Move it over the specimen container. c. Uncrimp the catheter and allow urine to ow into the specimen container. d. Crimp the catheter once more and move it back over the collection tray. e. Resume draining urine into the collection tray until the patients bladder is empty. 35. When urine ow has stopped, gently remove the catheter from the urethra and dispose of it. 36. Dispose of supplies, remove your gloves, and wash your hands to ensure infection control. 37. Secure the lid to the specimen container. Note the total amount of urine collected in both containers and then discard the excess urine in an approved manner. If the

38. 39.

40.

41.

patient has been experiencing urinary retention, the physician will want to know the total volume retained. Assist the patient off of the examination table and with dressing if necessary. Write the patient identication data on the specimen label and afx it to the side of the specimen container, not the lid, because the laboratory processes many specimens at one time and the lid may become separated from container. Complete the laboratory slip, package it with the specimen in the approved manner, and send it to the laboratory according to facility policy. Correct identication is critical to ensuring accurate results are recorded for each patient. Document the procedure in the patients medical record to ensure a complete, accurate medical record.

Date 11/20/08; 8:30 a.m. Straight cath done using aseptic technique, 550 ml clear, yellow urine obtained, specimen sent to lab. ---------------------------------------------------------------------------W. Jones, CMA

to medications should discuss these issues with their physician before undergoing a renal CT scan. If the scan does involve a contrast dye, the medical assistant should instruct the patient to refrain from eating or drinking for a period of several hours before the test. The general steps of a renal CT scan include:

The patient must remove clothing, jewelry, and other objects that may interfere with the procedure and put on a gown. If the test involves a contrast dye, a nurse will insert an intravenous (IV) line in the patients hand or arm. For oral contrast, the patient must drink a liquid that includes the contrast. The nurse should tell the patient that he may briey feel a warm, ushing sensation, salty or metallic taste in his mouth, headache, nausea, or vomiting. The patient must lie on a table that slides into the large, circular opening of the scanner. The technologist will be nearby in a separate room where the controls are located but will be able to view the patient through a window. The technologist will also be able to communicate with and hear the patient through a speaker system. As the scanner begins to rotate, the patient will hear clicking sounds. The technologist should reassure the patient that these sounds are normal.

The scanner transmits the x-ray information to the computer, which converts the information into an image that the radiologist will interpret. The technologist will instruct the patient to lie very still during the procedure and to briey hold his breath at various times. When the procedure is completed, the IV line is removed and the patient is asked to wait briey while the radiologist veries the clarity of the scan.

Intravenous Pyelography
Intravenous pyelography (IVP), also known as an intravenous pyelogram or intravenous urogram (IVU), is a radiological procedure used to identify abnormalities of the structures of the urinary system, including the kidneys, ureters, and bladder. It is the most common procedure to identify urinary tract dysfunction or kidney disease. It is typically done to investigate the cause of hematuria and to identify tumors or lesions. This procedure begins with injection of a radiopaque contrast dye, and then a series of x-rays taken over a 30-minute period record the progress of the dye as it lters through the kidneys. The radiologist will examine the x-rays for the shape, size, position, and equal ltration and ow of the kidneys. She will also examine the ureters for symmetry and smooth appearance and the bladder for a smooth appearance and complete

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emptying. Regular IVPs are less common than in the past. Instead, CT scans are replacing them or combined with IVPs because this procedure obtains better images with greater detail.

Cystoscopy
Cystoscopy is a procedure in which a cystoscope is introduced into the urethra and bladder to facilitate visual examination of the bladder wall, obtain tissue for biopsy, examine the ureters, locate and remove kidney or bladder calculi (stones), place stents, and distend (stretch) the bladder or dilate the ureters or urethra. This procedure may take place in the physicians ofce with or without topical anesthesia if simple visualization is planned. If the physician orders bladder distention (stretching) or biopsy, the procedure must take place in an operating room under general anesthesia. A cystoscope is generally the diameter of a pencil with a lighted tip. It may also have a second lumen (tube) for inserting instruments to obtain tissue specimens or treat urinary problems. Typical reasons for cystoscopy include the diagnosis and treatment of such conditions as interstitial cystitis (chronic inflammatory condition), frequent UTIs, unexplained hematuria, overactive bladder or urinary incontinence, unusual findings in a urinalysis, urinary blockages, stones, polyps, tumors, or cancer. There is usually no special preparation for a cystoscopy unless general anesthesia is planned, in which case the medical assistant should instruct the patient to avoid eating or drinking anything for a specied period of time beforehand. For the procedure, the medical assistant should instruct the patient to undress and put on an examination gown. The medical assistant should then help the patient assume the dorsal recumbent or lithotomy position and provide draping for warmth and privacy. She may also clean the genital area to reduce microorganisms and apply a topical anesthetic if ordered. When the physician inserts the cystoscope, the patient may feel a brief pinching sensation in the urethra. The physician may instill a sterile liquid, such as water or saline, into the bladder to fill it so that he can better visualize the bladder wall. This liquid may cause mild discomfort for the patient and the urge to urinate. The medical assistant should reassure the patient that the sensation will pass soon and that the physician will drain the liquid shortly. The entire procedure usually takes 20 minutes or less. The medical assistant should explain to the patient that, after the procedure, he may notice burning with urination or presence of blood in his urine. Less commonly, he may notice mild abdominal pains caused by bladder spasms. These spasms rarely last for more than 24 hours; however, the patient should report them to the physician

if they continue for more than a couple of days. The medical assistant should also encourage the patient to drink 1 L (approximately 1 qt) of water over the next 2 hours to reduce the risk of infection. He may also use mild heat in the form of a warm bath or the application of a warm washcloth to ease temporary discomfort.

Voiding Cystourethrography
Voiding cystourethrography examines the bladder and urethra as the bladder fills and empties. It helps identify structural abnormalities, urine flow abnormalities such as ureteral reflux, the cause of repeated UTIs, prostate enlargement, and causes of urinary incontinence. As with other procedures, the patient should notify her physician if she is or might be pregnant, is breastfeeding, or might be allergic to contrast dye. The medical assistant should also ask the patient about her use of bismuth-containing medications, such as Pepto-Bismol, or a history of using barium contrast dye within the past 4 days, because they may interfere with test results. Prior to the procedure the medical assistant should instruct the patient to remove her clothes, put on a gown, and empty her bladder. The medical assistant should then help the patient assume the dorsal recumbent position and provide draping for warmth and privacy. She may also clean the genital area to reduce microorganisms. The physician will then insert a urinary catheter and slowly instill a radiopaque dye into the bladder until it is full. The physician will then take x-rays with the patient standing, sitting, and lying down. The physician will then remove the catheter. The medical assistant should instruct the patient to urinate while the x-rays are taken. The test usually takes 45 minutes or less and is generally not painful, although the patient may find the procedure uncomfortable at times due to positioning requirements and the feeling of a full bladder. The medical assistant should explain to the patient that, after the procedure, she may notice burning with urination or presence of blood in her urine. Less commonly, she may notice mild lower abdominal pain. This pain rarely lasts for more than 24 hours; however, the patient should report it to the physician if it continues for more than a couple of days. The patient should also report problems with urine leakage, foul-smelling urine, flank pain, fever or chills, and nausea or vomiting. The medical assistant should encourage the patient to drink fluids to reduce risk of infection.

Creatinine
Creatinine is the decomposition product of metabolism of a substance called phosphocreatine, a source of energy for muscle contraction. Small amounts of it are normally found

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in urine and blood. Increased quantities are found in advanced stages of renal disease. The normal creatinine level is 0.5 to 1.4 mg/dl.

Blood Urea Nitrogen

Blood urea nitrogen (BUN) is a test that measures the amount of nitrogen in the blood that comes from the waste product urea and reects the balance between its production and excretion. It is normally removed from blood and excreted by the kidneys in urine. Normal BUN levels are generally between 6 and 19 mg/dl. When evaluating kidney function, physicians commonly order the BUN test along with creatinine.

should also tell the patient that some sperm may remain in the ducts and that it can take up to 1 month for all sperm to be gone. The patient should provide two specimens for a sperm count 4 to 6 weeks apart. Until these tests verify sterility, the patient should use some means of contraception. (See Conrming sterility.)

Prostate gland

Ejaculatory duct

Renal Angiography
Renal angiography, also called renal arteriography, is a procedure in which a contrast dye injected through a catheter into the renal vessels makes them visible on a radiological machine called a uoroscope. This procedure detects vascular abnormalities, evaluates renal disease, and examines the kidneys before or after transplantation. Prior to the procedure, the medical assistant may instruct the patient to avoid eating or drinking for 12 hours. Immediately before the procedure, she should instruct the patient to undress and put on an examination gown. During the procedure, the medical assistant should instruct the patient to lie very still. After the radiologist injects a local anesthetic near the site to be used (an artery in the arm or leg), he will thread a catheter through the aorta and into the renal artery. He then injects a contrast dye through the catheter and takes a series of x-rays as the dye circulates through the kidneys. The physician will then remove the catheter and apply pressure to stop any bleeding. During this time, the medical assistant should measure the patients vital signs and instruct her to rest. She should also instruct the patient to rest after discharge, avoid physical exertion for 24 hours, and report any excessive signs of bleeding or swelling.

Bladder Vas deferens

Urethra

Penis Testes

Vas deferens

Cut

FIG 31-6 Vasectomy.

Vasectomy
The most common male reproductive procedure performed in the medical office is the vasectomy, which is a surgical procedure performed to sterilize a man. The physician performs it in the office using a local anesthetic. In this procedure, the surgeon makes a small incision in the scrotum and lifts and removes a small section of the vas deferens. The surgeon then sutures or clips the ends of the vas deferens and closes the area with sutures. (See Figure 31-6.) After the procedure, the medical assistant should instruct the patient to rest for a couple of days and use cold application and analgesics such as ibuprofen for discomfort. She

Patient Education

Conrming Sterility
The medical assistant may need to explain to a patient that he must bring in two separate semen specimens 4 to 6 weeks apart after undergoing a vasectomy for testing. The physician cannot conrm sterility until the patient provides these specimens. The medical assistant should be sure to explain to the patient that he does not have to completely ll the specimen cup.

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Chapter Summary

The urinary system is responsible for ltering excessive uid and wastes from the blood and maintaining a healthy acid-base balance. Key structures of the urinary system include the kidneys, ureters, bladder, and urethra. The male reproductive system is responsible for procreation and regulation of several of the hormones in the body and shares many of the same structures with the urinary system. Medical assistants must be well versed in the language and vocabulary that pertain to the urinary and male reproductive systems. In addition to knowing common word elements, they should be familiar with common pathological terms and abbreviations. Some of the most common disorders of the urinary system include bacterial cystitis and urethritis, bladder cancer, renal cancer, Wilms tumor, nephrotic syndrome, hydronephrosis, polycystic kidney disease, renal calculi, acute renal failure, and chronic renal failure. Some of the most common disorders of the male reproductive system include BPH, prostate cancer, testicular cancer, STDs, and ED. Urology is a medical specialty that focuses on the study and treatment of diseases and disorders of the urinary system. Medical assistants assist physicians in urology with patient examinations, diagnostic testing, and procedures. A common procedure done in the urology ofce is urinary catheterization. The physician may order catheterization to empty the bladder or collect a urine specimen. Vasectomy is a surgical procedure to achieve male sterilization. Follow-up testing is essential to conrming sterility.

Team Work Exercises

1. Medical assistants must sometimes discuss personal subjects with patients. Doing so can be uncomfortable for the patient and medical assistant. However, the medical assistant can reduce discomfort for both parties by speaking in a sensitive, kind, clear manner and projecting a professional demeanor. The medical assistant will be more successful in achieving this goal if she practices discussing these topics with classmates rst. Divide into groups of three to ve students each. Each team must complete one of these assignments (as assigned by the instructor): a. Collection of a urine specimen is a common task for administrative and clinical medical assistants. Write up a set of instructions that would be clear and understandable to the average patient. Read the instructions to the rest of the class and solicit their suggestions for improvement or changes.

b. Write up postprocedure instructions that would be clear and understandable to a patient who has just undergone a vasectomy. Instructions should address self-care and follow-up testing. Read the instructions to the rest of the class and solicit their suggestions for improvement or changes. c. Write up a set of instructions and discussion points on self-care and prevention activities for UTI. Make sure the instructions would be clear and understandable to the average patient. Read the instructions to the class. Solicit their suggestions for improvement or changes. d. Write up a set of instructions and discussion points on self-care and prevention activities for STDs. Make sure the instructions would be clear and understandable to the average patient. Read the instructions to the class. Solicit their suggestions for improvement or changes. 2. Divide into groups of three or four students and select one of the following tests: a. renal computed tomography b. kidney ureter-bladder lms (KUB x-ray) c. intravenous pyelography (IVP) d. cystoscopy e. cystourethrography (voiding) f. creatinine clearance g. blood urea nitrogen (BUN) h. angiography (renal). Gather as much information about the test as you can from this text, other medical books, the Internet, and your local medical clinic. Create a teaching poster and present your information to the class. Be sure to address the most common reasons the test is ordered, any preparation the patient must complete before the procedure, a description of the actual procedure, description of the typical ndings (normal and abnormal), and any postprocedure information or activities the patient must know about. Be sure to create a poster that is colorful and visual (with illustrations, photos, and so forth) and that presents information in an organized manner.

Case Studies
1. Rick Bell is a 52-year-old man who is a regular patient at the clinic. He calls in the morning stating that he has been awake since 4 a.m. with intermittent, severe pain in his right ank that sometimes radiates down into his groin. The physician suspects that Mr. Bell may have a kidney stone. What testing will the physician probably order to rule out or conrm this diagnosis? When the physician conrms a diagnosis of nephrolithiasis, what treatment options will be considered? If the physician asks Mr. Bell to try to pass the stone naturally, what instructions should he receive? If the stone totally obstructs the ureter, what complicating condition could result?

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2. Howard Jameson comes to the medical ofce to discuss concerns about ED with his physician. List some potential causes and contributors to this condition. What data will the physician gather to formulate a diagnosis? Mr. Jameson is interested in trying one of the currently available prescription medications to help with this problem. List these medications. Describe how these medications work. Describe what patient education Mr. Jameson should receive if he decides to use one of these medications.

Resources

Information on prostate cancer: www.prostatecancerfoundation.org and www.nci.nih.gov/cancertopics/types/prostate Information on testicular cancer: www.nci.nih.gov/cancertopics/types/testicular National Kidney Foundation: www.kidney.org Senior health: http://seniorhealth.about.com/od/sexandsexuality/ Sex_and_Sexuality_for_Seniors.htm Urology patient education information: www.urologyhealth.org

CHAPTER

Obstetrics and Gynecology

Learning Objectives
Upon completion of this chapter, the student will be able to: dene key terms related to obstetrics and gynecology (OB-GYN) describe the function of the female reproductive system identify the structures of the female reproductive system identify the role of the medical assistant in OB-GYN identify instruments used during a gynecological examination assist with examinations and procedures explain diagnostic procedures related to OB-GYN describe prenatal and postpartum care calculate estimated due date (EDD) dene the stages of labor list common complications of pregnancy describe menopause identify common diseases and disorders related to OB-GYN identify common laboratory tests related to OB-GYN provide patient education perform patient teaching for breast self-examination. General Competencies Legal Concepts
Establish and maintain the medical record Document accurately

32
Procedures
Providing instruction on breast self-examination Preparing a patient for and assisting with a gynecological examination

Patient Instruction
Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention Identify community resources

Chapter Outline
Structures and Functions of the Female Reproductive System
Structures of the Female Reproductive System Internal structures External structures Breasts Functions of the Female Reproductive System Internal structures External structures Breasts

ABHES Competencies
Communication
Be impartial and show empathy when dealing with patients Adapt what is said to the recipients level of comprehension Serve as a liaison between the physician and others

Clinical Duties
Interview and record patient history Prepare patients for procedures Apply principles of aseptic techniques and infection control Take vital signs Prepare and maintain examination and treatment areas Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries Collect and process specimens Perform selected CLIA-waived tests (i.e., kit tests such as pregnancy, quick strep, dip sticks) that assist with diagnosis and treatment Dispose of biohazardous materials Practice standard precautions

Female Reproductive Cycle

Menstruation Follicular phase Luteal phase Menstrual phase Pregnancy Birth Process Menopause

Medical Terminology Related to the Female Reproductive System Common Obstetric and Gynecological Diseases and Disorders
Vaginal Infections Candidiasis Chlamydia Genital herpes Genital warts Gonorrhea

CAAHEP Competencies
Clinical Competencies Diagnostic Testing
CLIA-waived tests

Legal Concepts
Determine needs for documentation and reporting Document accurately

Patient Care
Prepare and maintain examination and treatment areas Prepare patients for and assist with routine and specialty examinations

Instruction
Instruct patients with special needs Teach patients methods of health promotion and disease prevention

599

Syphilis AIDS Trichomoniasis Bartholin gland cyst Menstrual Disorders Dysmenorrhea Amenorrhea Ovarian cysts Premenstrual syndrome Toxic shock syndrome Uterine Disorders Endometriosis Pelvic inammatory disease Uterine broids Uterine prolapse Complications of Pregnancy Ectopic pregnancy Abortion Gestational diabetes Placenta previa Abruptio placentae Eclampsia

Cancers of the Female Reproductive System Breast cancer Cervical cancer Uterine cancer Ovarian cancer Other Disorders of the Female Reproductive System Infertility Fibrocystic breast disease

Obstetric and Gynecological Procedures

Prenatal Care Initial visit Routine prenatal visits Assessment of the Neonate Postpartum Visit Assisting with the Gynecological Examination Breast examination Pelvic examination

Pap test, KOH preparation, and wet preparation Common Gynecological Surgical Procedures Cryosurgery Laparoscopy Dilatation and curettage Uterine ablation Hysterectomy Diagnostic Testing in Pregnancy Fetal ultrasound Amniocentesis Chorionic villus sampling Common Gynecological Diagnostic Tests Amplied DNA probe test Colposcopy with biopsy Endometrial biopsy Mammography

Chapter Summary Team Work Exercises Case Studies Resources

Key Terms
abortion

gravidity

Total number of pregnancies Spontaneous or induced termination of pregnancy before the fetus reaches a viable age
adenomyosis hormone

Chemical substance released from a gland or organ

lactation

Benign invasive growth of endometrial tissue into the myometrium

Bartholin glands

Process by which a mother produces milk for her newborn infant

mammary glands

Two small glands located at the opening of the vagina

blastocyte

Milk-producing glands in a female

menarche

Group of cells in early gestation that will form an embryo

coitus

Age of rst menstruation or the onset of menstruation

menopause

Sexual intercourse
colposcope

Permanent cessation of menstruation, usually occurring between ages 38 and 58

menstruation

Instrument used to examine the tissues of the vagina and cervix

colposcopy

Female cycle of producing and expelling the unfertilized ovum

neonate

Examination of vaginal and cervical tissues by means of a colposcope

conception

Newborn from birth to 1 month of age

ovaries

Time at which an ovum is fertilized

dilation

Glands that produce ova, the cells from the female necessary for procreation
Papanicolaou test

Increase in size
effacement

Test used to detect cancer of cervical cells

perineum

Thinning of the cervix during labor

endometrium

Area between the vaginal opening and anus

placenta

Mucous membrane that lines the uterus

episiotomy

Uterine structure that is connected to the fetus by the umbilical cord and from which the fetus obtains nourishment and oxygen
postpartum

Incision made into the perineum to facilitate delivery of a baby

estrogen

Time from birth up to 6 weeks

prenatal

Hormone that stimulates female characteristics

fetus

Time of gestation before birth

progesterone

Term used to describe a developing human in utero from 9 weeks gestation (after the embryonic stage) until birth
fundus

Hormone that prepares the uterus for pregnancy

prolactin

Area of the uterus above the openings to the fallopian tubes

gestation

Hormone that stimulates breast development and production of milk

zygote

Time from conception to birth

Fertilized ovum

CHAP TER 32

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Structures and Functions of the Female Reproductive System

The female reproductive system includes ovaries, fallopian tubes, a uterus, a vagina, a vulva, a clitoris, labia, and a perineum. The female reproductive system houses the organs necessary for the reproduction of another human. It also manufactures hormones, which are chemicals secreted into the bloodstream that cause reactions. The female reproductive system produces the hormones that are necessary for the development and functioning of reproductive organs.

Structures of the Female Reproductive System

The female reproductive system is made up of internal structures and external structures.

sides of the superior lateral surface of the uterus toward the ovaries. Although the fallopian tubes do not connect to the ovaries directly, they are attached to the broad ligament for stability. Each fallopian tube ends with wavelike structures called mbriae. The uterus is a thick-walled, muscular organ located posterior to the urinary bladder and anterior to the rectum. The uterus consists of the fundus, the rounded upper portion; the corpus, the body of the uterus; and the cervix, the narrowed section that opens into the vagina. The cavity of the uterus is triangular in shape and the innermost lining is called the endometrium. The myometrium, or muscular tissue of the uterus, consists of muscle bers that run in many directions, including circular, longitudinal, and diagonal.

External Structures
The external structures of the female reproductive system, also called the vulva, include the clitoris, urethral meatus, labia, mons pubis, and Bartholin glands. (See Figure 32-2.) This area in men and women is also called the perineum. The clitoris, made up of elongated erectile tissue, is located beneath the anterior aspect of the labia. The urethral meatus, located posterior to the clitoris and anterior to the vaginal opening, is the opening to the urinary bladder. The labia, which cover the clitoris, urethral meatus, and vaginal opening, consists of two layers. The labia minora is a thin layer of tissue that extends from the anterior clitoris to the posterior aspect of the vaginal opening. The labia majora lies

Internal Structures
Internal organs and structures of the female reproductive system include the ovaries, fallopian tubes, mbriae, uterus, cervix, vagina, endometrium, and myometrium. (See Figure 32-1.) The ovaries are at, oval-shaped structures located on each side of the uterus in the lower abdominal cavity, attached to the broad ligament. The ovaries contain the graaan follicles, in which are the immature ova, or eggs. The two fallopian tubes extend approximately 4'' from the

Uterus

Fallopian tube

Fimbriae Endometrium Ovary Myometrium Cervix Vagina

FIG 32-1 Internal structures of the female reproductive system.

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Mons pubis

Clitoris

Urethral meatus Labia majora Labia minora

Vulva Vaginal orifice

Bartholins glands

Perineum

FIG 32-2 External structures of the female reproductive system.

on either side of the labia minora and forms the lateral borders of the vulva. In the adult female, the labia majora and mons pubis, the pad of fatty tissue that covers the pubic symphysis (or pubic bone), is covered in coarse hair.

Breasts
During puberty, increased secretion of estrogen causes breasts to develop. (See Figure 32-3.) The center of each breast has a region of pigmented tissue called the areola. At the center of the areola is the nipple. Inside each breast are 15 to 20 lobes of glandular tissue, including mammary glands, which are the milk-producing glands in a female. This glandular tissue is surrounded by connective and adipose tissue.
Connective tissue

Adipose tissue Areola Nipple

Functions of the Female Reproductive System

The primary function of the female reproductive system is to bear offspring, that is, produce another human being. The internal and external organs and structures of the female reproductive system all function toward achieving this ultimate goal.

Glandular tissue

Internal Structures
Ovaries are the primary sex organs in females. Ovaries produce ova, one-half of the necessary components of a new life. They also produce two female hormones:

Mammary glands

FIG 32-3 Cross-section of the female breast.

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Estrogen acts to develop the female reproductive organs during puberty, produces secondary sexual characteristics such as breasts and pubic hair, and prepares the uterus for a fertilized egg. Progesterone is responsible for the changes in the endometrium, the lining of the uterus, which allows for implantation of the blastocyte (the developing embryo).

External Structures
The labia protect other external and internal structures. The clitoris responds to stimulation, causing orgasm. The vagina acts as the passageway for the penis during sexual intercourse and as the birth canal during the birth process.

The fallopian tubes are the pathways through which the ovum travels from an ovary to the uterus. The wavelike mbriae on the ends of the fallopian tubes help direct the ovum from the ovary into the tube. As the ovum travels down the tube, the ovary secretes estrogen and progesterone to change the endometrial tissue of the uterus to be more receptive to implantation of the ovum. The cervix and uterus house and protect the developing fetus. The muscular tissue of the uterus is able to expand during pregnancy to accommodate the growing fetus. The cervix will dilate during the birth process to allow delivery of the fetus. The multidirectional muscles of the myometrium also enable forceful contraction of the uterus during the birth process.

Breasts
The connective tissue of the breasts provides support and the adipose tissue provides insulation. The amount and distribution of the adipose tissue determine the size and shape of the breasts. However, the role of the breasts in reproduction is nourishing the neonate, or newborn baby, with the mothers breast milk, a process called lactation. The mammary glands of the breasts are the organ of milk production in response to the later part of pregnancy and after giving birth. During pregnancy, the breasts respond to four hormones:

Estrogen increases the size of the breasts. Progesterone stimulates the development of the duct system (for lactation).

Breastfeeding for a healthy baby and mother

The American Association of Pediatricians (AAP) recommends breastfeeding exclusively for the rst 6 months of an infants life. At 6 months of age, the mother can introduce solid food; however, the AAP recommends that breastfeeding continue to age 12 months. The health benets associated with breastfeeding for this length of time or longer are signicant for the baby and the mother. pneumonia, wheezing, and bronchiolitis bacterial and viral infections such as meningitis.

Benets for Mother

For some mothers and babies, breastfeeding goes smoothly from the start. For others, it takes a little time and several attempts to get the process going effectively. Like anything new, breastfeeding takes some practice. These difculties and adjustments are perfectly normal. The medical assistant should reassure a new mother who is struggling with breastfeeding and encourage her to talk to her doctors and nurses as well as her pediatrician. Other helpful resources include a lactation specialist and a breastfeeding support group. Benets of breastfeeding for the mother include: releases hormones in the body that promote mothering behaviors returns the uterus to the size it was before pregnancy more quickly may help with weight loss because milk production uses calories delays return of the menstrual period, helping to keep iron in the body reduces the risk of ovarian and breast cancers keeps bones strong, which helps protect against bone fractures in older age.

Benets for Baby

New research shows that babies who are exclusively breastfed for 6 months are less likely to develop infections, respiratory illnesses, diabetes, sudden infant death syndrome (SIDS), asthma, allergies, some cancers, and, possibly, childhood obesity. Benets of breastfeeding for babies include: physical closeness to the mothers body that helps create an emotional bond between the infant and mother more easily digested by the baby than formula no preparation required and always available all the nutrients, calories, and uids that a baby needs to be healthy growth factors that ensure the development of the babys organs many substances (that formula does not have) to protect the baby from various disorders, including: ear infection diarrhea

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Prolactin stimulates the production of milk. Oxytocin promotes the ejection of milk from the glands. (See Breastfeeding for a healthy baby and mother.)

and, instead, atrophies into a mass of fibrous tissue called the corpus albicans. In the absence of HCG and decreasing progesterone levels, the endometrium begins to deteriorate and menstruation begins.

Female Reproductive Cycle

The female reproductive system follows a cycle that parallels the life span. The cycle includes menarche, menstruation, pregnancy and childbirth (for some women), and menopause. The timing of these stages varies from woman to woman; however, the cycle will follow this order for every woman.

Menstrual Phase
The third and nal phase is the menstrual phase. In this phase, the uterus discharges necrotic endometrial tissue, mucus, and blood engorgement of the endometrium. The menstrual phase lasts between 5 to 7 days, after which the follicular phase begins again. (See Figure 32-4.)

Pregnancy
Fertilization is the process of one sperm penetrating an egg and forming a zygote. The resulting zygote has 23 chromosomes from the ovum and 23 chromosomes from the sperm and is a unique new being. The cell begins to grow and multiply immediately as it travels down the fallopian tube. The zygote reaches the uterus in 4 to 6 days and implants in the uterine endometrium. Implantation of the zygote causes a change in the menstrual cycle. The ovaries release high levels of estrogen and progesterone, causing the endometrium to be receptive to implantation. The corpus luteum secretes inhibin, which inhibits secretion of FSH in the anterior pituitary gland, and relaxin, which prevents contractions of the myometrium, increasing the likelihood of implantation of the zygote. The resulting low level of FSH along with low levels of LH prevents stimulation of a new follicle and disrupts the 28-day menstrual cycle. Secretions from the fallopian tubes and uterine glands provide nutrients for the developing zygote. After implantation, the placenta, the organ of nutrition for the growing zygote, forms within the wall of the uterus. As the zygote develops into an embryo and then a fetus, the placenta also grows to provide nourishment and supply oxygen. The placenta begins forming early after conception and is completely formed by 12 weeks gestation. The mature placenta is approximately 7'' in diameter and is in the shape of a at disc. It adheres to the wall of the uterus and connects to the developing fetus through the umbilical cord. The umbilical cord contains two arteries and one vein; the arteries supply oxygen and nutrients to the fetus while the vein removes carbon dioxide and wastes. The placenta secretes human chorionic gonadotropin (hCG), a hormone that stimulates the corpus luteum of the maternal ovary so that it will continue to secrete estrogen and progesterone. As the placenta increases in size, it will secrete estrogen and progesterone itself and hCG levels in the bloodstream will drop. Estrogen will prevent the secretion of FSH and LH (from the anterior pituitary gland), which prevents the normal menstrual cycle. Progesterone will prevent contractions of the uterus that would result in a miscarriage.

Menstruation
Menarche, the onset of menstruation (or menstruation), varies in adolescent females from age 9 up to age 17. The average age of menarche is age 13. Menstruation, also called the menstrual cycle, is a normal body process that occurs approximately every 28 days. The body gets rid of the thickened endometrial tissue that develops each month in preparation for pregnancy. The 28-day cycle occurs in three phases:

follicular luteal menstrual.

Follicular Phase
In the follicular phase, the hypothalamus of the brain secretes gonadotropin-releasing hormone (GnRH), which stimulates the anterior pituitary gland to secrete folliclestimulating hormone (FSH) and luteinizing hormone (LH). These hormones act on the graaan follicles of the ovaries, to secrete estrogen, which stimulates the growth and thickening of the endometrium of the uterus. In between 9 to 14 days, the graaan follicle ripens and bulges out of the ovarian wall in a process called ovulation. The wall becomes thinner until the ovum ruptures the wall and is released into the abdominal cavity. The spot of rupture on the ovary, now called the corpus luteum, begins to secrete progesterone, which acts on the endometrium to prepare it for pregnancy. The emergence of the ovum ends the follicular phase.

Luteal Phase
In the luteal phase, the ovum is propelled toward the fallopian tubes by the wavelike action of the fimbriae. During this phase, progesterone produced by the corpus luteum continues to cause extensive growth of the functional layer of the endometrium. If fertilization of the ovum, also called conception, occurs, the corpus luteum will secrete human chorionic gonadotropin (HCG). If no conception occurs, the corpus luteum does not secrete HCG

CHAP TER 32

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Ovarian activity

Mature follicle Secondary follicle Primordial follicle

Egg is released (ovulation)

Corpus luteum Corpus luteum

Uterine activity

Menstruation

Follicular phase

Luteal phase

Menstruation

Phase

Menstrual DAYS 1-5

Ovulatory 6-14

Postovulatory 15-28

Menstrual DAY 1

FIG 32-4 Phases of the menstrual cycle.

Pregnancy, also called gestation, is broken into three equal time periods, called trimesters. The rst trimester of pregnancy, called the embryonic and early fetal period, begins 2 weeks after fertilization when the zygote is well established in the uterus and lasts to 9 weeks gestation. During this period, the zygote becomes an embryo and develops all its tissues and organs. The pregnant patient should establish obstetrical care early in the prenatal period, the period during pregnancy and before birth. Ideally, the patient should establish regular prenatal care with an obstetrician early in the rst trimester. At 9 weeks gestation, the embryo is called a fetus. By 12 weeks, the ultrasound technician or obstetrician can determine the sex of the embryo using ultrasonography. The medical assistant can advise the pregnant patient that her body as well as that of the developing fetus is changing. Because of these changes, she will most likely experience symptoms during the rst trimester, such as fatigue, nausea, vomiting, breast tenderness, urinary frequency, constipation, and insomnia. The medical assistant and physician can encourage the patient to get proper rest, drink plenty of uids, exercise regularly, and eat small, frequent meals to minimize symptoms. During the second trimester, at 15 to 28 weeks gestation, the uterus has expanded to above the umbilicus and the expectant mother can feel the first fetal movements.

By 20 weeks, the fetus can open its eyes; by 24 weeks the fetus can hear sounds made outside the uterus. As the second trimester progresses, fetal movements become vigorous, and the mother can note when the fetus is sleeping or awake. At this time, fetal growth is rapid; by the end of the second trimester, the fetus has developed eyelashes and eyebrows and subcutaneous fat deposits. Even so, the fetus at this stage is not yet ready for birth because it still weighs less than 2 lb. If it were born at 23 weeks, it would have a 1 in 10,000 chance of surviving. During the third trimester, the fetus adds more subcutaneous fat, the testes descend in males, and the lungs grow toward full development. Maternal weight gain can be in excess of 1 lb per week. The patient may experience lower back pain and fatigue, due to the increase in fetal size and quantity of amniotic fluid. The medical assistant can encourage her patient to rest and elevate her feet if she experiences swelling, or edema. The physician must monitor weight gain and blood pressure to detect the possible onset of preeclampsia, a complication in late-term pregnancy. By the end of the seventh month, or 28 weeks gestation, the fetus has typically moved into the headdown position in anticipation of birth. At full term, 38 to 40 weeks gestation, the average weight of the fetus is 712 lb. (See Figure 32-5.)

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Period of dividing zygote, implantation, and bilaminar embryo (in weeks)

1 2

Age of embryo (in weeks)

3 CNS Heart 4 Eye Heart 5 Eye 6 Ear 7 8 Ear

Teeth Palate Limbs

Fetal period (in weeks)

9 16 20 36 38 Full term

External genitalia

FIG 32-5 Stages of embryonic and fetal development.

Birth Process
Toward the end of gestation, the placental secretion of progesterone decreases, while the levels of estrogen remain high. The myometrium will start to gently contract at irregular intervals. These early contractions that do not directly precede labor are called Braxton Hicks contractions. The beginning of labor and delivery is usually signaled by the

expulsion of the mucus plug that developed in the cervix to protect the fetus from organisms in the vagina. After the expulsion of the mucus plug, the amniotic uid from the uterus may start to leak slowly or may rush out of the body more quickly. The uterus will begin more rhythmic contractions due to a drop in the secretion of progesterone from the placenta.

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The rst stage of active labor starts with dilation and effacement of the cervix. The contractions of the uterus force the amniotic sac into the cervix, causing dilation, or expansion, of the diameter of the cervical opening. The degree of cervical dilation is measured in centimeters from 1 to 10 cm. At 10 cm, the cervix is large enough to accommodate delivery. Cervical effacement is the thinning of the cervix as the opening of the cervix (called the internal os) is pulled up into the lower portion of the uterus. This effacement further accommodates delivery. Uterine contractions increase in intensity in this stage and come at more frequent intervals. This rst stage of labor can last from 1 to 24 hours. Depending on the amount of time and the intensity of contractions, the patient may become exhausted. During this time, a nurse can provide analgesics or local anesthetics to the patient to help ease her discomfort. The second stage of labor involves delivery of the infant. In this stage, the posterior pituitary gland secretes oxytocin, a powerful hormone that causes even more forceful contraction of the uterus. During these contractions, the woman will feel the need to push, or bear down on these contractions. Eventually, as the woman bears down, the top of the babys head will appear at the cervical opening, called crowning. After the mother delivers the babys head, she will deliver the shoulders. Just before delivery of the shoulders, the babys head appears to rotate to the side. After the mother delivers the shoulders, the body of the baby passes easily through the opening, completing the second stage of labor. In the third stage of labor, the placenta detaches from the uterine wall, and the uterus expels it from the body, usually with a few more contractions. The uterus will continue to contract after delivery of the placenta to constrict open blood vessels and control bleeding. If the physician performed an episiotomy, an incision into the perineum to ease delivery, or tearing of the perineum occurred during the birth process, the patient may require sutures to the perineum.

women approximately 40 years after menarche. The menstruation may stop suddenly or the ow and frequency of menstruation may decrease gradually. Removal of the uterus or ovaries causes surgical menopause, which occurs immediately after the surgery. Symptoms of menopause vary widely in severity, begin soon after the ovaries stop functioning, and may last from a few months to several years. Signs and symptoms of menopause can include:

hot ashes, chills, night sweats excitability fatigue, apathy, mental depression, crying episodes insomnia vertigo headaches numbness, tingling, myalgia urinary and gastrointestinal disturbances.

Treatment of menopausal symptoms may include hormone replacement therapy (HRT). However, because of the risks associated with this drug therapy, the patient and physician must determine whether or not it is a viable option. The physician and medical assistant should encourage a menopausal patient to maintain a diet high in calcium, vitamins, and minerals. Such a diet will help her naturally reduce menopausal symptoms.

Medical Terminology Related to the Female Reproductive System

The female reproductive system is complex and changes throughout a womans life. The patient will seek care during her years of menstruation, pregnancy, menopause, and postmenopause. To be effective in their role, medical assistants must become well versed in the language and vocabulary that pertains to the female reproductive system. The following tables on pp. 608610. list common medical terminology related to the female reproductive system.

Menopause
The menstrual cycle continues throughout a womans life until a period called menopause, the normal cessation of menstruation. Menopause will occur naturally in most

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Table 32.1 |

Word Elements

This table contains combining forms, prexes, and sufxes related to the female reproductive system, along with examples of terms that use the word element, a pronunciation guide, and a denition for each. Word Element
Combining Forms amni/o cervic/o colp/o galact/o gynec/o amniotic sac neck; cervix vagina milk woman, female amniocentesis (am-ne-o-sen-TE-ss) cervicitis (ser-v-SI-ts) colpoptosis (kol-pop-TO-ss) galactopoiesis (ga-lak-to-poy-E-ss) gynecology (g-ne-KOL-o-je) transabdominal puncture of the amniotic sac inammation of the cervix prolapse of the vagina milk production study of diseases of the female reproductive system and the breasts hyster/o lact/o uterus (womb) milk hysterectomy (hs-ter-EK-to-me) lactation (lak-TA-shun) surgical removal of the uterus production and release of milk by mammary glands mamm/o mast/o men/o metr/o nat/o oophor/o ovari/o perine/o salping/o breast breast menses, menstruation uterus (womb); measure birth ovary ovary perineum tube (fallopian or eustachian) vagin/o Prexes antebefore, in front of antepartum (an-te-PAR-tum) period of pregnancy between conception and onset of labor dysendomultibad; painful; difcult in, within many, much dysmenorrhea (ds-men-o-RE-a) endometrium (en-do-ME-tre-um) multipara (mul-TIP-a-ra) pain associated with menstruation mucous membrane that lines the uterus woman who has delivered more than one viable infant postafter postmenopausal (post-men-o-PAW-zal) time period after permanent cessation of the menstruation preprimibefore rst precoital (pre-KO--tal) primigravida (pr-m-GRAV--da) prior to sexual intercourse woman during her rst pregnancy vagina vaginapexy (vaj-n-a-PEK-se) repair of a relaxed or prolapsed vagina mammography (mam-OG-ra-fe) mastectomy (mas-TEK-to-me) menopause (MEN-o-pawz) endometrium (en-do-ME-tre-um) prenatal (pre-NA-tal) oophorectomy (o-of-o-REK-to-me) ovariotubal (o-va-re-o-TU-bal) perineoplasty (per--NE-o-plas-te) salpingocele (sal-PING-go-sel) radiographic imaging of the breast surgical removal of the breast permanent cessation of menstrual activity mucous membrane that lines the uterus occurring before birth excision of an ovary concerning the ovary and oviducts reparative surgery on the perineum hernia of the fallopian tube

Meaning

Example

Meaning

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Table 32.1 |

Word Elementscontd
Meaning Example
menarche (men-AR-ke) uterocele (u-TER-o-sel) nulligravida (nul--GRAV-da) unipara (u-NIP-a-ra)

Word Element
Sufxes -arche -cele -gravida -para

Meaning

beginning hernia pregnancy to bear (offspring)

rst menstrual period; onset of menstruation hernia of the uterus woman who has never conceived a child woman who has had one pregnancy to 20 weeks duration or longer

-rrhea -salpinx

to ow, to discharge tube (fallopian or eustachian)

amenorrhea (a-men-o-RE-a) pyosalpinx (p-o-SAL-pnks)

abnormal absence of menstruation pus in the fallopian tube

-tocia

childbirth, labor

dystocia (ds-TO-se-a)

difcult or painful childbirth

Table 32.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to the female reproductive system with a brief denition of each. Term
adenomyosis ad-e-no-m-O-ss amenorrhea a-men-o-RE-a dysmenorrhea ds-men-o-RE-a eclampsia e-KLAMP-se-a endometriosis en-do-me-tre-O-ss broids FI-broyds gestational diabetes jes-TA-shun-al d-a-BE-tez menorrhagia men-o-RA-je-a placenta previa pla-SEN-ta PRE-ve-a preeclampsia pre-e-KLAMP-se-a uterine prolapse U-ter-n PRO-laps sexually transmitted disease SEK-shu-a-le TRANS-mt-ed ds-EZ infection that spreads by sexual contact diabetes mellitus that occurs during pregnancy benign uterine tumors disorder of pregnancy marked by hypertension, convulsions, and coma absence of menstruation or monthly period

Denition
benign invasive growth of endometrial tissue into the myometrium

painful menstruation

growth of endometrial tissue outside of the uterus, commonly on adjacent organs

menstrual bleeding that is excessive in amount of blood and number of days of menstruation condition in which the placenta is located over the cervical opening to the vagina

condition during pregnancy characterized by increasing blood pressure, proteinuria, and edema protrusion of the uterus through the vagina

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Table 32.3 |

Abbreviations

In obstetrics and gynecology, as in other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed below save time and effort in documentation and written communications. Abbreviation
C-section D&C FSH GYN IUD IVF LH LMP OB-GYN OC Pap test PID STD STI TAH TAH-BSO

Term
cesarean section dilatation and curettage follicle-stimulating hormone gynecology intrauterine device in vitro fertilization leutinizing hormone last menstrual period obstetrics and gynecology oral contraceptive Papanicolaou test pelvic inammatory disease sexually transmitted disease sexually transmitted infection total abdominal hysterectomy total abdominal hysterectomy with bilateral salpingo-oophorectomy

embarrassed by the odor that can accompany infection or may be irritable due to inability to sleep from symptoms of itching, burning, and pain. Although a symptomatic patient may be irritable, she will appreciate the care and concern of the professional medical assistant who helps the physician resolve the patients discomfort as quickly as possible. If left untreated, many vaginal infections can migrate up the reproductive tract and cause further infection and possible infertility. Common vaginal infections include candidiasis, chlamydia, genital herpes, genital warts, gonorrhea, syphilis, AIDS, trichomoniasis, and Bartholin gland cyst.

Candidiasis
ICD-9-CM code: 553.3 Candidiasis, also known as a yeast infection, is infection of the vagina by the Candida albicans pathogen. Nearly 75% of all adult women have experienced symptoms of a yeast infection. In addition, studies show that up to 19% of women may have experienced yeast infection without symptoms. (See Figure 32-6.) While infection with C. albicans can occur in other areas, such as the mouth (thrush), vaginal candidiasis usually occurs when the normal ora of the vaginal area has been disrupted. Causes of such disruption include antibiotic therapy, oral contraceptives, diabetes, clothing or undergarments that are too tight, and steroid therapy. Vaginal candidiasis during pregnancy is common, possibly as a result of increased estrogen levels. The most common cause of candidiasis is use of antibiotics. Although the intended effect of antibiotic therapy is to kill harmful bacteria, it also kills helpful bacteria (normal ora) as well. The resulting disruption of normal ora allows C. albicans to overgrow, possibly leading to infection. Signs and symptoms of vaginal candidiasis include pruritus and an odorless, white vaginal discharge that may be described as cottage cheese-like. Other patients may complain of burning with urination (dysuria). The physician

Common Obstetric and Gynecological Diseases and Disorders

There are innumerable diseases and disorders of the female reproductive system. Some of the most common include vaginal infections, menstrual disorders, uterine disorders, complications of pregnancy, infertility, brocystic breast disease, and cancer.

Vaginal Infections
Infections of the vagina, or vaginitis, may be acquired through sexual contact or as an adverse effect of medications, such as antibiotics or steroids. The medical assistant should keep in mind that the patient with a vaginal infection may be

FIG 32-6 Candida albicans.

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determines a diagnosis using a procedure called a wet preparation or wet prep. Using a speculum to open the vagina, the physician obtains a specimen from the vagina with a wooden applicator. She then places the specimen on a clean glass slide, adds 10% potassium hydroxide (KOH), and applies a glass cover slip. Positive results reveal groups of C. albicans cells, which have a characteristic appearance when viewed with a microscope. Treatment for vaginal candidiasis includes the use of vaginal antifungal drugs in oral form, such as uconazole (Diucan) or a vaginal cream or suppository, such as clotrimazole (Gyne-Lotrimin) or miconazole (Monistat). Topical creams can also be applied to the outer area if irritation is present. Typically, treatment is restricted to the female patient. However, if the infection recurs, treatment of a sexual partner may be necessary. To prevent reoccurrence of candidiasis while taking antibiotics, patients should eat active yogurt cultures and drink acidophilus milk to replenish good bacteria in the vagina. With treatment, 90% of C. albicans infections resolve. However, patients who are immunocompromised, such as those with cancer or HIV or those with diabetes may require a longer antifungal treatment regimen.

If left untreated, chlamydia can migrate up the reproductive tract, causing inammation and scarring of the fallopian tubes, resulting in permanent infertility. In addition, women with an active chlamydia infection are more susceptible than noninfected women to infection with the human immunodeciency virus (HIV) if they are exposed to the virus.

Genital Herpes
ICD-9-CM code: 553.3 Genital herpes is a sexually transmitted infection with the herpes simplex virus 2. It affects 85 to 90 million people worldwide. It is spread by sexual contact with an infected person. Symptoms of genital herpes include local pain and itching, burning, dysuria, and tingling or shooting pains 1 to 2 days before eruption of the rash. The rash is characterized by reddened patches with small vesicles in the genitorectal region. Some patients complain of fever and malaise during an outbreak. The rash lasts for approximately 10 days and is most contagious when the vesicles rupture during this time. However, asymptomatic shedding of the virus can cause transmission in the absence of an outbreak. Tests used to conrm HSV diagnosis use a sample of cells or uid, most commonly from lesions in the genital area or, less commonly, from spinal uid, blood, urine, or tears. There are two tests that conrm HSV infection:

Chlamydia
ICD-9-CM code: 553.3 Although chlamydia is a type of bacterial vaginal infection, it is also considered a sexually transmitted disease (STD) or sexually transmitted infection (STI). It is one of the most commonly transmitted STDs in North America, affecting 3 to 9 million people per year. It is thought to be present in 10% of all college students and in half of all patients with pelvic inammatory disease. The Centers for Disease Control and Prevention (CDC) recommends yearly chlamydia screenings for sexually active women under age 26. Up to 75% of females are asymptomatic, giving chlamydia its name as the silent STD. Chlamydia is caused by the pathogen Chlamydia trachomatis, which is spread through sexual contact. Symptomatic patients may complain of purulent vaginal or urethral discharge, pain in the genital area, itching, and dysuria. Diagnosis can be obtained from cultures, such as the wet preparation. Treatment may include antibiotic therapy for a minimum of 1 week with erythromycin, azithromycin (Zithromax), doxycycline (Vibramycin), or tetracycline (Sumycin). If acquired during pregnancy, chlamydia will also spread from the mother to the fetus during delivery and can cause conjunctivitis, pneumonia, or even blindness. (Note: Tetracycline is contraindicated in the pregnant patient. A pregnant patient should be prescribed mycins only.) The medical assistant should instruct the patient diagnosed with chlamydia to abstain from sexual intercourse to avoid infecting her partner and to prevent reinfection.

Herpes viral culture tests cells or uid from a fresh lesion. The physician collects the sample with a cotton swab and places it in a culture cup. It is the most specic method of determining infection and is, therefore, the most common test performed. Herpesvirus antigen detection tests cells from a fresh lesion. The physician scrapes some cells from a fresh lesion and smears them on a microscope slide. Herpesvirus antigens are visible through the microscope on the surface of cells infected with the herpesvirus. The physician may order this test along with a viral culture.

There is no cure for genital herpes; treatment with oral acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex) can be used for the initial outbreak and subsequent infections. Although these antivirals shorten the duration of the lesions, patients must be aware that the outbreak can return. The medical assistant should advise patients to abstain from sexual contact during an outbreak to prevent transmission to their partners. Genital herpes can also be transmitted from mother to fetus during delivery and can cause respiratory illnesses, retinal infection, encephalitis, or death of the neonate. Pregnant women with genital herpes can schedule a Cesarean delivery or take acyclovir to suppress the infection until after birth. Women with genital herpes have an increased risk of cervical cancer and should get yearly Papanicolaou (Pap) tests.

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Genital Warts
ICD-9-CM code: 553.3 A wart is a hypertrophy, or overgrowth, of the papillae and epidermis. Warts are small, soft, pink, raised, painless growths. Around 1 million people in the United States suffer from genital warts each year. Unlike warts that can appear on the hands or the feet, genital warts are sexually transmitted. Genital warts are caused by the human papillomavirus. The warts may be a single growth that becomes cauliower-like; they can spread to the perianal area. Most patients are asymptomatic, but some will report itching and burning. The physician diagnoses genital warts primarily by visual inspection. The diagnosis is conrmed if warts turn whitish in color when swabbed with acetic acid (vinegar). There is no complete cure for genital warts. Although topical podophyllin or laser surgery can be used to destroy genital warts, they may return after treatment. Treatment should be administered weekly until all warts are removed. After successful treatment, the patient should schedule a followup examination in 3 months. The medical assistant should instruct the patient to abstain from intercourse or use a condom to prevent infecting her partner. The lesions may disappear without treatment; however, active infection may still be present and transmission to a partner is possible. The patient should undergo testing for human immunodeciency virus (HIV) and other STDs and a Pap test every 6 months because genital warts increase her risk of cervical cancer.

of the bacterium. A Gram stain performed on a sample from the cervix or urethra, which can be done in the physicians ofce, will also reveal N. gonorrhoeae. Because of the increasing resistance of N. gonorrhoeae to uoroquinolones, the CDC currently recommends only cephalosporins to treat the disease. Such treatment may be administered through a single injection or single-dose pill. The medical assistant should emphasize to the patient the importance of completing the full course of antibiotics to prevent reinfection. She should also direct the patient to avoid contact with any discharge, because her eyes can become infected as well, and to refrain from sexual contact while being treated. After treatment, vaginal cultures ensure that the infection is gone. All people who have had sexual contact with the patient should be tested. The medical ofce must report all cases of gonorrhea to the local public health department. Pregnant patients with a known case of gonorrhea cannot deliver vaginally, because the bacteria can cause blindness in the neonate. Because many women are asymptomatic, routine treatment includes administration of silver nitrate solution to every neonates eyes immediately after birth to kill the bacteria if present. If left untreated, gonorrhea can cause pelvic inammatory disease (PID) and permanent sterility.

Syphilis
ICD-9-CM code: 553.3 Syphilis is a multistage infection caused by the spirochete Treponema pallidum. Syphilis is a sexually transmitted disease that is most commonly seen in teens, young adults, abusers of illicit drugs, and patients with HIV infection. Syphilis is most prevalent in sexually active adults between ages 20 and 29. In the United States, health ofcials reported over 36,000 cases of syphilis in 2006, including 9,756 cases of primary and secondary syphilis. Syphilis is transmitted from person to person by direct contact with skin and mucous membranes. The spirochetes can penetrate the skin and enter regional lymph nodes, spreading throughout the entire body. After an incubation period of 10 days to 2 months, painless ulcers, or chancres, appear in the primary stage of syphilis. The chancres are highly infectious and mostly appear on the genitals. In the secondary stage, a widespread body rash appears with symptoms of fever, headaches, malaise, and inammation of the lymph nodes. Moist, broad papules lled with infectious uid appear along the perineum. Shallow ulcerations in the mouth can also appear. If left untreated, secondary syphilis can progress to the third stage. Tertiary syphilis includes tissue damage to the aorta, central nervous system, bones, and skin. Permanent damage can include aortic aneurysm, meningitis, sensory and gait decits, and damage to the optic nerve, causing blindness. Diagnosis is made through a polymerase chain reaction test, available mostly at research hospitals, which detects

Gonorrhea
ICD-9-CM code: 553.3 Gonorrhea is a sexually transmitted disease caused by the pathogen Neisseria gonorrhoeae. Sexually active teens are at the highest risk for contracting gonorrhea. Co-infection with chlamydia is common and is estimated to occur in 30% of patients with gonorrhea. The CDC estimates that more than 700,000 persons in the United States acquire new gonorrhea infections each year. Only about half of these infections are reported to the CDC. In 2006, the rate of reported gonorrhea infections was 120.9 per 100,000 persons. Because the N. gonorrhoeae bacteria die with exposure to air, gonorrhea is spread only through direct sexual contact. Women with gonorrhea are commonly asymptomatic but may experience a greenish-yellow discharge from the cervix. If the fallopian tubes are affected, the patient may experience lower abdominal pain. Symptoms can also include swollen glands and a milky discharge from the anus. Three main tests are used to diagnose gonorrhea. The physician can use a swab to obtain a sample from the most likely site of infection (such as the cervix, penis, urethra, rectum, or throat). Laboratory analysis of the specimen will reveal the presence of N. gonorrhoeae. If the most likely site is the cervix or urethra, a urinalysis will also reveal presence

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antibodies to T. pallidum in blood, body uid, or tissue. Treatment consists of long-acting preparations of penicillin. The duration of treatment depends on the stage of syphilis and any co-infections, such as HIV. Doxycycline or tetracycline are substitutes if the patient is allergic to penicillin. The medical assistant should advise the patient to avoid sexual contact during treatment and refer the patient to the local public health agency to contact and locate all sexual partners. If diagnosed and treated during the primary or secondary stage, the patient will suffer no permanent damage. Latestage syphilis can lead to long-term health problems, such as heart and blood vessel damage (including aneurysm and aortitis) and damage to skin and bones.

to reduce risk of transmission to the developing fetus. Breastfeeding is contraindicated for HIV mothers because it is known to transmit the virus to the neonate.

Trichomoniasis
ICD-9-CM code: 553.3 Trichomoniasis is an infection of the vagina with the protozoa Trichomonas vaginalis. Symptoms of trichomoniasis include frothy white or yellow vaginal discharge with a characteristic foul odor. Occasionally, trichomoniasis is asymptomatic. Diagnosis is obtained by a wet preparation, which conrms the presence of T. vaginalis. Treatment with oral metronidazole (Flagyl) will kill the protozoa. If left untreated, trichomoniasis can cause an inflamed cervix and urethra. The medical assistant should instruct the patient to refrain from drinking alcohol during treatment with metronidazole, because confusion and psychosis can occur. Flagyl is contraindicated during the first trimester of pregnancy, due to potential damage to the developing fetus. First-trimester pregnant and breastfeeding patients can be treated with clotrimazole vaginal suppositories for temporary relief. The medical assistant can encourage her patient to contact her sexual partners to inform them of the diagnosis and initiate treatment. With treatment, a full recovery from infection is common. Previous infections can increase the risk of HIV transmission and delivering a baby with low birth weight. In addition, the patient with trichomoniasis is at greater risk for cervical cancer because of the damage to cervical cells.

AIDS
ICD-9-CM code: 042 (excludes asymptomatic HIV infection status V08) Acquired immune deciency syndrome (AIDS) is the most advanced stage of infection with human immunodeciency virus (HIV). The late stage of the condition leaves the body unable to ght opportunistic infections and tumors. In the United States, 40,000 new cases of AIDS are reported each year; worldwide, more than 25 million people have died from AIDS, making it the most deadly epidemic in history. Human immunodeciency virus (HIV), a retrovirus containing ribonucleic acid (RNA), causes AIDS. HIV is spread from person to person via direct contact with blood, semen, vaginal secretions, or breast milk. People at increased risk for HIV and AIDS are those with multiple sexual partners and those who abuse intravenous drugs. Symptoms of HIV include opportunistic infections, those that a healthy immune system could defend against. Signs and symptoms of these infections include fatigue, fever, chills, night sweats, oral ulcerations, dyspnea, dysphagia, anorexia, pneumonia, diarrhea, weight loss, confusion, and dementia. HIV is diagnosed by a blood test that conrms the presence of anti-HIV antibodies (IgG and IgM) and the HIV p24 antigen. AIDS is diagnosed as a later stage of HIV when the CD4+ helper T-cells are at a count of 200 or less (normal value is 1600). There is no cure for HIV. Treatment includes antiviral medications, such as AZT-zidovudine. Without treatment, the average time of survival after infection with HIV is 9 to 11 years. With treatment, the average life expectancy for newly diagnosed HIV infection is 20 years. The prognosis for AIDS varies from patient to patient. Some die in a very short time; others live for several years with a T-cell count of less than 200. The medical assistant should encourage patients who engage in behaviors at high risk for contracting HIV to get tested for HIV prior to pregnancy. If an HIV-positive patient does become pregnant, antiretroviral therapy should begin as soon as possible

Bartholin Gland Cyst

ICD-9-CM code: 616.3 The Bartholin glands are two small mucous glands located in each lateral wall of the vestibule of the vagina. These glands secrete a lubricating uid for intercourse. Approximately 2% of women develop a Bartholin gland cyst, and 85% of those cases occur during a womans reproductive years. Occasionally, the ducts of one or both of the Bartholin glands become blocked, although the cause of blockage is unknown. If blockage occurs, the lubricating uid cannot leave the gland, causing it to become inamed and tender, forming a cyst. Signs and symptoms of Bartholin gland cyst include a tender or painful lump near the vaginal opening, discomfort while walking or sitting, pain during intercourse, and fever. Visual inspection reveals an inamed gland, which conrms the diagnosis. The medical assistant can instruct the patient to try applying warm compresses to the area in an effort to open the duct and express the uid. If this treatment is unsuccessful, the physician may lance the gland with a scalpel and insert a small rubber tube to facilitate drainage. The patient must leave the drain in for a prescribed period of time,

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which varies based on the severity of the occlusion to the duct. The patient must then return to the ofce so that the physician can remove the drain. The cyst should not return, because the duct remains open after removal of the drain. The medical assistant should instruct the patient to abstain from intercourse until the drain is removed.

causes extreme weight loss. Symptoms include absent menstruation for 3 or more consecutive months (in the absence of pregnancy or breastfeeding). Treatment is directed at the cause of the lack of menstruation. HRT can regulate hormonal disruptions. In the case of anorexia or bulimia, the medical assistant should provide the patient with referrals for psychotherapy. Amenorrhea is reversible with treatment.

Menstrual Disorders
Many women experience symptoms related to menstruation. Intensity of symptoms can vary greatly. If possible, treatments are directed at decreasing symptoms without disrupting fertility. Common menstrual disorders include dysmenorrhea, amenorrhea, ovarian cysts, premenstrual syndrome, and toxic shock syndrome.

Ovarian Cysts
ICD-9-CM code: 620.2 Ovarian cysts are sacs of uid or semisolid masses that grow within the ovary. They can form any time between puberty and menopause, including during pregnancy. In the United States, nearly all premenopausal women have ovarian cysts and around 14% of postmenopausal women have them. A related disorder, polycystic ovary syndrome (PCOS), is an endocrine disorder that causes irregular ovulation, lack of menstruation, and secretion of excessive amounts of androgenic (male) hormones. The suppression of ovulation makes this syndrome a major cause of infertility. PCOS affects approximately 10% of all women in the United States. The denitive cause of ovarian cysts is unknown. Hypothyroidism and early age of menarche may contribute to the development of ovarian cysts. The cause of polycystic ovary syndrome is also unclear. However it is linked to a decrease in FSH as well as abnormally high levels of testosterone, estrogen, and luteinizing hormone. Most ovarian cysts are asymptomatic and benign. Larger cysts or cysts that occur in groups on the ovary can produce symptoms of lower back pain, nausea, vomiting, and abnormal uterine bleeding. Women with polycystic ovary syndrome are commonly diagnosed while being evaluated for infertility or absence of menstruation. Symptoms of this syndrome include acne, hyperinsulinemia, obesity, type 2 diabetes, male pattern baldness, and hirsutism (excessive body hair). The emotional effects of increased body hair and skin eruptions may adversely affect body image in young women. Because the follicles of the ovaries are not stimulated each month, absent menstruation is a common sign. Ultrasound conrms the diagnosis by revealing cysts. Treatment with oral contraceptives, which suppress ovulation and thus cause changes to the ovary, can slow the growth of ovarian cysts, reducing symptoms. If oral contraceptives do not control symptoms, the physician may perform a laparoscopic procedure to drain or remove the cysts. Emergency surgical removal is indicated if a large cyst ruptures or the ovary twists and blood supply to the ovary is compromised. Symptoms of this emergency condition include acute abdominal pain and massive intraperitoneal hemorrhage. Treatment of polycystic ovary syndrome is directed at normalizing hormone ratios and reestablishing normal menstrual cycles. Treatment for diabetes and obesity should accompany

Dysmenorrhea
ICD-9-CM code:625.3 Dysmenorrhea is pain in the lower abdominal and pelvic area associated with menstrual ow. It is most common in women in their 20s and early 30s. Causes of dysmenorrhea include hormonal imbalances, endometriosis, uterine broids, PID, and uterine malposition. Signs and symptoms include headache, nausea, vomiting, fatigue, and diarrhea. The patient may also complain of lower back pain and body aches. Symptoms typically begin 12 to 24 hours before menstruation begins and continue for 3 to 5 days. Diagnosis of dysmenorrhea depends on the health history. The patient suffering from dysmenorrhea will report an inability to go to work or school on some days during menstruation each month due to headache, backache, fatigue, and nausea. She may report that the quantity of blood is unmanageable even with a combination of extra-absorbent tampons and overnight sanitary pads. Treatment may include analgesics, warm or cold compresses, medications to reduce uterine contractions, or oral contraceptives, which suppress ovulation and, therefore, decrease symptoms. The medical assistant can advise her patient to get plenty of rest and avoid caffeine and alcohol. A healthy diet and moderate physical exercise have also been shown to lessen symptoms of dysmenorrhea. Some women experience a sharp decrease in symptoms of dysmenorrhea after pregnancy. Others experience a more gradual decrease with increasing age.

Amenorrhea
ICD-9-CM code: 626.0 Amenorrhea is the absence of menstruation in a woman between the ages of 16 and 40. Amenorrhea affects 2% to 5% of all women of childbearing age in the United States. Causes of amenorrhea include hypothalamic, pituitary, and endocrine dysfunction; congenital or acquired abnormalities of the reproductive tract; or an eating disorder that

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hormone therapy. With hormone therapy, masculinization will also decrease. With proper treatment to balance hormones, pregnancy is possible for patients with PCOS. The prognosis for ovarian cysts varies with age. Around 66% of women under age 20 who undergo treatment for ovarian cysts experience a reduction in cyst size and symptoms. About 75% of patients ages 21 to 49 experience a reduction in symptoms and size without treatment; 7% of women in this age group are diagnosed with ovarian cancer. The rate of cancer increases with age, so surgical removal of the cysts is recommended for postmenopausal women. In women age 80 and older, 60% of ovarian cysts show signs of cancer. Even so, surgery may not be warranted due to the patients age.

Toxic Shock Syndrome

ICD-9-CM code: 040.89 Toxic shock syndrome (TSS) is a rare disorder caused by an exotoxin, a dangerous substance produced by bacteria. The causative agents are Staphylococcus aureus and Streptococcus pyogenes. The CDC estimates that between 1 and 17 menstruating females out of 100,000 will get TSS. Although other sources of infection can result in TSS, it is most prevalent in young women who use tampons during menstruation. The toxin produced by S. aureus and S. pyogenes requires a neutral pH and protein-rich environment, which is provided by menstrual blood. The insertion of a tampon allows air to enter the vagina, making the normally anaerobic vagina aerobic. This air provides oxygen for further growth of the toxin. TSS may rarely develop through infection from cuts, surgical incisions, or burns on the skin. However, most people exposed to the toxin-producing strains of S. aureus and S. pyogenes do not develop TSS because of antibodies to these toxins in the normal ora of the skin. Symptoms include fever of 102F or greater and diffuse, erythematous rash followed by peeling of the skin 1 to 2 weeks after onset of the rash. The patient may experience hypotension and syncope; gastrointestinal disturbances, such as diarrhea and vomiting; and muscle aches and pains. Treatment with nafcillin or oxacillin will not affect the initial syndrome but may prevent its recurrence. The medical assistant can advise her patients who use tampons to change them often and discontinue their use if fever develops during use. Symptoms may progress to renal and hepatic failure. About 5% to 15% of TSS cases are fatal. Patients who have been successfully treated for TSS should never use tampons again because they are at an increased risk for recurrence.

Premenstrual Syndrome
ICD-9-CM code: 625.4 Premenstrual syndrome includes a range of symptoms that generally occur 7 to 14 days before menstruation begins. The severity of symptoms varies greatly and can include behavioral, neurological, respiratory, gastrointestinal, and musculoskeletal complaints. About 30% to 50% of women ages 22 to 40 suffer premenstrual syndrome. The cause of premenstrual syndrome is unknown. Increased levels of antidiuretic hormone are known to cause the signs and symptoms of fluid retention, bloating, headaches, and central nervous system symptoms. However, the cause of increased ADH is unknown. Behavioral complaints include depression, irritability, lethargy, and nervousness. Neurological complaints include headache, dizziness, fainting, and numbness in the extremities. Respiratory complaints include exacerbation of asthma, allergic rhinitis, and cold symptoms. Gastrointestinal complaints include diarrhea, constipation, abdominal cramping and bloating, temporary weight gain, and increased appetite. The patient may also experience an increase in acne and breast pain, tenderness, or enlargement. Diagnosis is based on the patients symptoms. A report of relief from symptoms on days 4 through 13 of the menstrual cycle conrms the diagnosis. Treatment is directed at reducing symptoms. The only denitive cure for PMS is hysterectomy, including removal of the ovaries. Thus, most patients manage symptoms with over-the-counter (OTC) medications, diet, and exercise. Medications can include diuretics, analgesics, stimulants such as caffeine, and antihistamines. OTC combination products such as Midol or Pamprin contain various combinations of medications to relieve symptoms. The medical assistant can advise her patient to discuss medication options with the physician and to record which OTC medications best reduce her symptoms. Women with PMS generally experience no long-term complications from the disorder, other than the continuing cycle of symptoms near the onset of menstruation. PMS alone is not linked to a decrease in fertility.

Uterine Disorders
The healthy uterus has the ability to cleanse itself with menstrual ow and secretion of normal mucus. Infections of the uterus can be caused by sexually transmitted diseases, poor hygiene, or untreated vaginal infection. Uterine disorders may also be caused by growth of abnormal tissues and uterine malposition. Common uterine disorders include endometriosis, PID, uterine broids, and uterine prolapse.

Endometriosis
ICD-9-CM code: 617.9 (site unspecied) Endometriosis is the growth of endometrial tissue outside of the uterus. Normally, the endometrium grows thicker in response to hormonal changes during the menstrual cycle. The uterus sheds the active endometrial layer during menstruation. In some women, endometrial tissue can grow outside of the uterus, affecting the ovaries, ligaments, and peritoneal tissues. (See Figure 32-7.) Endometriosis occurs in 7% to 10% of menstruating women worldwide. It can persist, though rarely, in postmenopausal women.

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Peritoneal cavity

Fallopian tube

Severe endometriosis can cause bowel and urethral obstructions, which adversely affect the urinary and GI systems.

Pelvic Inammatory Disease

ICD-9-CM code: 553.3 Pelvic inammatory disease (PID) describes any acute or chronic infection of the female reproductive system, including the vagina, cervix, uterus, fallopian tubes, and ovaries. More than 1 million women in the United States are affected by PID each year. It is most common in teenagers. PID can be caused by an untreated vaginal infection in which the infection ascends into the internal reproductive organs. The longer the infection goes untreated, the further it ascends, affecting more of the reproductive tract. The fallopian tubes may become blocked with pus or scar tissue, causing infertility. Common pathogens that cause PID include Neisseria gonorrhoeae and Chlamydia trachomatis. The patient may be asymptomatic or experience such signs and symptoms as purulent vaginal discharge, odor, fever, malaise, lower abdominal pain, dysuria, nausea, vomiting, and heavy bleeding. Culturing the discharge and identifying the causative organism conrm the diagnosis. Treatment includes antibiotic or antifungal medications as indicated by the causative organism. The medical assistant should encourage her patient to discuss STDs with her sexual partners, because they will most likely also be infected. Because PID may be asymptomatic, infection may progress untreated. Prolonged infection causes sterility through scarring of the fallopian tubes, ovaries, and uterus. The infection also increases the chances of a tubal pregnancy.

Suspensory ligaments

Ovary

FIG 32-7 Sites of endometriosis.

Although the cause of endometriosis is unknown, it is thought that either endometrial cells migrate during fetal development or the cells that are shed during menstruation are possibly expelled out of the fallopian tubes during menstruation. Recent trauma or uterine surgery are other possible causes. Endometrial tissue that grows outside of the uterus is not shed and can cause pain in the abdomen, pelvis, and vagina. Pain ensues 5 to 6 days before menstruation and lasts until 3 to 4 days after the menstrual period. The degree of pain and discomfort varies, depending on the quantity of tissue growth and its location. Diagnosis is based on visual examination via laparoscopy or biopsy, which reveal endometrial tissue outside of the uterus. Treatment options vary based on the patients age and her desire to preserve her fertility. Surgical removal of endometrial cysts can clear ovaries and fallopian tubes, restoring fertility. Oral contraceptives can suppress ovulation and, therefore, reduce symptoms. If fertility is not necessary, the physician may prescribe danazol (Danocrine) to inhibit the pituitary release of gonadotropins. Alternatively, the physician may prescribe leuprolide (Lupron) or nafarelin (Synarel) to suppress gonadotropin-releasing hormone (GnRH) production. These medications cause decline of FSH and LH, which decreases ovarian function and can induce an early menopause. If the patient decides that she no longer wants to bear children, severe cases of endometriosis are treated with complete hysterectomy, including the removal of the uterus, fallopian tubes, and ovaries. The main complication of endometriosis is impaired fertility. Around 30% to 50% of women who experience infertility are diagnosed with endometriosis. For patients who are able to decrease the amount of endometrial tissue growth outside the uterus, pregnancy is possible (if desired).

Uterine Fibroids
ICD-9-CM code: 218.9 (unspecied) Uterine broids are benign, smooth tumors made of muscle and fat, called leiomyomas. They grow in size during the reproductive years and may regress after menopause. Noncancerous tumors of the uterus are the most common tumor found in women. In the United States, about 20% to 40% of women age 35 and older have uterine broids. African American women are at greater risk. Fibroids are the most common cause of hysterectomy in premenopausal women. (See Figure 32-8.) The cause of uterine broids is unknown. They are typically asymptomatic until age 30 but cause symptoms later as they grow in size and number. Uterine broids most commonly occur in clusters and symptoms are related to their specic location. Those that encroach on the bladder region will produce urinary frequency and dysuria; those that encroach on the rectum can cause spasm of the anal sphincter. The patient may feel an abdominal fullness due to enlargement of the uterus. The most common site of uterine broids is within the endometrium. Such broids can cause

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Subserosal

Uterus

Most women who experience uterine broids and infertility also suffer from other disorders, such as decreased production of ova.

Uterine Prolapse
Fallopian tube Pedunculated

Intramural

Uterine cavity Submucosal

Cervix Vagina

ICD-9-CM code: 618.1 Uterine prolapse is the displacement of the uterus downward into the cervix. In the United States, approximately 14% of women who have given birth at least once have some degree of uterine prolapse. African American women have the lowest risk; Hispanic women have the highest risk. Parity and obesity increase the risk of uterine prolapse. Causes of uterine prolapse include age, weakening of the musculature, pelvic tumors that press the uterus downward, traumatic vaginal delivery, or chronic constipation and straining. The patient may experience an inability to empty her bladder or be asymptomatic. Diagnosis is based on physical examination. During the examination, the physician asks the patient to bear down. This pressure causes the cervix to protrude out through the vaginal opening. There are three stages of uterine prolapse:

FIG 32-8 Types of uterine broids.

mildprotrusion of the cervix into the lower portion of the vagina moderateprotrusion past the vaginal opening severeprotrusion of the entire uterus past the opening of the vagina. (See Figure 32-9.)

menorrhagia (excessive menstrual ow) and dysmenorrhea. If the broid is attached to the uterus by a stalk, pain is caused by uterine contractions in an attempt to expel the broid. Diagnosis is based on the patients report of symptoms and visualization by ultrasound conrms the diagnosis. Ultrasound is the most common diagnostic tool because it is minimally invasive and available in most medical ofces. Less commonly, a MRI or hysteroscopy is used to conrm the presence of broids. Ultrasound may also serve as an assessment tool to determine if broids are growing in size and number. Asymptomatic broids should be left untreated and observed for changes throughout the patients life. Treatment of broids that cause symptoms includes oral administration of luteinizing hormone-releasing hormone (LHRH), which causes the broids to shrink. If the patient no longer wants to preserve fertility, uterine ablation can debulk endometrial broids. The ablation procedure is a one-day surgery under general anesthesia. In the procedure, the surgeon lls the uterine cavity with heated uid that destroys the active layer of the endometrium. If uterine broids are connected by a stalk, the surgeon removes them before the ablation. As a result of the ablation, the broids blood supply is diminished and the tumor will shrink. Treatment of uterine broids is commonly successful. Depending on their location, broids may impact fertility.

Surgical correction, called uteropexy, can lift the uterus into its normal position. After surgical correction, most patients experience no further problems, but some women

Mild

Moderate

Severe

FIG 32-9 Three stages of uterine prolapse.

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suffer from recurrent prolapse and require additional surgical correction.

Complications of Pregnancy
Many women enjoy a healthy pregnancy and deliver a child without complication. Unfortunately, some pregnancies are difcult for the mother or fetus or both. Some pregnancies are unsuccessful and the patient does not deliver a live infant. In the event of complications, the medical assistant and physician can work together to treat the patient in a compassionate manner and educate her as needed. Common complications of pregnancy include ectopic pregnancy, abortion, gestational diabetes, placenta previa, abruptio placentae, and eclampsia.

Ectopic Pregnancy
ICD-9-CM code: 633.9 Ectopic pregnancy involves implantation of a fertilized ovum in places other than the uterine wall. Most ectopic pregnancies occur in the wall of the fallopian tube; however, it may occur in other places, including the cervix, abdomen, and ovaries. Ectopic pregnancy occurs in approximately 1% of all pregnancies. About 98% of these cases involve implantation in the fallopian tube. Normally, fertilization occurs in the outer one-third of the fallopian tube. The corpus luteum releases secretions from the glands within the tubes, and the fertilized cell, now called a zygote, normally moves from the fallopian tube into the uterus for implantation. If the zygote does not move into the uterus and begins to implant into the wall of the fallopian tube, it will not be able to grow and develop in the narrow space of the tube. As the cells begin to divide and the zygote grows in size, the patient may experience sharp pain, fever, and bleeding. Diagnosis is based on a positive urine pregnancy test (indicating the presence of hCG in urine) and a blood test also indicating the presence of hCG. Abdominal ultrasound shows an empty uterus and may show a gestational sac with a fetal heart within the fallopian tube. Approximately 50% of ectopic pregnancies result in miscarriage and require no surgical intervention. The other 50% require surgical removal of the embryo to prevent rupture of the tube and infection. The patient may be able to conceive again if there is no damage to the other fallopian tube. The medical assistant can comfort the patient; the physician can also console the patient and explain when she can try to conceive again.

Abortion
ICD-9-CM code: 632 Abortion is the spontaneous or therapeutic loss of a pregnancy that is less than 20 weeks gestation. Spontaneous abortion, also called miscarriage, occurs in 30% of all rst

pregnancies and up to 15% of all pregnancies. Some miscarriages occur so early in gestation that the patient is unaware that she was ever pregnant. The most common cause of spontaneous abortion is an error in fetal development that is incompatible with life. Other causes include abnormalities of the placenta, endocrine disturbances, acute infectious disease, severe shock, or trauma. Signs and symptoms of a spontaneous abortion include abdominal cramps, vaginal bleeding, and passage of clots of tissue. If the patient is aware of the pregnancy, diagnosis is conrmed by examination of expelled fetal tissue. Ultrasound may conrm complete expulsion of tissue. The medical assistant must monitor the vital signs of a patient who suffers a spontaneous abortion to ensure that the blood loss does not indicate tearing damage to the uterus. The medical assistant can submit any tissue that the patient passes and collects for examination in the laboratory. The physician must also examine the patient for shock and sepsis. If the abortion is incomplete and fetal tissue is still present in the uterus, the patient must undergo dilatation and curettage (D&C) to eliminate any remaining tissue that could cause infection. A patient may decide to end her pregnancy for emotional or physical reasons. Women who are victims of rape or incest, have an unplanned pregnancy, or have a medical condition that will compromise the pregnancy (such as cardiac or kidney disease) may elect a therapeutic abortion. In addition, if genetic defects are detected in the fetus, the patient may decide to end the pregnancy. The patient who elects to have an abortion may have some of the same emotional reactions as a patient who suffers a spontaneous abortion. The medical assistant must comfort and support her patients emotional needs in both forms of unsuccessful pregnancies. (See Emotional support after abortion.) Prognosis for surgical and spontaneous abortion in the rst trimester of gestation is usually good. The patient should recover and, if no underlying fertility issues are present, should be able to become pregnant in the future. Second- or third-trimester abortions can have complications resulting from hemorrhage and damage to internal organs, which may lead to an inability to become pregnant. Unsafe abortions, performed illegally, commonly by unqualied individuals, are a public health concern worldwide due to the high incidence of incomplete abortion, sepsis, hemorrhage, and damage to internal organs. The World Health Organization estimates that 19 million unsafe abortions are performed annually and 68,000 deaths occur as a result each year.

Gestational Diabetes
ICD-9-CM code: 648.8 Gestational diabetes is the development of type 2 diabetes mellitus in a woman during pregnancy when she did

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Emotional support after abortion

The medical assistant caring for a patient who has experienced a spontaneous or elective abortion must try to ease the patients anxiety and help her cope with the loss of the pregnancy. Whether she has miscarried or has elected to end the pregnancy for physical, economic, or other personal reasons, the patient must process the experience emotionally. The emotional response of the individual patient may vary from grief and anger to guilt, depression, sadness, or even relief. The medical assistant can refer the patient to the many support groups that are available online and through local organizations. Some other resources include: http://www.fertilityplus.org/faq/miscarriage/resources.html http://www.bellaonline.com/subjects/6461.asp Cohen, J.: Coming to Term: Uncovering the Truth about Miscarriage. New Brunswick, NJ: Rutgers University Press, 2007. McLaughlin, S.: Surviving Miscarriage: You Are Not Alone. Bloomington, IN: iUniverse, Inc., 2005.

not have diabetes before becoming pregnant. In the United States, gestational diabetes occurs in about 4% to 8% of pregnancies and usually resolves after the woman gives birth. Pregnancy brings on many changes in a patients body, including how the body uses glucose. The cells of the body may also become resistant to insulin, causing them to be starved of needed glucose. Some patients who have normal blood glucose metabolism when not pregnant develop diabetes during pregnancy. Patients at risk for gestational diabetes include women over age 25, women who are overweight at the onset of pregnancy, and women who have a family history of diabetes. Women who have miscarried or given birth to very large babies are at increased risk. Because there is a high incidence of diabetes among Native Americans, African Americans, Pacic Islanders, and Mexican Americans, patients from these ethnic groups are also at an increased risk for developing gestational diabetes. Signs and symptoms of gestational diabetes are the same as diabetes in the nonpregnant patient, including extreme thirst, fatigue, dehydration, and sudden weight loss or gain. Although not all pregnant women are considered at risk for gestational diabetes, all obstetric patients should undergo screening to prevent damage to the fetus and the mother. Such screening involves an oral glucose tolerance test for all patients at 24 to 28 weeks gestation. The test shows the patients ability to metabolize a specic load of glucose over time. After fasting for at least 12 hours, the patient must rst undergo blood testing to determine the fasting blood glucose value. She must then drink a specic dose of a

glucose solution, and, an hour later, provide another blood sample for testing to evaluate how much glucose has left the bloodstream and entered the cells. If the blood glucose level is elevated at 1 hour after ingestion of the solution, it indicates poor glucose metabolism and requires a more comprehensive 3-hour test. In the 3-hour test, the patient must continue fasting, drink more of the glucose solution, and provide blood samples at 1-, 2-, and 3-hour intervals. Blood glucose levels should peak within the rst hour after drinking the glucose and then begin to drop. Normal blood glucose values are 60 to 100 mg/dl when fasting, less than 200 mg/dl at 1 hour, and less than 140 mg/dl at 2 hours. Because the patient must remain at the hospital or laboratory for an extended period of time, the medical assistant should suggest that she bring reading materials. Treatment of gestational diabetes includes a calorierestricted diet, regular exercise, blood glucose monitoring, and, possibly, insulin injections (depending on severity) to maintain normal blood glucose levels. Oral hypoglycemic medications are contraindicated during pregnancy and should not be administered. Although gestational diabetes usually subsides after the patient gives birth, the patient has a 50% chance of developing type 2 diabetes later in life. If left untreated, gestational diabetes can cause fetal developmental problems resulting from macrosomia (excessively large fetus). In addition, the mother is at increased risk for hypertension, eclampsia, and the need for cesarean delivery.

Placenta Previa
ICD-9-CM code: 641.00 Placenta previa is the implantation of the placenta, the organ of nutrition for the developing fetus, in the lower uterine segment. The placenta normally adheres to the central or upper portion of the uterine wall. Upon labor, the fetus leaves the uterus before delivery of the placenta. However, if the placenta implants in the lower uterine segment, it can obstruct delivery of the fetus. Placenta previa occurs in approximately 1 out of every 200 pregnancies. There are three degrees of placenta previa:

centralis, where the placenta completely covers the cervix marginalis, where the placenta partially obstructs the cervix lateralis, where the cervix is not obstructed by the placenta but the placenta is placed low enough to possibly obstruct a vaginal delivery of the fetus. (See Figure 32-10.)

The cause of placenta previa is unknown but advanced maternal age (age 35 and older), increased parity (number of pregnancies), and previous uterine surgery, including cesarean section (regardless of incision type), increase the risk. Signs and symptoms of placenta previa include slight hemorrhage with recurrent severity in the seventh or eighth month of pregnancy. Gradually, the patient will experience

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FIG 32-10 Placenta previa. (A) Centralis. (B) Marginalis. (C) Lateralis.

anemia, pallor, rapid weak pulse, air hunger, and low blood pressure. Diagnosis is obtained using ultrasound. Treatment prior to delivery should include hospital bedrest and treatment of anemia. Vaginal examination is deferred, if possible, until 36 weeks gestation to prevent infection. Vaginal delivery may be attempted in cases of placenta previa marginalis and lateralis, but not for the centralis form. If vaginal delivery is attempted, the obstetrician will order a double set-up, where all equipment and personnel are available for emergency cesarean delivery. Immediate postpartum care includes monitoring the mother closely for continued bleeding and administering prophylactic antibiotics because of the high risk of infection. The risk of complications increases with the severity of placenta previa and can include medical problems for the neonate secondary to blood loss, small birth weight due to restriction of space to grow in utero, and increased incidence of congenital anomalies. Risks to the mother include A B

life-threatening hemorrhage, cesarean delivery, increased risk of postpartum hemorrhage, and increased risk of placenta accreta (in which the placenta attaches directly to uterine muscle, requiring surgical removal).

Abruptio Placentae
ICD-9-CM code: 641.20 Abruptio placentae is the sudden, premature detachment of the placenta from the uterine wall. It is estimated that 1 in 120 births are complicated by placental abruption. There are three levels of abruption:

Grade 1 is detachment of less than 20% of the surface of the placenta. Grade 2 is detachment of 20% to 50% of the placental surface. Grade 3 is detachment of more than 50% of the placenta. (See Figure 32-11.) C

Placenta Uterine wall Blood

Placenta Uterine wall Blood

Placenta Uterine wall Blood

FIG 32-11 Abruptio placentae. (A) Grade 1. (B) Grade 2. (C) Grade 3.

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The cause of abruptio placentae is unknown; however, cocaine abuse and toxemia increase the risk. Symptoms of mild abruption (grade 1) include vaginal bleeding, uterine tenderness, and mild tetany (muscular spasm). Grade 2 symptoms include those of grade 1 as well as fetal distress, because the fetus is not getting enough oxygen and nutrition. In grade 3, uterine tetany is severe, the mother is in shock, and the fetus dies due to lack of oxygen. Diagnosis is usually made when the patient reports painless bleeding during the third trimester. Ultrasound provides a visual conrmation of the diagnosis. Treatment of abruptio placentae varies with the severity of detachment. Women with a grade 1 detachment may be restricted to bedrest and undergo monitoring to prolong the pregnancy to a safe gestational age for the fetus. Administration of betamethasone, a drug that expedites development of fetal lungs, may be necessary if the fetus must be delivered early. Grade 2 detachment at or near term is treated by delivery of the fetus, either by vaginal induction or cesarean section. Because grade 3 detachment results in the death of the fetus, treatment aims to care for the mother. Depending on the degree of separation, abruptio placentae causes fetal death in 20% to 40% of cases. It can also cause maternal death, due to shock and hemorrhage. In cases of hemorrhage, an emergency hysterectomy may be necessary to save the mothers life. About 40% to 50% of infants who survive abruptio placentae experience complications, which range from mild to severe. Women who have had the condition are more likely to have reoccurrence in subsequent pregnancies.

Treatment is directed at managing seizures, monitoring blood pressure, and continuing the pregnancy for as long as possible. The patient must be hospitalized and an indwelling catheter inserted. Hourly monitoring of urinary output is necessary to diagnose renal failure. The hospitalized patient is given IV magnesium sulfate in an attempt to stop seizures. Induction of labor and cesarean section are necessary if blood pressure becomes dangerously high. Eclampsia is the most serious complication of pregnancy and can lead to maternal and fetal death. Organ damage can involve the kidneys, liver, brain, and placenta. Damage to the placenta includes infarcts, thromboses, and hemorrhages. The developing fetus may suffer severe developmental delays due to inadequate supplies of blood, oxygen, and nutrition from the damaged placenta. The medical assistant should monitor the patients blood pressure and encourage her to keep regular obstetric appointments in an attempt to diagnose pre-eclampsia and avoid life-threatening eclampsia.

Cancers of the Female Reproductive System

Some of the most common forms of cancer are cancers of the female reproductive system, including breast cancer, cervical cancer, uterine cancer, and ovarian cancer.

Breast Cancer
ICD-9-CM code:174.9 (primary) Breast cancer is the growth of abnormal cells in the tissue of the breast. It usually forms in the lactiferous ducts, the tubes that carry milk to the nipple, and the lobules, the glands that produce the milk. Breast cancer is the second leading cause of cancer death in women in the United States. According to the American Cancer Society, 1 in 8 women develop breast cancer and 1 in 28 risk death from the disease. Breast cancer occurs most commonly in women age 35 and older. It is the leading cause of death in American women ages 40 to 55. The exact cause of breast cancer is unknown. Scientists have discovered a link between breast cancer and the two genes, BRCA-1 and BRCA-2. Discovery of these genes shows that breast cancer has some genetic predisposition; however, that does not indicate the only cause of breast cancer is genetic. Risk factors for breast cancer include:

Eclampsia
ICD-9-CM code: 642.60 A condition called pre-eclampsia is characterized by severe hypertension in pregnancy. If left untreated, pre-eclampsia can progress to eclampsia, which includes convulsions and coma. About 3% to 5% of all pregnant women suffer from pre-eclampsia. Of those women, 1 in 20 progress to eclampsia. The causes of pre-eclampsia and eclampsia are unknown. However, the risk is greater in teen pregnancy, firsttime pregnancy, women age 35 and older, African American women, and women with multiple fetuses or a history of diabetes, hypertension, or renal disease. Signs and symptoms of pre-eclampsia include hypertension, proteinuria, and edema. Progression to eclampsia is indicated by severe muscle aches, severe agitation, one or more grand mal seizures, coma, and convulsions. Without treatment, seizures may recur within minutes. Severe right upper quadrant pain, indicative of hepatic edema, and generalized abdominal pain may also be present. Blood tests used to diagnose pre-eclampsia include creatinine to assess kidney function. Monitoring of blood pressure and breathing is important as well. Difculty breathing can be a sign of pre-eclampsia or eclampsia.

family history of breast cancer or presence of BRCA-1 or BRCA-2 early onset of menstruation (age 12 or earlier) or late menopause (age 55 or later) never having children or having a rst child after age 35 high-fat diet, obesity, and alcohol intake history of endometrial or ovarian cancer use of estrogen replacement therapy or oral contraceptives history of brocystic breast disease.

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Signs and symptoms of breast cancer include a dominant breast mass, bloody or brown discharge from the nipple, and breast nodules or irregularities. The breast mass is usually painless and freely moveable in the early stage but later becomes xed. If done regularly, breast self-examination (BSE) is the most reliable method for early detection of breast cancer. If the patient palpates a painless lump in her breast during BSE, the physician will conduct a breast examination and further testing to conrm the diagnosis. A mammogram can conrm the presence of a breast mass. It can also detect tumors that are too small to palpate. About 70% of masses found by mammography are benign. If a mass is found, a ne needle aspiration can be used to determine if the mass is solid or a uid-lled cyst. A biopsy of the tissue evaluates the cells for malignancy. Upon conrmation of a breast cancer diagnosis, the physician will assess the stage, or progression, of the disease. Staging involves assessment of the size of the tumor and metastasis to the chest wall, skin, axilla, or distant sites. (See Cancer staging.) Treatment for breast cancer is based on the stage of the disease, the patients age, and whether she is currently menstruating or in menopause. Treatments include various combinations of surgery, radiation, chemotherapy, and hormone therapy:

Lumpectomy involves removal of the tumor, surrounding tissue, and, possibly, adjacent lymph nodes (for testing) through a small incision. Lumpectomy is a treatment for small, well-dened lesions and is effective in early stage breast cancer. Partial mastectomy involves removal of the tumor, a wedge of surrounding normal tissue, skin and fascia, and, possibly, axillary lymph nodes. This procedure is used for early

Cancer staging
Cancer staging is used in cancers of the female reproductive system as well as cancers of other organ systems. Staging indicates the extent of the spread of cancerous tumors and provides standardized descriptions of tumors, treatment recommendations, and outcomes. It is used to create criteria for including patients in clinical trials and determine a treatment regimen as well as a prognosis. The universally used tumor, node, metastasis (TNM) staging system is based on three factors: tumor (T)size or extent of local spread of a primary tumor node (N)presence or absence and extent of regional or distal lymph node metastasis metastasis (M)presence or absence of distant metastasis (cancer in other organs).

stage breast cancer with small, well-dened lesions. Radiation or chemotherapy is common after surgery to destroy undetected diseased tissue in the breast. Total mastectomy involves surgical removal of the entire breast and is done if the cancer is conned to the breast tissue and no lymph node involvement is noted. If the patient does not have advanced disease, surgery can be performed for cosmetic reconstruction. Modied radical mastectomy involves removal of the entire breast, axillary lymph nodes, and chest fascia. This procedure is used for advanced stages of breast cancer that may include metastasis to lymph nodes or adjacent tissues. If cancer has spread to the lymph tissue, radiation and chemotherapy are used to destroy more cancer cells. This procedure replaces the older radical mastectomy procedure, where chest muscles were also removed. This newer procedure allows the patient more function and upper body strength after surgery. Radiation therapy involves the administration of radioactivity externally via external beam radiation or internally via brachytherapy, which places radioactive substances near or within cancerous cells. Radiation therapy destroys malignant cells. The radiation directed at the tumor and a margin of healthy tissue around it ensures that all of the malignant cells are affected. Radiation therapy can also be used before or after surgery to destroy small, early stage tumors. Before surgery, it weakens cancerous tissue, making it easier to remove. After surgery, it treats the local area to kill any remaining cancer cells and prevent recurrence. Chemotherapy involves the use of drugs (cytotoxins) to kill cancer cells. It can be used alone or in combination with surgery or radiation therapy. Chemotherapy is administered in a hospital, a physicians ofce, or the patients home. The drugs can be administered orally, IM, subcutaneously, or IV. Cyclophosphamide, methotrexate, and uorouracil are commonly administered in combination. Hormone therapy involves administration of antihormonal drugs, including tamoxifen, aminoglutethimide, and uoxymesterone. Breast cancer cells are thought to grow in response to such hormones as estrogen and progesterone, so these drugs suppress production of those hormones. Hormone therapy is generally offered only to women who are postmenopausal.

Prognosis is based primarily on the tumors stage. Patients with large tumors that have metastasized to lymph nodes, the chest wall, or distal organs have a poor prognosis. Patients with smaller tumors with no metastasis have better outcomes. Complications include metastasis to secondary tumors and adverse effects of chemotherapy, including nausea, vomiting, immunosuppression, fatigue, and hair loss. Because early diagnosis and treatment of cancer provides the best outcome, the medical assistant should emphasize

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the importance of routine cancer screenings to all her patients.

Cervical Cancer
ICD-9-CM code: 180.9 (primary) Cervical cancer is an abnormal growth and development of the cells of the cervix. Cervical cancer is the third most common cancer of the female reproductive tract, causing 5% of all cancer deaths in women. About 80% of all cervical cancers are squamous cell carcinomas (changes in the surface cells of the cervix) and the remaining 20% are adenocarcinomas (changes in the cells of the mucus-producing glands of the cervix). Very few cases of cervical cancer involve both types of carcinoma. Most women who get cervical cancer are in their 50s; however, younger women can also get cervical cancer. The cause of cervical cancer is unknown. Factors contributing to cervical cancer include smoking tobacco, early age intercourse, multiple sexual partners, herpes simplex 2 virus, and a history of more than one pregnancy. Because some strains of human papilloma virus (HPV) are carcinogenic to the cervix, many patients with HPV infection contract cervical cancer. (See Cervical cancer and HPV.) Early cervical cancer is asymptomatic. Pap test screening enables a diagnosis before symptoms appear so that treatment can begin early. The Pap test detects abnormal cellular changes with a 95% accuracy rate. Later stage cervical cancer signs and symptoms include abnormal vaginal bleeding, persistent discharge, and pain and bleeding after intercourse. Treatment for cervical cancer varies from cryosurgery to laser treatments to eliminate intraepithelial cancer cells.

Conization (removal of a cone-shaped section of cervical mucous membrane cells), surgical resection, radiation, and chemotherapy treat cancer that has grown deeper into the cervix. Hysterectomy is a treatment option for women with preinvasive cervical cancer who do not wish to preserve fertility. The survival rate for patients with preinvasive cancer is almost 100%. For patients with invasive cervical cancer, the survival rate is approximately 91%. About 35% of patients with invasive cervical cancer experience recurrence.

Uterine Cancer
ICD-9-CM code: 179 (primary) Uterine cancer is called an adenocarcinoma because it begins in the endometrial cells of the uterus, usually in the glandular tissue. It is the most common malignancy of the female reproductive system. Uterine cancer typically affects postmenopausal women between ages 50 and 60. The incidence is more common in white women but the death rate is higher in black women. Signs and symptoms include bleeding in the postmenopausal patient; yellow, watery discharge with a foul odor; and cramping or pressure in the abdomen or pelvis. Results of a uterine biopsy, when viewed under a microscope, will show cellular changes consistent with cancer. If the biopsy is inconclusive, the physician will perform a D&C to obtain an adequate sample to determine malignancy. Treatment for uterine cancer is most commonly a total hysterectomy to prevent recurrence of cancer to any of the reproductive organs. The physician may prescribe radiation therapy before surgery if the tumor is poorly dened. The physician may also prescribe chemotherapy after surgery to prevent growth of cancer in adjacent organs. Administration of progesterone before surgery reduces uterine bleeding during the procedure. The 1-year survival rate for uterine cancer is 92% and the 5-year survival rate varies from 65% to 70%, based on the time of diagnosis.

Cervical cancer and HPV

In 2006, researchers identied a history of human papilloma virus (HPV) as the most signicant risk factor for cervical cancer. In response to these ndings, the federal government issued a policy recommending immunization against HPV for all sexually active females. The immunization, a three-shot series, can be given to girls as young as age 8 to establish immunity prior to sexual activity. Because the federal government recommends administration of the vaccine to girls at a very young age, the policy is considered somewhat controversial. Some parents may feel the vaccine encourages or sanctions sexual activity at an early age. In addition, although the statistical correlation between HPV and cervical cancer is signicant, there is no denitive proof to date that HPV causes cervical cancer. The HPV vaccine (Gardasil) is currently available in most gynecologists ofces.

Ovarian Cancer
ICD-9-CM code: 183.0 (primary) Ovarian tumors arise from three different types of ovarian cells:

Epithelial tumors, which are changes to the surface cells of the ovary, are the most common type of ovarian cancer. Germ cell tumors are abnormal changes to the cells that produce the ova. Stromal tumors are abnormal changes to cells of the connective tissue that holds the ovary together and produces estrogen and progesterone.

Ovarian cancer accounts for 4% of all cancers among women. About 85% to 90% of ovarian cancers arise from the

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surface epithelium of the ovary. The other 10% to 15% arise as germ cell tumors from the ova within the ovary. Germ cell tumors usually occur in younger women, even prepubescent girls. Epithelial tumors most commonly affect women ages 40 to 65. Many patients who develop ovarian cancer have the BRCA-1 or BRCA-2 gene, suggesting that they have a hereditary predisposition to ovarian cancer. Early stage symptoms include mild abdominal pain, abdominal bloating, diarrhea or constipation, indigestion, gas, upset stomach, fatigue, and abnormal menstrual or vaginal bleeding. Because these symptoms are vague, many patients do not get diagnosed in the early stages. Most cases are diagnosed when the disease has already progressed and symptoms include a buildup of fluid in the abdominal cavity (ascites); shortness of breath; dry, persistent cough; nausea; vomiting; abdominal tumors; and weight loss. Treatment depends on the stage and grade of the tumor and includes surgical removal of the entire reproductive system and affected adjacent tissues, such as the regional lymph nodes and omentum. The physician may prescribe radiation and chemotherapy to kill cancer cells that have spread to adjacent organs and cannot be surgically removed. (See Taking care during radiation and chemotherapy.) Because most ovarian cancers progress to a late stage before diagnosis, only 25% of patients survive for 5 years.

assistant can assist the physician in diagnosis, treatment, and patient education related to these disorders.

Infertility
ICD-9-CM code: 628.9 (unspecied origin) Infertility is an inability to achieve pregnancy after trying to conceive for a period of 1 year or more. The condition affects 20% of all couples and may be caused by a problem in the male or the female. Infertility can be:

primary, which is the inability of a woman to conceive her rst child secondary, which is infertility in a woman who previously conceived.

Other Disorders of the Female Reproductive System

Other disorders of the female reproductive system include infertility and fibrocystic breast disease. The medical

Female causes of infertility vary from hormonal imbalances that suppress ovulation to structural problems, such as blocked fallopian tubes or uterine malposition. Eating disorders or nutritional disorders may also decrease the chance of successful conception. Diagnosis of the cause of infertility is based on a comprehensive health history of both partners with assessment of their usual timing for intercourse. Female assessment includes evaluation of ovulation by charting basal body temperature. Laparoscopic examination of the ovaries, fallopian tubes, and uterus may reveal structural abnormalities. Blood tests include an evaluation of hormone levels, which may indicate under- or overproduction of one or more of the female hormones. Hormonal balance is necessary for normal ovulation, implantation of the ova, and successful pregnancy. Treatments for infertility vary. Nonsurgical treatments are directed at correcting hormonal imbalances that suppress

Patient Education

Taking Care During Radiation and Chemotherapy

Radiation and chemotherapy are used to kill cancer cells. Unfortunately, these treatments also kill healthy cells of the body. Both regimens can cause such symptoms as nausea, vomiting, diarrhea, hair loss, fatigue, stomatitis (inammation of the tissues of the mouth), tissue necrosis, and weakening of the immune system. The medical assistant should advise her patient undergoing radiation and chemotherapy to: eat cool, soft, bland foods to reduce nausea and prevent vomiting eat iron-rich foods or take a multivitamin and mineral combination to replace red blood cells (RBCs) lost during treatment and maintain tissue oxygenation use acupuncture to treat nausea and stimulate appetite use a soft toothbrush to avoid gum irritation and infection and apply a topical, over-the-counter antibiotic to the gums use an electric razor to avoid cutting the skin and increasing the risk of infection rest oftenradiation and chemotherapy cause fatigue and ask friends or family to help with daily chores and driving to the hospital or clinic for treatments report symptoms of infection, such as fever, cough, sore throat, and dysuria, so that the physician can initiate treatment of infection or stop radiation or chemotherapy to allow the patients body to ght the infection report sudden headaches, which can indicate intracranial bleeding; a situation needing immediate attention.

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ovulation or make it impossible for the embryo to implant in the uterus. Surgical treatments include in vitro fertilization, where ova are harvested and fertilized outside of the mothers body and then implanted in the uterus. An obstetrical medical practice waiting room is commonly lled with pregnant patients; this environment can be stressful to the woman trying to conceive, as can the fact that treatments for infertility are expensive and often not covered by medical insurance. Patients who are experiencing infertility may be depressed and extremely emotional. The medical assistant can listen to and comfort her patient who is trying to conceive. The success rates for infertility treatment depend on the cause, the age of the couple, and any underlying health problems that may impact fertility. The CDC reports that assisted reproductive therapy is successful in 38% of women under age 35, 30% of women ages 35 to 37, 20% of women ages 38 to 40, and only 11% in women age 41 and older.

involving the treatment and care of a pregnant female. The physician who specializes in obstetrics is called an obstetrician. Gynecology is the specialized branch of medicine involving the female reproductive system. The physician who specializes in diagnosing and treating diseases and disorders of the female reproductive system is called a gynecologist. Medical assistants working in OB-GYN, or womens health, obtain vital signs and histories on all patients; assist with Pap tests, pelvic examinations, and breast examinations; and perform routine laboratory tests, such as urinalysis and pregnancy tests. (See Common OB-GYN interview questions.) In this area, patient education is an important part of the medical assistants job. The medical assistant should instruct patients to perform a breast self-examination every month.

Prenatal Care
Obstetric care ideally begins early in pregnancy, continues through the pregnancy, and ends in the postpartum period, the period extending several weeks after delivery. Ideally, care ends with a checkup at 2 weeks postpartum, which enables the obstetrician to monitor the patients progress throughout the pregnancy and provides many opportunities for the patient to ask questions and obtain information. The medical assistant can play a major role in educating these patients.

Fibrocystic Breast Disease

ICD-9-CM code: 610.1 Fibrocystic breast disease is the presence of multiple lumps in the breast, consisting of brous tumors or uid-lled cysts. About 33% of women ages 30 to 50 and 50% of all women at some point in their lifetime will develop brocystic breast disease. Causes of brocystic breast disease are unknown and may be related to normal aging. Symptoms include palpable, rm, well-dened, painless nodules in the breast. The cysts may be more tender than the broids and tenderness may increase in relation to the menstrual cycle. Over time, the uid-lled cysts enlarge and become brous, increasing in density and rmness. Diagnosis is conrmed by a manual breast examination and mammography. Treatments for broids include needle aspiration of uid-lled cysts. After aspiration, the cysts rarely rell with uid. The medical assistant should advise patients to reduce intake of caffeine and dietary fat, which are known to exacerbate brocystic breast disease. If dietary changes decrease the symptoms and the patient can maintain these changes, recurrence of cysts may be avoided. Although the presence of broids does not increase the risk of breast cancer, their presence may interfere with the diagnosis of breast cancer by mammogram.

Initial Visit
During the initial prenatal visit, the medical assistant or obstetrician will obtain a complete health history, including medical, surgical, family, and obstetric history. The obstetric history includes:

gravidity, which is how many times the patient has been pregnant number of live births (indicated by the term para) number of spontaneous and elective abortions (indicated by the term ab).

So, if a woman experienced 3 pregnancies, 2 births, and 1 miscarriage, she would be designated as a gravida 3, para 2, ab 1.

Common OB-GYN interview questions

The medical assistant working in an obstetric-gynecological (OB-GYN) ofce should be sure to include these questions when taking a health history: When was the rst day of your last menstrual period (LMP)? Are you sexually active? Do you use birth control? When was your last Pap test? Do you do monthly breast self-examinations?

Obstetric and Gynecological Procedures

Obstetrics and gynecology (OB-GYN), two separate specialties that are commonly combined, is also called womens health. Obstetrics is the specialized branch of medicine

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In addition to establishing the patients history, the obstetrician can determine the expected date of delivery (EDD) using Ngeles rule. (See Ngeles rule.) Many ofces have an EDD wheel, which automatically computes the EDD using Ngeles rule. (See Figure 32-12.) Also during the initial visit, the obstetrician will perform a complete breast, abdominal, pelvic, and rectal examination. The medical assistant must check vital signs, including weight, and perform baseline laboratory tests. Tests include:

over the course of the pregnancy. (See Supplements during pregnancy.) The medical assistant can also set future appointments and help establish a trusting relationship between the patient and the staff. The patient who feels comfortable with the physician and staff will be more

Ngeles rule
Ngeles rule is a formula that uses the rst day of the last menstrual period (LMP) to determine the estimated date of delivery (EDD) of an infant. Here is the formula: LMP 7 days 3 months 1 year

complete blood count (CBC) urinalysis rubella RPR Blood typing and Rh Pap test screening tests for chlamydia, gonorrhea, group B beta Streptococcus, hepatitis B and, possibly, HIV.

So, for a woman whose LMP was July 12, 2008, the EDD would be: July 12 7 days July 19 July 19 3 months April 19 April 19 1 year April 19, 2009 EDD April 19, 2009

At the rst prenatal visit, the medical assistant should educate her patient verbally and through written materials on pregnancy, food choices, and how her body will change

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Supplements during pregnancy

Most obstetricians advise their pregnant patients to take prenatal vitamin supplements during pregnancy and lactation to ensure that the developing fetus or growing infant receives the nutrients necessary for proper growth and development. Prenatal vitamins contain higher doses of folate, iron, and calcium than regular vitamin-mineral supplements, which aids in: fetal red blood cell development (iron) fetal bone and tooth development (vitamin D and calcium) deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) synthesis (folate, vitamin B12, iron, and zinc). These supplements are especially benecial if a woman experiences nausea, food aversions, or vomiting or has poor eating habits in general. The patient who is carrying multiple fetuses, smokes cigarettes, or uses illicit drugs is especially in need of vitamin and mineral supplementation.

initiate early treatment of potentially harmful conditions, conrm the due date, and identify the sex of the fetus. After the medical assistant has conducted the interview and examination, she must prepare the patient for the physicians examination. The medical assistant must ask the patient to change into an examination gown with the opening directed to the front. When the patient has nished changing, the medical assistant must knock on the door and then help the patient onto the examination table, if she needs assistance. The medical assistant should support the patient and be ready to assist the physician as she conducts the examination, which includes:

measurement of the fundal height, or how much the top of the uterus has grown upward, to determine normal growth, excessive fundal height (which can indicate multiple fetuses or excess amniotic uid), or limited fundal height (which can indicate poor fetal development or fetal death) measurement and recording of fetal heart rate using a fetoscope or Doppler fetal pulse monitor to ensure fetal circulation and detect multiple fetuses

likely to keep prenatal appointments, ask questions, and share health information.

Weight gain during pregnancy

Most physicians recommend that a pregnant woman should gain no more than 35 lb during her entire pregnancy. Excess weight gain during pregnancy can cause hypertension, increased stress on the heart, and gestational diabetes. Excess weight gain also puts the mother at risk for diabetes, heart disease, orthopedic injuries, and reduced self-esteem related to excess body weight after pregnancy. In addition to the weight contributed by the growing fetus, weight gain during pregnancy is also the result of the growing placenta, uterus, and breasts as well as amniotic uid, increased blood volume, and increased fat in the breasts for breastfeeding and in the thighs to support the growing fetus. Following is a breakdown of the average values for each element involved in weight gain for a pregnant woman who gains 20 lb during pregnancy. Although the baby may contribute a few more pounds, the placenta, uterus, and breasts remain fairly steady, regardless of other factors. Thus, the majority of additional weight gain is typically in additional fat and uid. Total weight of baby Placenta Enlarged uterus Enlarged breasts Additional fat and uid Total 7.5 lb 1.0 lb 2.0 lb 1.5 lb 8.0 lb 20.0 lb

Routine Prenatal Visits

At each visit, the medical assistant must follow a set format to ensure consistent evaluation of the mothers health and development of the fetus. This format includes:

Interviewing the patient and recording any complaints, such as food intolerances, nausea, vomiting, and fatigue. Early treatment of problems can reduce symptoms and avoid more serious complications later in the pregnancy. Requesting a urine sample and testing for glucose and protein. Glucose in the urine is an indication of diabetes or poor blood glucose control (hypoglycemia or hyperglycemia). Protein in the urine is an indication of kidney disorders, such as urinary tract infection, glomerulonephritis, and nephritis, or other pregnancy-related disorders, such as preeclampsia, eclampsia, and toxemia. Measuring the patients weight and recording the ndings. Weight gain reects the mothers nutrition and the related health of the fetus. Excessive weight gain could be due to overnutrition, poor eating habits, or uid retention. Inadequate weight gain can compromise the growth and development of the fetus. (See Weight gain during pregnancy.) Measuring and recording the patients vital signs. Changes in blood pressure may indicate hypertension and other complications. Checking the patients medical record to ensure that all laboratory test results are included. Laboratory ndings help

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internal examination of the patient, which is not performed at every visit but is used to assess the cervix to determine pregnancy or cervical dilation and effacement patient education, including asking the patient if she has questions or concerns and educating her about teratogens

(any drug or chemical that can cause damage to the developing embryo) to empower the patient to make the best decisions for her baby and her own health (See Food and drug safety during pregnancy.) orders for further testing, such as a fetal ultrasound, to determine the health and development of the fetus.

Food and drug safety during pregnancy

The medical assistant and physician need to educate the patient on the risks of teratogens, any drug or chemical that can cause damage to the developing embryo. There are several categories of teratogens that the pregnant woman should be aware of, including: environmental contaminants alcohol tobacco some medications. midface that lacks a groove between the lips and nose; and a small jaw. The affected child commonly exhibits persistent growth retardation, hyperactivity, and learning decits. The neonate with FAS may experience alcohol withdrawal symptoms during the rst few days of life. No quantity of alcohol consumption is safe during pregnancy; all physicians recommend abstaining from alcohol during pregnancy.

Tobacco
Smoking during pregnancy or exposure to second-hand smoke has been linked to low fetal birth weight, abruptio placentae, and premature birth.

Environmental Contaminants
The most common environmental contaminants that impact pregnancy are lead and mercury. Lead and mercury easily cross the placental barrier and can inict severe damage on the developing fetal nervous system. Infants and young children whose mother was exposed to lead or mercury during pregnancy show signs of delayed mental and psychomotor development, behavior problems, and impaired hearing. Fetal exposure to lead is also linked to low birth weight. Although fatty sh contains omega-3 fatty acids, which are benecial to the mother and developing fetus, many types of fatty sh contain high levels of mercury. The medical assistant should advise her pregnant patients to avoid eating shark, swordsh, king mackerel, and tilesh during pregnancy and lactation. She should also advise her patient to avoid exposure to lead by following these measures: having the water in the home tested for lead using only cold water for drinking, cooking, and making formula, because cold water absorbs less lead avoiding storing acidic foods or beverages (such as orange juice or vinegar) in ceramic dishware storing canned food after opening in a lead-free container.

Medications
In addition to the dangers of alcohol and cigarettes, the medical assistant should explain to her patient that many medications are contraindicated during pregnancy. Medication safety during pregnancy is grouped into ve categories by the U.S. Food and Drug Administration (FDA): ANo harm has been demonstrated in well-designed studies of pregnant and lactating women (for example, folic acid supplements). BWithout known risk in human pregnancy or breastfeeding; studies in laboratory animals have been performed with positive or negative effects but no known demonstrable risk in pregnancy is yet known (for example, amoxicillin, a commonly used antibiotic, and acyclovir, an antiviral medication used for herpes). CUse in human pregnancy or breastfeeding has not been adequately studied; risk of usage cannot be excluded but has not been proven (for example, albuterol, hydrocodone, omeprazole, and verapamil). DKnown to cause fetal harm when administered during pregnancy or harm to infants during breastfeeding (for example, tetracycline antibiotics). XContraindicated during pregnancy; evidence of risk has been accrued from clinical trials or postmarketing surveillance (for example, isotretinoin, thalidomide, and warfarin).

Alcohol
Alcohol is unsafe for pregnant women to consume in any dosage. At high dosages, alcohol consumption will cause fetal alcohol syndrome (FAS), a collection of characteristics that include a small head with multiple facial abnormalities; small eyes with short slits; a wide, at nasal bridge; a

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Lactation Consultation
During the last trimester of pregnancy, the medical assistant should ask her patient if she will bottle feed or breastfeed her baby. She should give the patient who plans to breastfeed written information, such as pamphlets, as well as video instruction if available. The medical assistant can also provide a referral to a lactation consultant with whom the patient can meet in the hospital after the birth or prior to the birth of her baby for a one-on-one consultation or a series of classes. The medical assistant should encourage patients to try breastfeeding because it is benecial for the mother and infant. Maternal antibodies contained in breast milk will protect the baby from many childhood illnesses. Studies have also shown that breastfed babies are less likely to suffer from high cholesterol, obesity, diabetes, allergies, and asthma. Breastfeeding also stimulates uterine contractions and helps the uterus return to pregravid (prepregnancy) size. The medical assistant should also make the patient aware of her additional nutritional requirements while breastfeeding. (See Breastfeeding diet.)

cord. Rapid changes in the respiratory and circulatory systems are evident as the infant becomes independent of the mothers circulation. The infant inhales and starts to breathe spontaneously. Carbon dioxide (CO2) levels in the infants blood rise and stimulate the respiratory center of the brain in the medulla. Full expansion of the lungs may take up to 7 days after birth. Respiration during the rst few days of life is rapidup to 40 respirations per minute. Breathing stimulates blood circulation in the neonate and the bluish color of the neonates skin changes to a normal skin tone within a few minutes. Because the neonates liver is not fully developed, his skin may look yellow, or jaundiced, due to an inability to excrete bilirubin. The obstetrician or pediatrician will assess the neonate at 1 and 5 minutes after birth. (For more information on neonatal assessment, see Chapter 33, page 641.)

Postpartum Visit
The postpartum visit is approximately 6 weeks after vaginal delivery or 2 to 3 weeks following a cesarean delivery. The medical assistant must weigh the patient and check her vital signs. The physician examines the perineum. If an episiotomy was performed, the physician checks to assess proper healing; if cesarean section was necessary, the physician assesses the sutures of the incision. The physician also performs a breast and pelvic examination and discusses birth control options with the patient. (See Contraception, page 630.)

Assessment of the Neonate

Immediately after delivery, the obstetrician suctions the infants nose and mouth and clamps and cuts the umbilical

Breastfeeding diet
The average lactating mother produces 25 oz of milk per day. In order to maintain this rate of production, she must take in an extra 500 calories each day for the rst 6 months of lactation. As the infant tapers his nursing and adds more solid foods to his diet, the need for extra calories decreases. The medical assistant can help her patients make good nutritional choices by offering information on healthy foods. Dietary requirements for a nursing mother in the rst 6 months of lactation include: additional carbohydrates, such as whole grains, fruits, and vegetables, to replace glucose used to make lactose in breast milk intake of protein and fatty acids, such as sh (other than those on the list to avoid), chicken, tofu, and legumes, at the same level as in the late stage of pregnancy intake of adequate uids, such as water, juice, and herbal or decaffeinated tea, and ber, such as whole grain breads and pastas, to prevent maternal dehydration and constipation avoidance of alcohol, caffeine, and many prescribed medications.

Assisting with the Gynecological Examination

The gynecological examination consists of vital signs assessment, height and weight measurement, breast examination, and pelvic examination, which often includes a Pap test. The patient should undergo examination annually to avoid delaying treatment of reproductive system abnormalities. When preparing a patient for the gynecological examination, the medical assistant must measure and record the patients weight and height, record the date of the patients LMP, and obtain vital signs and a health history. The patient undergoing a gynecological examination should not be menstruating. To prepare the patient for the examination, the medical assistant should advise her to void or instruct her on collecting a urine specimen if required. The patient will be more comfortable during the examination if she has an empty bladder. When taking the gynecological history, the medical assistant must be sure to ask about certain subjects, including:

menstrual cycle age at menarche (if the patient is new to the practice) regularity amount and duration of ow history of menstrual symptoms and previous treatments

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Contraception
The gynecological patient may request information on contraception (birth control). Methods for preventing pregnancy vary in their level of risk, convenience, and effectiveness. The medical assistant can offer her patient information on the various types of birth control so that she can make an informed decision with her physician. The following table lists some of the most common methods of contraception, along with a description, rate of effectiveness, contraindications, and adverse effects for each.

Type
Abstinence Surgical sterilization

Description
Refraining from sexual intercourse In females, cutting the fallopian tubes and cauterizing the ends (tubal ligation); in males, surgical resection of the vas deferens (vasectomy)*

Effectiveness
100% 100%

Contraindications
None None

Adverse Effects
None None

Diaphragm, cervical cap

Barrier method that involves insertion of a rubber disk that is roughly the size of a baseball (diaphragm) or a thimble (cap) over the cervix

89% to 98%

Latex, rubber, or spermicide allergy in either partner Uterine prolapse Cystocele

Increased risk of UTI (diaphragm) Increased risk of abnormal Pap test result (cap)

Condom

Barrier method that uses a rubber or latex sheath that ts over the penis

90% to 98%

Latex or spermicide allergy in either partner

Possible allergic response to spermicide or latex

Female condom

Barrier method that uses a latex pouch suspended from an inner ring that ts over the cervix

75% to 97%

Latex or spermicide allergy in either partner

Possible allergic response to spermicide or latex

*In some cases, vasectomy can be reversed.

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Contraceptioncontd
Effectiveness
94% to 98%

Type
Intrauterine device (IUD)

Description
T-shaped copper or plastic wire that a physician inserts into the uterus, which causes endometrial inammation, thus preventing implantation of a fertilized egg

Contraindications
Cervicitis Vaginitis History of STDs, ectopic pregnancy, endometriosis, or pelvic infection

Adverse Effects
Increased risk of PID Spotting in 10% to 15% of users

medroxyprogesterone (Depo-Provera)

Prescription medication administered via IM injection (150 mg every 3 months) that inhibits development of a follicle and prevents ovulation

99.5%

Not recommended if the patient wants to become pregnant within 1 year Breast cancer Liver disease

Headache, weight gain, depression Return of fertility may take 12 to 18 months

Oral contraceptives

Oral medication taken daily that suppresses ovulation and induces endometrial atrophy

99%

Coronary artery disease Thrombolytic disorder Breast, liver, reproductive tract cancer Smoking Diabetes Sickle cell anemia

Nausea Breakthrough bleeding Breast tenderness and uid retention Hypertension, elevated blood lipids, and blood clots Stroke

Contraceptive patch (Ortho-Evra)

Transdermal patch applied once per week for 3 weeks and nothing for the 4th week of the menstrual cycle that suppresses ovulation

99%

Coronary artery disease Thrombolytic disorder Breast, liver, reproductive tract cancer Smoking Diabetes Sickle cell anemia

Nausea Breakthrough bleeding Breast tenderness and uid retention Hypertension, elevated blood lipids, and blood clots Stroke

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urinary symptoms frequency itching and burning vaginal pain or discharge breast health (if the patient has felt any lumps and date of last mammogram) date of last Pap test sexual history, including history of STDs number of pregnancies and live births date of LMP social history, including smoking and alcohol use medications the patient is presently taking, including oral contraceptives any questions the patient has for the doctor (include on note in the medical record).

and ask her to undress completely, put on the gown with the opening in the front, and use the drape to cover her legs.

Breast Examination
When the physician is ready to begin the examination, the medical assistant should assist the patient into the supine position. The physician or nurse practitioner will begin by performing the breast examination and may use this time to explain to the patient how to do her own breast self-examination (BSE). The provider commonly asks the medical assistant to teach the patient how to do a BSE with the use of a model breast or written instructions. (See Procedure 32-1: Providing instruction on breast selfexamination.)

Pelvic Examination
The physician or nurse practitioner talks with the patient to answer questions and establish rapport. The provider should

After the medical assistant records the gynecological history, she should provide the patient with a gown and drape

PROCEDURE 32-1

Providing instruction on breast self-examination

Task Instruct the patient on how to conduct a breast selfexamination. Conditions Breast model, written patient instructional brochure, or both Patients medical record Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully instruct the patient on how to conduct a breast selfexamination. Performance Standards 1. Greet and identify the patient. 2. Discuss the importance of performing a breast selfexamination as a way to detect breast lumps. 3. Explain to the patient that she should perform a breast self-examination monthly and that the best time to conduct the examination is in the middle of her menstrual cycle because her breasts are likely to be less tender at that time. Suggest to the patient that she use a calendar to remind her to do the examination monthly. 4. Instruct the patient to stand in front of a mirror with her shoulders straight and arms on her hips. Tell her to look at each breast for changes in size, shape, or color; dimpling or puckering; redness; rash; swelling; changes in nipple shape; or discharge from the nipple. Such abnormalities may be an indication of breast pathology. 5. Tell the patient that she should next raise her arms and repeat step 4 to get a clear view of her breasts. 6. Instruct patient to inspect her nipples for discharge by squeezing them. 7. Explain to the patient that she should also inspect her breasts by lying down on a bed to allow access to all parts of the breast and palpating each breast for lumps. a. The patient should palpate the left breast with the rst two ngers of the right hand and the right breast with the rst two ngers of the left hand. Using the opposite hand enables the patient to palpate the entire breast. b. The patient should cover the entire breast, using the same starting point and going in a back-and-forth motion. You can suggest to the patient starting at the nipple and going in a circular motion from inside to outside or starting at the upper portion of the armpit and moving back and forth, covering the entire breast. Performing the procedure consistently ensures that the entire breast is evaluated. c. Instruct the patient to check for lumps in her armpits as well as the area above the breast around the collarbone. Lumps in these areas can also be an indication of breast pathology.

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8. Explain to the patient that she is looking for a small, hard, round lump and that as she performs the procedure on a regular basis, she will begin to see a pattern in her breasts and feeling a lump will become easier. 9. If available, use a breast model to demonstrate the proper technique for inspecting for lumps. A breast model will also contain simulated lumps for the patient to feel. 10. Give the patient an instructional brochure to take home. Written instructions will reinforce understanding of the procedure and aid in patient compliance.

11. Ask the patient if she has any questions and remind her to call the ofce immediately if she feels a lump. Early detection and treatment can prevent the spread of breast cancer. 12. Document the patient education in the patients medical record.
Date 08/19/08; 1:15 p.m. Pt. instructed on SBE and given written instructions. ------------------------------------------------------------J. Morgan, CMA

try to make the patient feel comfortable and not rushed. If the provider is male, the medical assistant commonly stays in the room during the pelvic examination, even if the provider does not require her assistance. For the pelvic examination, the medical assistant should assist the patient into the lithotomy position with her feet in stirrups. Because this position can be uncomfortable for the patient, the medical assistant should wait until the physician is ready to do the examination before assisting the patient into this position. She should make sure the patients buttocks are at the edge of the table and assist her as necessary to reassure and support her. As the examination continues, the physician may ask the medical assistant to hand her each instrument. It is the responsibility of the medical assistant to make sure all instruments have been properly cleaned or sterilized and are available to the physician. The medical assistant should also label all specimens accurately before taking them to the laboratory. During the examination, the physician will perform a bimanual pelvic examination. The physician places two ngers (pointer and ring ngers) inside the vagina and pushes down on the abdomen superior to the fundus (top of the uterus) with the other hand. (See Figure 32-13.) The physician will then insert a vaginal speculum into the vagina to retract the walls of the vagina in order to obtain a specimen for the Papanicolaou (Pap) test. (See Figure 32-14.) In addition to the vaginal speculum, a uterine curette, biopsy forceps, and uterine sounds are used for various gynecological procedures.

Fundus

Pubic bone

Vagina Uterus FIG 32-13 Bimanual pelvic examination.

Pap Test, KOH Preparation, and Wet Preparation

The Papanicolaou (Pap) test, also called Pap smear, is used to detect cancer cells in the cervix. Named after George Nicholas Papanicolaou, the Pap test helps diagnose cervical cancer so treatment can begin early. An older version of the test involved collecting cells and smearing them on a slide and spraying a xative. A newer version of the Pap test involves scraping the patients cervix with a cytology brush

and then immediately placing the brush in a vial of transport uid. The potassium hydroxide (KOH) preparation is used to diagnose fungal infection. The wet preparation is used to diagnose yeast, bacteria, and Trichomonas infections. Because both of these tests involve taking a sample of vaginal discharge, the physician performs them at the same time as the Pap test. (See Procedure 32-2: Preparing a patient for and assisting with a gynecological examination, pages 634 and 635.)

Common Gynecological Surgical Procedures

Gynecologists commonly treat pathologies of the vagina, cervix, and uterus with minor surgical procedures. Some procedures are offered in the physicians ofce and some require an outpatient hospital setting, where the patient is

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Bladder

Speculum

discharged on the same day as the procedure. More complicated procedures, such as a hysterectomy, require overnight hospitalization and observation.

Cryosurgery
Cryosurgery is a surgical technique that uses extremely cold probes to destroy unwanted, cancerous, or infected tissues. The physician may choose to treat the cervix with cryosurgery in cases of cervical erosion, when cervical tissue grows downward into the endocervical canal, or chronic inammation of cervical epithelial tissue due to infection. Cryosurgery uses a special machine that ows liquid nitrogen through a probe to freeze and destroy the unwanted tissue. With the patient in the lithotomy position, the physician cleans the cervix with a cotton swab soaked in sterile saline solution to remove mucus and cellular debris. Then the physician places the probe against the cervix and turns on the machine. The liquid nitrogen freezes the area in about 3 minutes. The patient may feel discomfort similar to menstrual cramping during the procedure and may take an analgesic after the procedure as directed by the physician. The medical assistant should advise the patient that

Vagina

Uterus

Cervix

FIG 32-14 Speculum retracting the walls of the vagina to obtain a specimen for the Pap test.

PROCEDURE 32-2

Preparing a patient for and assisting with a gynecological examination

Task Prepare a patient for and assist with a gynecological examination that includes a Papanicolaou (Pap) test. Conditions 3 pairs of gloves Lubricant Tissues Patient gown and drape Disposable vaginal speculum Light source Pap test container Cytology requisition form Biohazard specimen transport bag Specimen collection swab, cytobrush, or cervical scraper Biohazardous waste container Pen Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully prepare a patient for a gynecological examination, assist the physician with the examination, and prepare for and process a Pap test. Performance Standards 1. Wash or sanitize your hands and assemble the supplies, making sure supplies are situated for easy access by the physician. Label the specimen bottle and complete the cytology requisition form, being sure to list the source of the specimen (vaginal or cervical). 2. Greet and identify the patient and explain the examination procedure to ensure accurate results. 3. Instruct the patient on how to collect a urine specimen, if required. If a urine specimen is not required, ask the patient if she needs to void, because a full bladder may cause discomfort during the examination. 4. Obtain and record proper patient history, vital signs, and height and weight. 5. Instruct the patient to remove all clothing and advise her on the proper way to put on the gown (with the opening in the front) and to wrap the drape around her waist. Leave the room to allow the patient to undress, unless the patient requires your assistance. 6. Notify the physician when the patient is ready for examination. 7. Knock before re-entering the room to ensure patient privacy.

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PROCEDURE 32-2contd

8. Assist the patient into the supine position for breast examination and then into the lithotomy position for the gynecological examination, redraping as necessary. 9. Check the light source for the physician and make sure the supplies are readily available. 10. Put on gloves and assist the physician in the examination as needed. 11. Lubricate or warm the speculum according to ofce policy and hand it to the physician. Support patient as necessary. 12. Hand the cytobrush or other specimen collection swab to the physician. 13. Open the bottle so the physician can insert the cytobrush into the bottle. Swirl the cytobrush in the solution 10 times. Withdraw the cytobrush from the bottle, being sure to tap it against the side of the bottle to dislodge the cells from the cytobrush. 14. Dispose of the cytobrush in the biohazardous waste container to ensure infection control. 15. Secure the lid on the bottle. 16. If a wet mount sample is required, follow these steps: a. Hand the cotton-tipped applicator to the physician. b. After the physician takes a sample of the vaginal discharge, take the applicator from the physician and immediately put it into a test tube containing 0.5 ml of sterile saline solution. c. Vigorously mix the applicator in the test tube, pressing the tip of the applicator against the sides of the test tube to ensure that an adequate quantity of the sample is transferred to the test tube. d. Place a drop of the solution on a microscopic slide and add a coverslip. e. Place the slide on the microscope for the physician to view.

17. If a KOH preparation is required, follow the steps for a wet mount and add a few drops of 10% potassium hydroxide (KOH) to the microscope slide before adding a coverslip. 18. Apply lubricant to the physicians gloved index and middle ngers. Support the patient as necessary while the physician performs the bimanual examination. 19. After the physician completes the bimanual examination, hand a new pair of gloves to the physician for the rectal examination to avoid contaminating the rectal area with vaginal secretions. 20. When the physician has completed the examination, assist the patient out of the stirrups and back onto the examination table. Provide tissues to the patient to wipe away any lubricant before she gets dressed. 21. Explain to the patient that she may get dressed and tell her where to dispose of the gown and drape. 22. Explain to the patient how the ofce will communicate the test results to her, based on ofce policy, and release the patient. 23. Process the bottle and cytology requisition form for proper transport to the laboratory. 24. Wash your hands to ensure infection control. 25. Document the examination and Pap test, as well as other tests if performed, in the patients medical record to ensure a complete, accurate medical record. 26. Clean up the examination room according to proper disposal techniques to ensure infection control and cleanliness for the next patient.
Date 05/30/08; 9:45 a.m. Annual gynecological examination with ThinPrep Pap test. ----------------------------------------------------------J. Morgan, CMA

discharge after the procedure is normal and will last from 1 week to 1 month. The patient should avoid using tampons and engaging in sexual intercourse for 1 month after the procedure. The patient should report to the physician any foul odor in the discharge, which is an indication of infection, or heavy bleeding.

any questions she may have. The medical assistant can schedule the laparoscopy and advise the patient not to drink or eat after midnight the night before the procedure.

Dilatation and Curettage

The physician performs a dilatation and curettage (D&C) to remove the contents of the uterus in the case of an incomplete abortion and to examine the endometrial tissue in the case of excessive menstrual bleeding. In the procedure, the physician dilates the cervix and scrapes away the endometrial tissue. A D&C is performed in an operating room with the patient under general anesthesia. The physician will explain the procedure to the patient and answer any questions. The medical assistant can schedule the D&C and advise the patient not to drink or eat after midnight the night before the procedure.

Laparoscopy
For patients with suspected endometriosis, ovarian cysts or tumors, or other local internal pathologies, the physician may view the internal reproductive organs with a laparoscope. The physician performs a laparoscopy in an operating room with the patient under general anesthesia. The scope is inserted into the patients body through a small incision next to the umbilicus or the vagina. The physician must explain the procedure to the patient beforehand and answer

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Uterine Ablation
A patient suffering from dysmenorrhea (painful, difcult menstruation) who does not wish to preserve fertility can benet from a uterine ablation. Uterine ablation destroys the entire thickness of the endometrium (active layer of the uterus) and some supercial myometrium (muscle layer of the uterus). The glandular material within the endometrium responds to hormonal changes each month that cause the menstruation. Removal of the active layer causes menstruation to cease. Some women will continue to have a menstruation after the procedure since some glandular tissue may be present in the myometrium, a condition called adenomyosis. Uterine ablation is performed in an operating room with the patient under general anesthesia and in an outpatient hospital setting. The physician lls the uterine cavity with heated uid that destroys the active layer of the endometrium. The uid is introduced into the uterus via a balloon or free ow of uid. In either case, the physician will drain the uid through the tube to prevent burning the external vaginal tissues. When scheduling a uterine ablation, the medical assistant should ask the patient to have someone drive her to the hospital or surgical center. The patient should be instructed to have nothing to drink or eat after midnight the night before the procedure.

Hysterectomy
Hysterectomy is the surgical removal of the uterus. In addition, the fallopian tubes and ovaries are sometimes removed in a procedure called a salpingo-oophorectomy. Hysterectomy is the second most common abdominal surgery for women in the United States. Over 600,000 hysterectomies are performed every year, and one in three women has a hysterectomy by the age of 60. The removal of the uterus can be complete or partial:

tested and has BRCA1 or BRCA2, the two genes responsible for breast cancer. The surgeon performs a hysterectomy through an abdominal incision, if the uterus is very large or there is a large amount of scar tissue, or through the vagina, if the uterus is small and easy to remove. In a laparoscopic supracervical hysterectomy (LSH) the surgeon uses a lighted laparoscope to aid removal of the uterus in small pieces through small incisions in the abdomen. This method allows the surgeon to remove a larger uterus with a smaller abdominal incision. In a laparoscopically assisted vaginal hysterectomy (LAVH), the surgeon removes the uterus through the vagina and uses the scope to examine the area for possible pathology to adjacent organs or tissues. Complications of hysterectomy include blood clots; postsurgical infection; excessive bleeding; damage to the urinary tract, bladder, or rectum; and early onset of menopause. The gynecologist will advise the patient to abstain from sexual activity for 6 weeks after surgery. If the cervix is still intact, the gynecologist will advise the patient to have regular Pap tests to detect possible cervical cancer or dysplasia. Premenopausal women who have hysterectomy with salpingooophorectomy will experience a sudden onset of menopause. Women who undergo hysterectomy without removal of the ovaries may experience menopause sooner, but not immediately after surgery. For many women, a hysterectomy alleviates years of suffering from excessive uterine bleeding. Unless the patient has uncontrolled postpartum bleeding or cancer, she does not have to rush to a decision about hysterectomy. The medical assistant can provide the patient with information on the procedure, recovery, and alternatives to hysterectomy. (See Alternatives to hysterectomy.)

Diagnostic Testing in Pregnancy

A patient may tell the medical assistant that she did a home pregnancy test and got a positive result or she just feels that she may be pregnant. The medical assistant can then confirm the pregnancy by using a urine pregnancy test. The test results are clearest on a first morning urine sample, but accurate results can be obtained with urine obtained later in the day. Detection of human chorionic gonadotropin (HCG) indicates the presence of a placenta and, therefore, confirms pregnancy. The medical assistant can perform the urine test at the onset of the physical examination. Testing in the medical office is the same as a home urine pregnancy test; accurate results depend on following instructions. In addition to routine examinations, the physician may order additional testing to further understand the development of the fetus and initiate early treatment if abnormalities are diagnosed. Such tests include fetal ultrasound, amniocentesis, and chorionic villus sampling.

Complete, or total, hysterectomy is the most common form of the procedure. It involves the removal of the cervix as well as the uterus. Partial, or subtotal, hysterectomy is the removal of the upper portions of the uterus, the fundus and the corpus, leaving the cervix in place. Radical hysterectomy is the removal of the uterus, cervix, upper part of the vagina, and the supporting connective tissue. This form of hysterectomy is performed in cases of cancer.

Hysterectomy is indicated in cases of uterine broids, endometriosis, adenomyosis (glands embedded in the myometrium causing bleeding), vaginal prolapse, heavy menstrual bleeding, uterine cancer, advanced cervical cancer, ovarian cancer, and uncontrollable postpartum bleeding. A patient may elect to have a hysterectomy if she has a strong family history of reproductive cancers, especially if she is

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Patient Education

Front ofceBack ofce connection

Alternatives to Hysterectomy
The patient experiencing excessive menstruation and painful menstruation due to broids can elect to undergo a less invasive procedure than a hysterectomy. These options are a better choice than hysterectomy if the patient is younger and possibly interested in preserving fertility. Such procedures include: myomectomy to remove broids within the muscle of the uterus via a surgical incision through the abdomen or the vagina, depending on their size and location embolization, a relatively new procedure that cuts off the blood supply of uterine broids, causing them to shrink, using a catheter threaded into the uterine artery, which sends particles to block the blood supply to the broid.

Coding Ultrasound
Most health insurance plans do not pay for fetal ultrasound unless the physician can establish a medical necessity to perform the procedure. The physician may establish medical necessity if, for example, she is concerned about the progress of fetal development (inadequate weight gain or lack of fundal height growth) or to conrm multiple fetuses. The administrative medical assistant can inform the physician and the clinical medical assistant of the codes that will support medical necessity for fetal ultrasound for various insurance plans. If the ultrasound is performed without medical necessity, the administrative medical assistant should tell a couple who wishes to have an ultrasound to determine the sex of their baby that insurance may not cover the procedure.

Fetal Ultrasound
During the course of a womans pregnancy, the physician may order a fetal ultrasound for various reasons. The ultrasound can conrm multiple pregnancies and determine fetal age, position, and sex. It can also detect such fetal abnormalities as defects in the heart or other organs. A fetal ultrasound may be vaginal or abdominal. The medical assistant should instruct the patient to drink at least 32 oz of water 1 hour before the test because a full bladder enhances visualization of the fetus. If the ultrasound is performed at 12 weeks gestation or later, the physician can determine the sex of the fetus. The patient may choose to know the sex of the fetus or may elect to be surprised when the baby is born. If the patient does not want to know the sex of her baby, the medical assistant should be sure to note this wish in her medical record. (See Coding ultrasound.) Microscopic and chemical examination of the sample evaluates the chromosomal, enzymatic, and DNA status of the fetus. The physician performs this procedure, if necessary, at 8 to 12 weeks gestation. CVS is not a routine procedure because it is more invasive than amniocentesis. A woman who experienced miscarriage or gave birth to a baby with chromosomal abnormalities is considered high-risk and, therefore, may require CVS.

Common Gynecological Diagnostic Tests

The gynecologist may order diagnostic tests to detect infection or early stages of cancer. The medical assistant must assist the physician and comfort the patient during and after testing and provide patient instruction as needed. Common gynecological diagnostic tests include amplied DNA probe test, endometrial biopsy, and mammography.

Amniocentesis
Amniocentesis is performed at 16 to 18 weeks gestation. The physician inserts a hypodermic needle into the amniotic sac and extracts a sample of 10 to 20 ml of amniotic uid. The laboratory examines the chromosomes of fetal cells present in the uid to identify possible chromosomal abnormalities, such as Down syndrome. Because the risk of having a child with Down syndrome increases with maternal age, many physicians routinely order amniocentesis for patients over age 35.

Amplied DNA Probe Test

An amplied DNA probe test detects for chlamydia and gonorrhea. The test is available for men and women. The female patient must be tested prior to the gynecological examination because the lubricant used during examination interferes with test results. The Probe TEC pink kit contains preservatives, one large swab, one culturette, and instructions. In the procedure, the medical assistant hands the large swab to the physician, who uses it to clean the cervix, removing mucus, blood, and cellular debris that could interfere with test results. The medical assistant then discards the large swab. The physician then inserts the culturette into the cervical canal and rotates the swab for 15 to 30 seconds.

Chorionic Villus Sampling

In chorionic villus sampling (CVS), the physician inserts a biopsy catheter through the vagina and cervix to collect a small portion of the chorionic villi, the vascular projections from the chorion that form the fetal portion of the placenta.

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The physician breaks off the swab into the liquid in the transport tube and caps the tube. The medical assistant should comfort and reassure the patient during the procedure.

Colposcopy with Biopsy

If a Pap test returns an abnormal result, the physician performs a colposcopy, which is visualization of the vagina and cervix using a specialized instrument called a colposcope. With the patient in the lithotomy position, the physician cleans the vagina with a long cotton-tipped applicator moistened with sterile saline. Using another swab, she then cleans the cervix with acetic acid, which dissolves cervical mucus, aiding in visualization of normal and abnormal cells. The medical assistant should reassure the patient that the acetic acid will not burn. The physician then introduces the colposcope into the vagina and examines the cervix. Because lubricant blurs images of the tissues, the physician cannot use it to aid insertion of the colposcope. If the physician sees an area of abnormal tissue, she will perform a cervical punch or cone biopsy. The cervical punch biopsy removes small pieces of tissue with a cervical punch biopsy forceps. Because the tissue samples are small and the procedure is quick, a topical anesthetic can be used. If the physician suspects a more invasive cancer, she can obtain a larger sample with a cone biopsy. The cone biopsy requires a local anesthetic injection and can be used to remove an entire lesion. (See Figure 32-15.) The physician may cauterize the tissue to control bleeding. After obtaining the sample, the physician packs the vagina with sterile packing, applying a thick substance,

called Monsels solution, with cotton swabs to the cervix to control bleeding. The yellow solution turns black upon exposure to blood. Thus, the patient can expect to see a coffee-ground discharge. The medical assistant must place the specimen in a container of formalin, label it, complete the requisition form, and send it to the pathology laboratory for analysis. The medical assistant should tell the patient when the results will be available and conrm a phone number where the patient can be reached. She should also explain to the patient that she may experience some discomfort or cramping after the procedure. She should also advise the patient to refrain from exercising or lifting heavy objects for 24 hours and to keep the packing material in the vagina for 24 hours and report any bleeding that is greater than a normal menstrual period. The patient should also report any fever or signs of infection. (See LEEP.)

Endometrial Biopsy
The physician may perform an endometrial biopsy to determine the cause of postmenopausal bleeding. Because the postmenopausal patient no longer ovulates, the endometrium should not proliferate and cause bleeding. Postmenopausal bleeding may indicate polycystic ovaries. Estrogen replacement therapy (ERT) may also be a cause. High levels of estrogen stimulate endometrial hypertrophy and bleeding. If the patient with postmenopausal bleeding is taking ERT, the physician may decrease the dosage to determine if doing so will resolve the bleeding before performing an endometrial biopsy. In an endometrial biopsy, the physician cleans the cervix with povidone-iodine solution. Before the procedure, the medical assistant should make sure the patient does not have an iodine allergy. If the patient is allergic to iodine, the physician will use a chlorhexidine (Hibiclens) solution. Then the physician pushes a long, strawlike tube that houses a sampling device into the cervical os (the opening of the

LEEP
Some physicians prefer to perform a loop electrosurgical excision procedure (LEEP), which is less invasive than a colposcopy. In this procedure, the physician injects a local anesthetic into the cervix and places a wire loop in the vagina. A high-frequency electrical current runs through the loop and burns off abnormal tissue from the cervix and cervical canal. The LEEP procedure is a diagnostic tool, a method of obtaining biopsy specimens, and a treatment (removal of abnormal cells). Because the electrical current cauterizes tissue, this procedure causes less bleeding than a cervical punch or cone biopsy.

FIG 32-15 Biopsy forceps. (A) Punch biopsy forceps. (B) Cone biopsy forceps.

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cervix) and then the uterus. When the tube enters the uterus, the physician pulls back on a plunger, creating suction that pulls a sample of endometrial tissue from the uterine wall into the sampling device. The physician removes the tube and device and hands it to the medical assistant. The medical assistant puts the sampling device into a container, labels the container with the appropriate patient information, and completes a requisition form for transport to the pathology laboratory. The procedure is quick and almost painless. The medical assistant should explain to the patient that she may experience some cramping and can use an analgesic for pain as directed by the physician.

the patients breast on a mammography machine. Pressure is rst applied from the top and bottom of the breast and then laterally from each side to atten the breast, aiding in imaging. The patient may experience some discomfort and slight bruising. When scheduling the mammogram, the medical assistant can give written as well as verbal instructions. (See Mammography preparation.)

Chapter Summary

Mammography
Mammography is considered one of the most effective methods for early detection of breast cancer when used in combination with breast self-examination. It is recommended that women receive their rst mammogram at age 40 and have follow-up mammograms yearly or as directed by their physician. A mammogram is taken by positioning

Patient Education

Mammography Preparation
The medical assistant should provide education and instruction on mammography to a patient before the examination. She should be sure to include these instructions: If possible, do not schedule the examination immediately before or during the patients menstrual cycle. Breasts are commonly tender at this time, so the examination would be more uncomfortable. The test requires the patient to stand for approximately 15 minutes. Accommodations can be made for a patient who cannot stand for that amount of time. Avoid caffeine for several days before the test to reduce the risk of swelling and soreness, which caffeine exacerbates. Do not use any lotions, powders, antiperspirants, or deodorants on the morning of the test, because these products may interfere with the image produced. The machine will compress each breast rst from top to bottom and then from side to side. The patient may experience some discomfort; however, full compression allows for an accurate picture of the breast. Clothing from the waist up must be removed for the test. Slacks and comfortable shoes are recommended. The patient may take an analgesic, as directed by the physician, after the examination if she is sore or experiences pain.

The female reproductive system houses the organs necessary for the reproduction of another human and manufactures the hormones necessary for the development and functioning of the reproductive organs. Medical assistants must be well versed in the language and vocabulary that pertains to the female reproductive system. In addition to knowing common word elements, they should be familiar with common pathological terms and abbreviations. Obstetric patients should receive routine prenatal care and education to promote the health both of the mother and the developing fetus. Gynecological patients need health screenings and education regarding reproductive health, early diagnosis of cancers, and general health promotion. Common disorders of the female reproductive system include vaginal infections, including STDs and bacterial and fungal infections; menstrual disorders; uterine disorders; cancer; complications of pregnancy; infertility; and brocystic breast disease. Common diagnostic tests include the Pap test, breast selfexamination, biopsy, and mammogram. Common treatment procedures include cryosurgery, ablation, hormone therapy, and surgical correction.

Team Work Exercises

1. Divide into two groups. Research the HPV vaccination and debate the advantages and disadvantages of administering the vaccine to 8-year-old girls. Include such topics as vaccine safety, vaccine efcacy, and social and moral implications. Does giving the vaccine to girls encourage promiscuity? 2. Divide into four groups. Each team must create posters and computer presentations on one of the topics given here. All teams must host a womens health fair at the school to present the information. Topics include: a. breast cancer prevention (early diagnosis) b. nutrition for women c. STD prevention d. prenatal care.

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Case Studies
1. Cheryl is a 42-year-old mother of three who is interested in permanent contraception. Her husband is unwilling to have a vasectomy. Cheryl is considering tubal ligation but also wants information on pharmaceutical methods of birth control. What information can the medical assistant give to Cheryl? 2. Cynthia calls the ofce complaining of pain and bleeding after her LEEP procedure 6 days ago. What should the medical assistant discuss with the patient regarding normal aftercare for a LEEP procedure? Does she need to be seen by the physician? Explain your answer.

Information on breast cancer: www.cancer.gov/cancerinfo/ types/breast and www.nationalbreastcancer.org Information on HPV and the HPV vaccine: www. emedicine.com/MED/topic1037.htm and www.gardasil.com Information on infertility: www.resolve.org/site/ PageServer?pagename=lrn_home Information on menopause: www.nlm.nih.gov/medlineplus/ menopause.html and www.menopause.org/default.htm Information on seafood safety during pregnancy: http://www.epa.gov/waterscience/sh/advice STD information from the CDC: www.cdc.gov/std

Resources

General information on the female reproductive system: www.nlm.nih.gov/medlineplus/femalereproductivesystem.html

CHAPTER

Pediatrics
Learning Objectives
Upon completion of this chapter, the student will be able to: dene, spell, and pronounce terminology related to pediatrics identify the role of the medical assistant in pediatrics review normal growth and development identify reasons for a well-child examination describe a sick-child examination differentiate between adult and pediatric vital sign values obtain pediatric vital signs chart growth and development on male and female charts identify common screening tests for pediatric patients identify a state-mandated immunization schedule perform immunization injections identify vitamin supplements identify common childhood illnesses provide patient education regarding safety for pediatric patients.

33
ABHES Competencies
Clinical Duties
Interview and record patient history Prepare patients for procedures Take vital signs Prepare and maintain examination and treatment area Maintain medication and immunization records Perform capillary puncture Obtain throat specimen for microbiological testing Perform urinalysis Asthma Behavioral disorders Autism Down syndrome Constipation Failure to thrive Cerebral palsy Eczema Scoliosis Obesity Lead poisoning Phenylketonuria

Pediatric Procedures
Assisting with Examination Vital signs Vision screening Hearing screening Well-child examination Sick-child examination Reporting Abuse Physical abuse Sexual abuse Neglect Immunizations Vaccine registry Objections to vaccination Pediatric Laboratory Tests Urinalysis Hemoglobin and hematocrit Rapid Strep test Nutritional Counseling Birth to 6 months 6 months to 1 year Age 1 Ages 2 to 5 School-age children Adolescents Vitamin and mineral supplements

Procedures
Collecting a urine specimen from an infant

Chapter Outline
Pediatric Patients Growth and Development Medical Terminology Related to Pediatrics Common Pediatric Diseases and Disorders
Communicable Pediatric Diseases and Disorders Common cold Conjunctivitis Croup Diarrhea Impetigo Inuenza virus Otitis media Respiratory syncytial virus Strep throat Oral thrush Chickenpox Warts Noncommunicable Pediatric Diseases and Disorders Allergies Eating disorders

CAAHEP Competencies
Clinical Competencies Patient Care
Obtain vital signs Prepare and maintain examination and treatment areas Prepare patients for and assist with routine and specialty examinations Prepare patients for and assist with procedures, treatments, and minor ofce surgeries Maintain medication and immunization records

Chapter Summary Team Work Exercises Case Studies Resources

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Key Terms
adolescent

Pediatric Patients
Pediatrics is a specialty branch of medicine dealing with the care and treatment of children, including the:

Person from approximately age 12 to age 18

cerumen

Yellow or brown waxy substance produced in the ceruminous glands of the ear
child

Person from age 1 to around age 12

circumcision

Surgical removal of the prepuce

infant

neonate, or newborn, from birth to age 28 days infant, from age 1 month to 1 year child, from age 1 year to age 12 years (or onset of puberty) adolescent, from age 12 (or onset of puberty) to 18 years (or full growth).

Child between ages 1 month and 1 year

neonate

Newborn baby to age 28 days

pediatrics

Medical science relating to the care of children

pediatrician

Specialist in the treatment of childrens diseases

vaccine

A pediatrician is a medical doctor who specializes in diagnosing and treating diseases and disorders of these patients. The medical assistant or nurse, as instructed by the pediatrician, will administer vaccines, which are preparations usually provided via injection that immunize a child against contracting various childhood illnesses, some of which can be life-threatening or impact normal growth and development.

Preparation used prophylactically to improve immunity or prevent a particular disease

Growth and Development

Physical and intellectual growth and development begin at conception and continue through life. Growth can be evaluated by measuring physical aspects, such as height, weight, and head circumference, as well as by assessing development of language, social skills, and gross and ne motor skills. (See Developing motor skills.) A neonate grows at a rapid rate physically and intellectually. He changes almost daily by gaining weight and learning how to identify sounds and faces. The pediatrician assesses changes as a child grows, identifying normal and abnormal developments. Early indications of a developmental delay alert the pediatrician to address this concern.

Medical Terminology Related to Pediatrics

Terms used the in the pediatric ofce will include those that relate to growth and development; diseases common to neonates, infants, children, and adolescents; and procedures regularly performed as part of pediatric practice. Working in these practice settings will afford the medical assistant the opportunity to assist with diagnostic testing and therapeutic procedures performed on neonates, infants, children, and adolescents. To be effective in her role, a medical assistant must become well versed in the language and vocabulary that pertain to pediatrics. The following tables list common medical terminology related to pediatrics.

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Developing motor skills

Motor skills are particular skills of movement that a child acquires as he grows and develops. These motor skills are categorized as gross or ne. Gross motor skills are those skills that show the development of control over large muscle groups, producing large movements, such as rolling over. Fine motor skills show control over smaller muscle groups, producing more exact movements, such as putting nger and thumb together to grasp an object. The following table lists gross and ne motor skills along with the age of normal development.

Age in Months
2 4

Gross Motor Development

Can lift head briey in prone position Rolls front to back Can hold head up in prone position with arms extended

Fine Motor Development

Follows object vertically when in supine position Brings toys to mouth Looks at objects in hand Reaches for toys with one hand Reaches after a dropped toy Performs a thumb-nger grasp of small objects Grasps toys by handles Helps to turn pages in a book Imitates scribbling

Sits leaning with arms forward Bears full weight on legs when held in standing position

10

Walks using two hands on a rail or furniture Lets self down from standing with partial control

12

Walks a few steps Stands well alone Climbs stairs on hands and knees

15

Walks well Moves on hands and knees backwards down stairs Can get to standing position without support

Stacks two or three 1 cubes Scribbles with colors on paper Attempts feeding self with spoon Turns door knobs Stacks six to seven cubes

24

Jumps Kicks ball Throws ball overhand

Table 33.1 | Element

Word Elements
Meaning
child formation, production; origin protection from or resistance to disease

Example
pediatrician (pe-de-a-TRISH-an) congenital (kon-JEN--tal) immunization (m-u-n-ZA-shun)

Meaning
Specialist in the diagnosis and treatment of children Present at birth Protection from disease in the form of vaccination

Combining Forms ped/o gen/o immun/o

juven/o nat/o Prexes neoSufxes -iatric

young birth

juvenile (JU-ve-nl) prenatal (pre-NA-tl)

Pertaining to childhood Before birth

new

neonate (NE-o-nat)

Infant from birth to 28 days

medicine, medical profession, treatment

pediatrics (pe-de-AT-rks)

Concerning the treatment of children

-plasia -trophy

formation, growth growth, development

dysplasia (ds-PLA-ze-a) atrophy (AT-ro-fe)

Abnormal development Lack of development or growth, decrease in size of an organ or tissue

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Table 33.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to pediatrics with a pronunciation guide and brief denition for each. Term
anorexia nervosa an-o-REK-se-a ner-VO-sa asthma AZ-ma attention decit disorder a-TEN-shun DEF--st attention decit hyperactive disorder a-TEN-shun DEF--st h-per-AC-tv bronchiolitis brong-ke-o-LI-ts bulimia nervosa bu-LEM-e-a ner-VO-sa cerebral palsy SER-e-brul PAWL-ze constipation kon-st-PA-shun Down syndrome Mild to moderate mental retardation and physical characteristics due to three copies (trisomy) of chromosome 21 failure to thrive Health status assigned to infants with insufcient weight gain Psychological disorder characterized by compulsive overeating followed by selfinduced vomiting or misuse of diuretics and laxatives Disorder characterized by muscle weakness, loss of control, spastic muscle; due to birth defects or infection acquired soon after birth. Difcultly defecating due to hard, compacted stools

Denition
Psychological disorder characterized by self-starvation and morbid fear of weight gain Condition marked by recurrent attacks of dyspnea (difculty breathing) with wheezing due to bronchial spasm Behavior marked by the inability to focus attention for short periods of time or engage in quiet activities Behavior marked by the inability to focus attention or engage in quiet activities and uncontrolled compulsive behavior Inammation of the bronchioles (small passages of the bronchial tree)

febrile FE-brl obesity o-BE-s-te otitis media o-TI-ts pediculosis pe-dk-u-LO-ss scoliosis sko-le-O-ss stridor STRI-dor tonsillitis ton-sl-I-ts

Pertaining to fever

Body weight that is 20% or more over the patients ideal weight

Presence of infectious uid in the middle ear

Parasitic skin disorder caused by lice

Lateral curvature of the spine

Shrill, harsh respiratory sound heard during inhalation or in the presence of obstruction to the larynx Inammation of the tonsils, usually due to a viral infection

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Table 33.3 |

Abbreviations

In pediatrics, as in other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed below save time and effort in documentation and written communications. Abbreviation
ADD ADHD AGA APGAR BSA DDH DPT

Term
attention decit disorder attention decit hyperactive disorder appropriate for gestational age activity, pulse, grimace, appearance, respiration body surface area developmental dysplasia of the hip diptheria, pertussis, and tetanus (combination vaccine)

the likelihood of transmission of pathogens from the object to the childs mouth or from the childs mouth to the object. (See Communicating about communicable diseases.) Some of the most common pediatric communicable diseases and disorders include the common cold, conjunctivitis, croup, diarrhea, impetigo, inuenza virus, otitis media, respiratory syncytial virus, Strep throat, thrush, chickenpox, and warts.

Common cold
ICD-9-CM code: 460 The common cold is actually a group of symptoms that may be caused by several viruses. Young children are especially susceptible to common colds because their immature immune systems have not yet developed resistance to most of the viruses that cause them. Children, especially preschoolers, can have a cold 8 to 10 times per year, more than double the amount of the average adult, who has a cold 2 to 4 times per year. Although the most common cause of colds is the rhinovirus, more than 200 viruses can cause a cold. Symptoms appear 1 to 3 days after exposure to a cold virus and can include:

Hep B HiB IPV MMR

hepatitis B vaccination Haemophilus inuenzae type B vaccine inactivated poliovirus vaccine measles, mumps and rubella (combination vaccine)

PCV PDA Peds ROP SIDS

pneumococcal conjugate vaccine patent ductus arteriosis pediatrics retinopathy of prematurity sudden infant death syndrome

runny or stuffy nose sore throat coughing, sneezing, and congestion body aches and mild headache watery, itchy eyes low-grade fever (up to 102F) mild fatigue.

Diagnosis is based on physical examination and history of signs and symptoms. Treatment for the common cold

Common Pediatric Diseases and Disorders

There are innumerable pediatric diseases and disorders. Some of the most common are discussed below, grouped by communicable and noncommunicable diseases and disorders.

Front ofceBack ofce connection

Communicating About Communicable Diseases

In order to stop the spread of communicable diseases in the reception area of the pediatric medical ofce, the administrative and clinical medical assistants must work together. When a pediatric patient suspected of having a communicable disease visits the ofce, the administrative medical assistant should immediately check with the clinical medical assistant in order to remove the child from the waiting room to an examination room as soon as possible. In the reception area, where there are many patients who are well and ill, infection control is only minimally possible. In an examination room, infection control measures are in place that will more successfully inhibit the spread of disease.

Communicable Pediatric Diseases and Disorders

Communicable diseases and disorders are those that are spread from one person to another via droplets from exhaled air, blood, body uids, and contact with a surface that the infected person has touched. Children are more susceptible to communicable diseases and disorders because they are less likely to follow or be able to follow precautions such as proper hand washing. In addition, young children are prone to putting objects in their mouths, which greatly increases

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involves rest and uids. The discharge from the childs nose may become thick and yellow or green in color as the cold runs its course. The medical assistant should assure the parent or caregiver not to be alarmed by the nasal discharge. She should also advise them to contact the physician if the childs symptoms do not resolve within 1 week. In addition, she should teach caregivers and patients about infection prevention techniques. (See Preschool prevention practices.) Persistent viral colds can result in bacterial infection in the lungs, sinuses, or ears, which requires treatment.

yellow or green discharge in one or both eyes that forms a crust during the night tearing.

Conjunctivitis
ICD-9-CM code: 372.30 Conjunctivitis, commonly called pink eye, is an inammation or infection of the conjunctiva, which is the transparent membrane that lines the eyelid and part of the eyeball. A recent study estimated 4% of school children and 6% of high schoolers see a physician for conjunctivitis each year. Causes of conjunctivitis include a bacterial or viral infection, an allergic reaction, or irritation by a foreign object in the eye. Inammation of the small blood vessels in the conjunctiva cause the sclera, or white of the eye, to appear pink or red, giving it the name pink eye. The most common signs and symptoms of conjunctivitis include:

itchiness in one or both eyes redness in one or both eyes sensitivity to light blurred vision gritty feeling in one or both eyes

Bacterial conjunctivitis is the most common form found in children. It commonly produces a thick, yellow-green discharge and may be associated with a respiratory infection or a sore throat. The viral form shares the same signs and symptoms as the bacterial form except it does not develop a yellow or green discharge. Treatment for bacterial conjunctivitis consists of antibiotic eye ointment for infants and young children and eye drops for older children. An ointment is commonly easier to administer to an infant or young child than eye drops. The medical assistant should provide thorough patient teaching on eye care. (See Teaching about eye care.) Antibiotics are not effective in treating viral conjunctivitis. However, warm compresses to soothe the eye may provide symptomatic relief until the virus resolves. With treatment, conjunctivitis usually resolves within 3 to 5 days without long-term implications for vision or eye health. A neonate may be born with an incompletely opened tear duct, which causes the infection. A neonates eyes are susceptible to bacteria normally present in the mothers birth canal. In rare cases, these bacteria can cause infants to develop a serious form of conjunctivitis known as ophthalmia neonatorum, which requires immediate treatment to preserve sight. To prevent this serious complication, most hospital policies require administration of a preventive antibiotic, such as erythromycin ointment, to the eyes of every neonate.

Croup
ICD-9-CM code: 646.4 Croup is a severe, viral respiratory illness that involves swelling and edema of respiratory passages. Because children under age 5 have small airways, they are most susceptible to croup. Croup may be caused by several viruses, most commonly the parainuenza virus and, less commonly, respiratory syncytial virus (RSV), the measles virus, or other viruses. Croup is rarely caused by a bacterial infection. Croup is marked by a harsh, repetitive cough caused by swelling and edema around the larynx (vocal cords) and trachea. The sound is similar to the noise of a barking seal. Attacks of croup commonly wake a sleeping child as he gasps for breath; the experience can be frightening for the parent or caregiver and the child. Because the cause of the croup is viral, treatment is directed at keeping the child comfortable and allowing the body to ght the infection. (See Home care for croup.) Because it is contagious, hand washing and cleaning surfaces touched by the infected child can prevent spreading croup to siblings or other children. Croup is also sometimes

Patient Education

Preschool Prevention Practices

Because cold viruses are highly contagious, preschoolers who spend a lot of time with their peers are repeatedly exposed to the common cold. However, teaching prevention will reduce the number of colds. The medical assistant should teach the young child to wash his hands and cover his mouth and nose when he sneezes. Adults and children should not share towels, face cloths, or drinking glasses with infected people. To teach hand washing techniques to a child, the medical assistant can show parents and children how hand washing can be fun. She can teach the child to sing while he washes his hands. Singing Happy Birthday or a favorite nursery rhyme while hand washing will ensure that the child spends enough time lathering and rinsing his hands to remove possible pathogens that cause disease.

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Patient Education

Patient Education

Teaching About Eye Care

When treating bacterial conjunctivitis, the medical assistant should show the parent or caregiver how to administer ointment or drops properly. She must tell the caregiver to take care not to touch the container to the contaminated eye. She should also explain to the caregiver that the child should not attend school or day care until she has been treated for 24 hours to prevent spread of infection throughout the school. In addition, she should explain that frequent hand washing can prevent transmission from one eye to the other eye or to classmates and family members. Sometimes a child is born with a blockage in one or both tear ducts. If left untreated, this condition can lead to infection, because the damaged duct does not allow the eye to drain and clean the area. The pediatrician or medical assistant should instruct the caregiver to clean and massage the blocked duct. To clean the duct and the eye, the caregiver should use a moistened clean cotton ball or washcloth with warm (not hot) water, wiping away drainage around the eye from the inner canthus to the outer part of the eye. If ordered by the physician, the medical assistant should also instruct the patient to massage the tear duct two to three times each day for several months, according to the physicians order. If ordered, the medical assistant can demonstrate the proper technique by massaging the duct in an upward motion from the side of the nose to the inner canthus of the eye.

Home Care for Croup

The medical assistant can instruct parents or caregivers on proper home care for children with croup. She should instruct the parent to provide plenty of uids and encourage lots of rest. She should also instruct the parent to administer moist air using a humidier or running a hot shower and sitting in the bathroom with the child to help him to breathe more easily. Because breathing is difcult, the child could become anxious. The medical assistant should instruct the parent or caregiver to remain calm while administering moist air to help the child relax and avoid panic. While most cases of croup can be treated at home, the medical assistant should instruct parents to bring the child in if he: makes noisy, high-pitched breathing sounds when inhaling (stridor) has difculty swallowing (dysphagia) or begins to drool is extremely irritable or agitated has difculty breathing (dyspnea) develops blue or grayish skin around the nose, mouth, or ngernails (cyanosis).

treated with corticosteroids to decrease inammation in the airway. While croup is usually self-limiting, it occasionally results in death from complete obstruction of the airway. Also, if treatment includes corticosteroids, immune suppression from such medication can result in secondary infections.

Diarrhea
ICD-9-CM code: 787.91 Diarrhea is the elimination of large amounts of watery stool and mucus from the gastrointestinal tract. Because the causes of diarrhea vary, its incidence is common across all populations, regardless of age, sex, race, and socioeconomic status. Outbreaks of diarrhea may occur within a family or at a day care center, where widespread transmission of the offending pathogen causes the condition in many people. The most common cause of diarrhea in children is an infection with various forms of bacteria, viruses, or parasites. Less commonly, it may be caused by food allergy or adverse reactions to medications. Because the body is focused on

ridding itself of the offending organism, the digested food, called chyme, moves too quickly through the digestive tract to provide sufcient time for the intestines to absorb water. The irritated, inamed lining of the digestive tract secretes mucus to protect the surface of the intestines from the irritant. The result is watery stool with strings of mucus. Diarrhea may accompany another illness, such as the u, or may be present with no other symptoms. Diagnosis is based on the parent or caregivers report that the child has had two or more loose or watery stools within a 24-hour period. If bloody stool is present, the pediatrician will order collection of a fecal sample to identify the causative agent. Treatment of diarrhea aims to replenish uids and remove the cause of diarrhea, including removing foods or medications if they are the cause. If stool cultures are positive for bacteria, the pediatrician will prescribe an antibiotic. In addition to replenishing uids, an infant or a child recovering from diarrhea must eat. Withholding food can damage or cause atonia (loss of muscle tone) in the intestines. An infant should also continue to take breast milk or formula. Although the infants appetite may be poor if diarrhea is due to a cold or u, the parent or caregiver should continue to offer food. The parent or caregiver of a toddler

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and older child should feed him a mild diet that is high in carbohydrates. The child should avoid soda, juice, and sports drinks, because they lack electrolytes and contain sugar, which can cause further diarrhea. (See Home treatment for diarrhea.) The day after an infant or young child comes into the pediatric ofce with diarrhea, the medical assistant should check in with the parent or caregiver by telephone. The medical assistant can ask the parent if the diarrhea is subsiding and if the child is eating, drinking, and producing urine. The medical assistant should instruct the parent to bring the child back into the ofce if the parent sees no improvement at home. If the infant or childs diarrhea causes severe dehydration, the pediatrician may decide to admit the child to the hospital to administer IV uids and electrolytes. Most cases of diarrhea resolve with dietary changes. If diarrhea is left untreated, it could lead to decreased pulse

rate, hypotension, diminished urine output, kidney failure, confusion, acidosis and, possibly, death.

Impetigo
ICD-9-CM code: 684 Impetigo is a common, highly contagious skin infection. Impetigo accounts for 10% of all skin problems seen in the pediatric ofce. It is most prevalent in warm, humid environments and is rarely seen in northern states during the winter months. It is most common in preschoolers and commonly spreads through day care centers and preschools. Impetigo appears as small, uid-lled vesicles around the mouth or nose. The vesicles quickly enlarge and rupture, excreting a yellow exudate. The lesions then crust over and the crusty area is inamed and moist. The cause of impetigo is infection with the Streptococcus or Staphylococcus aureus pathogen. It is easily spread because

Patient Education

Home Treatment for Diarrhea

When a child has diarrhea, the medical assistant can advise the caregiver on several measures to treat it at home, including avoiding the P foods and dairy, ensuring hydration, providing a mild diet high in carbohydrates when the child is recovering, and looking for signs of serious dehydration or other signs that require a visit to the physician. The pediatrician may recommend the use of oral rehydration products, such as Pedialyte or Infalyte. The medical assistant should instruct the caregiver to give small amounts of these products, approximately 3 tablespoons, every 15 minutes. She should also be sure to tell the caregiver never to give infants or small children over-the-counter antidiarrheal medications, such as Pepto-Bismol or Imodium, because they can decrease bowel motility and cause respiratory depression and drowsiness. These products are designed and dosages are given only for older children and adults.

P foods and dairy

When a child is suffering from diarrhea, the rst care measure the caregiver can institute is eliminating certain foods from the childs diet that stimulate peristalsis (movement of food through the digestive tract). An easy way to remember these foods is to remember the letters P and D. Most fruits that start with the letter P, such as prunes, peaches, and pears (as well as apricots) will exacerbate diarrhea. In addition, the caregiver should eliminate dairy, such as milk, cheese, and yogurt, for the same reason.

BRAT for recovery

When a toddler or older child is recovering from diarrhea, the caregiver should provide foods that are high in carbohydrates, to help enhance fluid and sodium absorption, and mild, to avoid irritating the intestines. For this reason, most pediatricians recommend the BRAT diet, which consists of: Bananas Rice Applesauce Toast.

Hydration
Prolonged diarrhea will cause dehydration, electrolyte imbalance, and diaper rash in infants. The medical assistant can educate parents to look for the signs of dehydration that accompany diarrhea, including: lack of tears when crying lethargy few wet diapers dry mouth and lips weight loss irritability.

When to come to the ofce

The medical assistant should advise the parent or caregiver to bring a young child who has diarrhea for more than 2 days to see the physician to determine the cause and appropriate treatment.

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the rash is pruritic (itchy). Thus, when scratched, it spreads to other areas on the childs face and to other family members. The pediatrician will prescribe topical antibiotic ointment to kill the offending organism. The medical assistant should instruct patients and parents to wash hands frequently and refrain from sharing drinking glasses, towels, or facecloths to prevent spreading the infection. Most cases of impetigo completely resolve with treatment. As the lesions heal, they appear red; however, permanent scarring is rare. Rarely, cellulitis and lymphadenitis occur, prolonging treatment. Acute poststreptococcal glomerulonephritis is a rare but serious complication.

pediatric patients to prevent transmission by frequently washing everyones hands and toys as well as other objects used by the infected person. In addition, parents should try to prevent the sharing of toys between infected and uninfected children. Initially, the u may seem like a common cold, with a stuffy or runny nose, sore throat, headache, or fatigue. However, unlike the common cold virus, inuenza symptoms appear quickly and are more severe than the common cold. Signs and symptoms of the u in children include:

Inuenza Virus
ICD-9-CM code: 487.1 Inuenza is a respiratory viral infection that attacks the nose, throat, bronchi, and lungs. According to the Centers for Disease Control and Prevention (CDC), as many as 36,000 Americans die each year of complications of inuenza and more than 200,000 are hospitalized. Young children, patients with weakened immune systems, patients with chronic illnesses, and the elderly are especially vulnerable. Children who are taking medications that suppress the immune system have an increased risk of contracting inuenza. Also, those with asthma or other chronic lung disease, cardiovascular disease, diabetes, chronic kidney disease, HIV infection, or sickle-cell anemia are also at increased risk. The u is caused by three types of viruses:

fever can be as high as 103 to 105F diarrhea and vomiting chills and sweats headache dry cough muscle aches and pains in the back, arms, and legs weakness, fatigue, and lethargy nasal congestion loss of appetite.

inuenza type A, which is responsible for the deadly inuenza pandemics (worldwide epidemics) that strike every 10 to 40 years inuenza type B, which can cause smaller, more localized outbreaks that generally occur every 3 to 15 years inuenza type C, which is the least common form and causes only mild symptoms.

Once a patient has had the u, he develops antibodies to the specic virus that caused it. These antibodies will prevent recurrence of symptoms if the infection occurs again. However, those antibodies do not protect against new strains of the virus. The patient can also obtain antibodies from a u vaccine. The vaccine contains the virus in an attenuated (weakened) form so that the body will develop antibodies to it but will not suffer from u symptoms. Thus, when the patient comes in contact with that strain of the virus, the immune system is ready to ght off the infection. Infants and young children (as well as people over age 65) are considered at high risk for complications of inuenza. Thus, for these patients, physicians recommend an annual u vaccination, which is safe for children over age 6 months, according to the CDC.

Otitis Media
ICD-9-CM code: 382 (use 4th and 5th digits for further classication) Otitis media is an infection of the middle ear. It occurs most commonly in babies and children between ages 4 months and 5 years. Otitis media accounts for an estimated 16 million pediatric visits each year in the United States. About 17% to 20% of American children have had at least one case of otitis media by age 2. Normally, the middle ear is filled with air; in otitis media, infection causes fluid to collect behind the tympanic membrane. Infection in children is typically caused by an immature immune system and frequent viral upper respiratory infection. In addition, collection of this fluid is more common in children because the position of the eustachian tube is more horizontal, allowing fluid to collect behind the tympanic membrane, rather than drain.

Each type encompasses many different strains. Types A or B cause the u that circulates almost every winter and, occasionally, a stronger strain of these types causes a deadly pandemic or more serious local outbreak. Types A and B are constantly changing, with new strains appearing regularly, whereas type C is more stable. All three types of inuenza virus are transmitted through the air in droplets when someone with the infection coughs, sneezes, or talks. These droplets spread throughout the immediate environment of the infected person, landing on objects (such as toys and doorknobs), the hands of the infected person, or the hands or face of another person. Transmission occurs when another person touches a contaminated object and then touches her eyes, nose, or mouth. A person can also breathe the droplets into the respiratory tract from the air before they land. The medical assistant should instruct parents or caregivers of

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As more fluid is produced by the infection, increased pressure on the tympanic membrane causes pain. The fluid may be serous (clear) or purulent (pus-filled). While both serous and purulent otitis media cause pain, the purulent form can cause fever as well. An infant or young child with otitis media who cannot yet talk may pull at her ear or simply cry inconsolably. Fever and cough may accompany otitis media. Diagnosis of the infection is conrmed by physical examination of the tympanic membrane using an otoscope. A healthy tympanic membrane is gray and shiny; an infected tympanic membrane appears inamed, bulging, pink or red, and dull. (See Figure 33-1.) The child may also cry when the otoscope is inserted into the ear due to pain. If uid is present in the canal, the pediatrician may order a culture to determine the causative pathogen. In the past, the standard treatment for otitis media was administration of antibiotics. However, the overuse of antibiotics has led to resistant strains of bacteria, thus lessening the effectiveness of antibiotics overall. Thus, many pediatricians refrain from prescribing antibiotics in cases of mild or moderate infection and recommend treating pain with acetaminophen and a decongestant to promote drainage. (See Home care for otitis media.) A child with recurrent ear infections, hearing loss, or other health conditions may require antibiotics or a tympanostomy. Tympanostomy is a surgical procedure that creates an opening in the tympanic membrane to insert a small tube, which facilitates drainage of uid. (See Figure 33-2.) Patients with chronic otitis media may require a tympanostomy to prevent hearing loss from permanent damage to the ossicles of the ear.
Middle ear

Patient Education

Home Care for Otitis Media

Most parents or caregivers who take their child to see a pediatrician for otitis media expect to receive a prescription for antibiotics. To avoid overuse of antibiotics, most pediatricians now recommend treating mild otitis media with pain relievers and decongestants. Thus, the medical assistant should encourage the parent to try to manage the ear infection with home care. She should advise the parent to call the pediatrician if the child develops a fever or severe pain, which are signs of a more advanced infection that would most likely require antibiotics. Attempting to provide home care at the onset of symptoms may clear the infection, precluding the need for antibiotics. By treating fewer ear infections with antibiotics, the patient is less likely to develop resistance to antibiotics from repeated use. The medical assistant should educate the parent on how to treat an ear infection at home, including methods of pain relief, such as: pain reliever, as directed by the physician applying warm compresses to the affected ear putting a hairdryer on a low setting and gently warming the affected ear massaging the temples, nasal sinuses, and mastoid (behind the ear), which can also relieve congestion.

Tympanostomy tube

Tympanic membrane
Ear canal Tympanic membrane Eustachian tube

FIG 33-1 Tympanic membrane in otitis media.

FIG 33-2 Tympanostomy.

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Respiratory Syncytial Virus

ICD-9-CM code: 079.6 Respiratory syncytial virus (RSV) is a virus that causes infections of the respiratory tract and the lungs. It is so common that most children have been infected with the virus by the time they reach age 2. It is the leading cause of serious respiratory infection in infants and children. Children at higher risk for RSV include those with weakened immune systems (such as from chemotherapy or transplantation) or congenital heart or lung disease, those born prematurely or with a low birth weight, and those attending child care or who have siblings attending child care. Infants who are exposed to cigarette smoke or high levels of air pollution are also at increased risk for developing RSV. RSV is caused by exposure to the virus and is spread by respiratory secretions of infected persons. Signs and symptoms of severe RSV in young children include:

can lead to a lower respiratory tract illness, such as pneumonia (inammation of the lungs) and bronchiolitis (inammation of the bronchioles). RSV is the most common cause of these disorders.

Strep Throat
ICD-9-CM code: 034.0 Strep throat is an infection that causes throat soreness, inammation and tenderness of cervical lymph glands, and fever. It can occur at any age; however, it is rarely seen in children younger than age 3. Strep throat is caused by infection with group A Streptococcus bacteria. Family members who carry the Streptococcus bacteria may be asymptomatic (experience no symptoms). These family members can pass the infection to children, who then experience repeated infection. Some people, called carriers, harbor the Streptococcus bacteria in their throats but never experience symptoms. Signs and symptoms of Strep throat in infants and small children include sleeplessness, irritability, fever, refusal to breastfeed or drink from a bottle or cup, and, occasionally, a ne, red rash on the torso, arms, and legs. Throat culture conrming the presence of Streptococcus diagnoses the condition. Treatment of Strep throat involves administration of antibiotics. Treatment is the same for younger and older children. The medical assistant should encourage the parent or caregiver to administer the entire prescription of antibiotics to avoid superinfection. (See Antibiotics and superinfection page 652.) If the parent tells the medical assistant that she cannot afford to purchase the entire prescription, the medical assistant should investigate offering samples to the parent. Additionally, the medical assistant can investigate social services available in her state to ensure that her patient gets the proper medication. The medical assistant should also explain the dangers of sharing prescriptions. The pediatrician prescribes the medication for one patient only. Splitting a medication between two children can cause superinfection. Also, the medication may be contraindicated for the other child due to an allergy, a medical condition, or a possible drug interaction with another medication the child is taking. In addition to the prescribed antibiotics, cool uids will soothe the throat and prevent dehydration. Most cases of Strep throat resolve with treatment. However, recurrence is common, in part because it is so easily spread to other family members and friends. The recurrence of Strep throat is likely not a sign of an underlying problem with the childs immune system. Complications of Strep throat include rheumatic fever, which produces skin rash, joint inammation, and, possibly, damage to heart valves. Kidney damage and inammation can result from lack of treatment.

fever of 103F or higher severe cough wheezing (high-pitched noise usually heard on exhalation) tachypnea (rapid breathing) marked drawing in of the chest muscles and skin between the ribs, which indicates dyspnea (difculty breathing) orthopnea (breathing is eased by sitting, rather than lying down) cyanosis (bluish color of the skin due to lack of oxygen) poor appetite.

In older, healthy children and adults, the symptoms of RSV are that of the common cold, including runny nose or congestion, dry cough, sore throat, low-grade fever, mild headache, lethargy, and malaise. In severe and mild cases, signs and symptoms typically appear about 4 to 6 days after exposure to the infection. The same precautions to prevent transmission of the common cold apply to RSV, including hand washing and not sharing towels, facecloths, and drinking glasses. Diagnosis of RSV is determined by sputum analysis, which reveals presence of the virus, viral antigens, or viral RNA. Treatment for severe RSV includes acetaminophen for discomfort and fever and hospitalization to administer intravenous fluids and electrolytes as well as oxygen therapy and, sometimes, mechanical ventilation. Ribavirin aerosol may be used to treat some patients with severe RSV. Treatment for less severe RSV includes fluids and acetaminophen. Most children completely recover from RSV in 8 to 15 days. Death from RSV infection is relatively rare; however, it can cause death in high-risk infants under age 6 months. RSV in infancy may increase a childs risk of developing asthma and allergies as they age. RSV in children ages 3 and under

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Antibiotics and superinfection

When the pediatrician prescribes antibiotics to a patient, the medical assistant should advise the parent to give the child the entire prescription to avoid superinfection. A superinfection occurs when the patient takes some of the antibiotic but stops taking it when she starts feeling better, rather than completing the entire course of medication as prescribed. In such a case, the antibiotic the patient takes only kills the weakest bacteria. The stronger bacteria survive and reinfect the patient, who experiences a rebound of symptoms, which are commonly much worse than the initial infection. In addition, the remaining bacteria may acquire resistance to the antibiotic, forcing the physician to nd a stronger antibiotic to kill the remaining bacteria. If the patient or another child whom the patient infects has had many infections and taken many different antibiotics, the physician may not be able to nd an antibiotic to treat the infection effectively.

Oral thrush is a minor problem for healthy children, but for those with weakened immune systems, symptoms of oral thrush may be more severe, widespread, and difcult to control. Uncontrolled thrush may lead to diaper rash and vaginal yeast infections. Severe complications that spread to the esophagus, brain, heart, and joints are rare but may occur in immunocompromised infants, such as those with HIV.

Chickenpox
ICD-9-CM code: 052.9 Chickenpox is a highly contagious virus that causes fever and a rash. Prior to the vaccine developed in 1995, approximately 4 million Americans (mostly children) contracted chickenpox each year. Widespread administration of the vaccine reduced the number of cases and hospitalizations. The virus is highly contagious for people who are not immunechildren or adults who have not previously had chickenpox or the vaccine. Chickenpox is caused by the varicella-zoster virus, which is part of a group of viruses called herpesviruses. The virus spreads easily from person to person through direct contact with the rash or by droplets dispersed into the air by coughing or sneezing. (See Chickenpox will not wait.) Signs of chickenpox include the classic red, itchy rash on the face, scalp, chest, and back. The rash can also spread to the entire body, including the throat, eyes, and vagina. The chickenpox rash usually appears less than 2 weeks after exposure to the virus and begins as supercial spots. These spots quickly turn into small, uid-lled blisters that break open and crust over. New spots continue to appear for several days and may number in the hundreds. Itching may range from mild to intense. The rash may be preceded or accompanied by:

Oral Thrush
ICD-9-CM code: 112.0 (neonate 771.7) Oral thrush is a fungal infection of the mouth. Although it can affect anyone, it occurs most commonly in babies and toddlers. The infection usually occurs within the rst 6 months of life. Oral thrush is caused by Candida albicans. Most healthy people have a small amount of fungus in the mouth and digestive tract, but the normal ora of the GI tract keep the fungus in balance. Oral thrush and other Candida infections occur when antibiotics disturb the natural balance of microorganisms in the body or the immune system is weakened by disease or immunosuppressive drugs, such as prednisone. Oral thrush causes creamy white lesions, usually on the inner cheeks and tongue. The lesions can be painful and may bleed slightly when scraped or when brushing the childs teeth. A healthy neonate with oral thrush usually develops symptoms during the rst few weeks of life. In addition to the distinctive white lesions in the mouth, the parent or caregiver may notice that the infant is irritable and fussy and may not want to eat. During breastfeeding, the neonate can pass the infection to the mother. Occasionally, oral thrush may spread to the roof of the mouth, gums, tonsils, or back of the throat. Treatment of oral thrush consists of administration of an antimycotic, such as uconazole (Diucan), which caregivers can administer to infants and children as a liquid. Although the baby may be fussy, the parent or caregiver should try to continue the normal feeding schedule.

fever abdominal pain or loss of appetite mild headache malaise, lethargy, and irritability

Front ofceBack ofce connection

Chickenpox Will Not Wait

Because children with chickenpox are highly contagious, the administrative medical assistant should work quickly with the clinical medical assistant to get him into a treatment room immediately. He should not wait in the waiting room with the other children. If a parent calls the ofce suspecting that her children have chickenpox, the administrative and clinical medical assistants should coordinate examinations so that a treatment room is waiting for the patients when they arrive.

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mild cough and runny nose for the rst 2 days of illness before the rash appears. A person who has chickenpox can transmit the virus for up to 48 hours before symptoms appear and remains contagious until all spots crust over.

Treatment for chickenpox involves acetaminophen for pain and fever and rest at home. Children with chickenpox should not go to school until all lesions have crusted over. The medical assistant should instruct the parent or caregiver to call the ofce if any of the more severe effects occur, including:

marked increase in warmth, tenderness, or redness of the rash, which possibly indicates a secondary bacterial skin infection spread of the rash to one or both eyes dizziness or disorientation rapid heartbeat or shortness of breath tremors or loss of muscle coordination stiff neck worsening cough vomiting fever higher than 103F.

Diagnosis is based on physical examination. Treatment for warts at home can include over-the-counter wart dissolving medication that contains salicylic acid. Another effective home remedy involves wrapping the wart in duct tape. Destroying the wart helps prevent common warts from spreading to other parts of the body or to other people. If these treatments are ineffective, the physician may freeze the wart with liquid nitrogen or burn it with electrocautery to remove it. Unless the warts are large or extremely uncomfortable, surgical removal is generally avoided. Surgery can cause a permanent scar and subsequent warts can be more severe because they can grow over the scar tissue. Because warts are caused by a virus, they may recur after treatment and can become a persistent problem. The medical assistant should instruct patients and their parents to notify the physician if warts are painful or rapidly multiplying, because these signs may indicate a suppressed immune system or skin cancer, which require immediate evaluation and treatment.

Noncommunicable Pediatric Diseases and Disorders

Noncommunicable disorders are those that are not transmitted via contact with other people. These disorders may have a genetic component or may be the result of the environment, trauma before or at birth, inappropriate nutrition, and other factors. Some of the most common noncommunicable pediatric diseases and disorders include allergies, anorexia or bulimia nervosa, asthma, attention deficit disorder, autism, Down syndrome, constipation, failure to thrive, cerebral palsy, eczema, scoliosis, obesity, lead poisoning, and phenylketonuria.

Chickenpox usually lasts about 2 weeks and rarely causes complications. Although the disease is generally mild in healthy children, it can be serious for anyone. There is no way to know which infected child or adult will develop a severe case. Thus, most states have made administration of the chickenpox vaccine a requirement for attendance in public school. The medical assistant should advise her patients on their states mandate for vaccination. For most patients, the chickenpox vaccine is a safe, effective way to prevent chickenpox. In the small number of cases when the vaccine does not stop chickenpox completely, the resulting infection is much milder than it would have been without the vaccine. Many people who experience chickenpox as a child will contract shingles, a reemergence of the varicella-zoster virus that usually occurs in older adults.

Allergies
ICD-9-CM code: 995.3 (unspecied) An allergy is a response by the immune system to a substance that it perceives as harmful. About 11% of the U.S. population has an allergy to one or more substances. Children are more likely to have allergies before age 10. After that age, symptoms typically decrease. The rst time that the substance is introduced into the body, the body manufactures antibodies to ght the substance. After the initial contact, any time that the allergen is introduced into the body, the antibodies begin to attack. Antibody formation causes a release of histamine and prostaglandins. The combined effects of histamine and prostaglandins production can cause these reactions:

Warts
ICD-9-CM code: 078.10 Common warts are noncancerous skin growths. Children and teens are susceptible to common warts. Approximately 4% of 9- to 14-year-olds in the United States develop common warts. Warts are caused by human papillomavirus (HPV). HPV causes a rapid growth of cells on the outer layer of skin. These growths are small, eshy, grainy bumps that are rough to the touch and usually painless. Warts may occur singly or in multiple clusters. They commonly contain one or more tiny black dots, which are small, clotted blood vessels. They usually occur on the hands or ngers or near the ngernails. Nail biting can also cause warts to spread on to the ngertips and around the nails.

Histamine causes mucous membranes to secrete. The patient will develop a runny nose and itchy, watery eyes. Prostaglandins cause constriction of smooth muscle, such as the bronchioles, which results in constriction of the airways and difculty breathing.

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Capillary permeability increases, which pushes uid out of the bloodstream and into the tissues, causing a drop in blood pressure.

Common allergens include dust, animal hair, pollen, stings from such insects as bees or wasps, drugs, and such foods as peanuts, tree nuts, wheat, eggs, milk, soy, and sh or shellsh. Common signs and symptoms of an allergic reaction include hives, eczema, hay fever, and asthma. Skin testing is the most common type of test used to identify potential allergens causing a reaction. One type of skin test, called the scratch test, involves placing a small amount of a common allergen on the skins surface and scratching the area so that the substance is introduced under the skin. The result is positive if the skin in that area reacts with swelling and redness. Another allergy test, called the radioallergosorbent test (RAST), measures specic allergyrelated substances in the bloodstream. (For more information on allergy testing, see Chapter 25, page 411.) Mild allergic responses in children can be treated with antihistamines and behavior changes to avoid the offending allergen. Childhood food allergies to eggs, milk, and soy may diminish with age. However, allergies to such foods as peanuts are commonly more severe and the child is less likely to outgrow such an allergy. (See Food allergies at school.) Severe allergic reactions to substances such as bee stings or certain medications can cause anaphylactic shock, which is a medical emergency. In anaphylactic shock, the patient experiences bronchial constriction, increased mucus production, and increased capillary permeability, which can cause severe dyspnea and dangerously low blood pressure. A child with severe allergies should wear a medical alert bracelet, which explains the childs allergies to medical personnel and others who need the information to treat the patient (See Figure 33-3.) In addition, the child should carry an Epi-Pen, which is a prelled syringe of epinephrine for use if the child is exposed to the allergen. Epinephrine causes an increase in

heart rate and blood pressure. The medical assistant should instruct parents on the use of the Epi-Pen. She should also teach the child how to use it himself if he is old enough to understand. The medical assistant should emphasize that the child should have the Epi-Pen with him at all times. She must emphasize to the patient and parents that avoiding the allergen is the primary goal. If the child comes in contact with the allergen and uses the Epi-Pen, he must undergo examination by a physician immediately. (See Figure 33-4.)

SEVE ALLER RE G P E A N Y TO L AU R E U T S N WHI TE

FIG 33-3 Medical alert bracelet.

Food allergies at school

Allergy to peanuts is severe in many children, so much so that many schools offer a peanut-free section of the school cafeteria and ban peanut butter or other peanut products in the classroom. Most schools also require an ingredient list for snacks prepared by a student or parent that will be shared with the entire class, such as birthday cupcakes or brownies. Some schools even discourage such foods for celebrations and encourage instead handing out pencils, stickers, or other inexpensive items instead. In addition, schools try to discourage children from trading foods at school.
FIG 33-4 Epi-Pen.

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Eating Disorders
Anorexia nervosaICD-9-CM code: 307.1 Bulimia nervosaICD-9-CM code: 307.51 Anorexia nervosa and bulimia nervosa are psychological disorders marked by altered eating behaviors. In anorexia nervosa, the patient suffers extreme weight loss due to selfstarvation. In bulimia nervosa, self-starvation also occurs; however, this disorder is characterized by a cycle of starvation, binge eating, and purging of the food by forced vomiting or use of laxatives or other medications to forcibly expel the food from the body. An anorexic or bulimic patient may also engage in excessive exercise in an attempt to lose weight. Anorexia and bulimia are typically pediatric disorders that mainly occur in girls, with a peak onset period from ages 12 to 14. Anorexia nervosa and bulimia nervosa may be caused by emotional disorders that create extreme anxiety about physical appearance and a distorted body image. Certain personality traits, such as perfectionism or overachieving, also predispose a person to developing an eating disorder. In addition, recent research suggests genetic, nutritional, or neurobiological links. Some research shows that eating disorders may have a genetic link because a sibling of a person who experiences anorexia or bulimia is more likely to develop an eating disorder. Researchers have also connected these disorders to a decrease in the amount of the neurotransmitter serotonin. A link has also been made between zinc deciency, which causes decreased appetite, and deciency of other nutrients, such as tyrosine and tryptophan, both precursors of neurotransmitters, and vitamin B1. Deciency in these nutrients contributes to a cycle of malnutrition. The typical anorexic or bulimic patient is a high achiever and a perfectionist. An anorexic patient is usually extremely thin. In bulimia, the patient may be thin, overweight, or normal weight, making the condition more difcult to diagnose. Diagnosis is based on physical examination ndings and the health history. The anorexic patient will typically refuse to maintain a normal body weight and may weigh less than 85% of normal body weight for height. She may express a fear of gaining weight and describe her body as too fat, denying the seriousness of her current low body weight. She may also experience absence of three or more consecutive menstrual cycles due to her reduced body weight. Diagnosis of the bulimic patient is more difcult because she is not necessarily underweight and the patient may be ashamed and unwilling to discuss her behavior. Physical ndings in bulimia include erosion of gum tissues and esophageal damage from forced vomiting. Diagnosis is based on these ndings as well as a detailed health history, which may reveal fatigue, lethargy, signs of depression, low self-esteem, previous suicide attempt, or general demeanor of apathy. As with the anorexic patient, the bulimic patient may have missed menstrual cycles.

The pediatric medical assistant should be aware of the need for specialized care of her anorexic or bulimic patient. Parents and patients should be given referrals for appropriate treatment. Structured programs designed for patients with eating disorders can include:

nutritional counseling behavioral therapy family therapy group therapy psychological and psychiatric consultation.

Prognosis for anorexia nervosa and bulimia nervosa depends on the severity of the disorder and how long it has been occurring before treatment. Approximately 6% of diagnosed anorexic and bulimic patients eventually die from complications related to organ failure and from suicide. Girls with anorexia may experience amenorrhea (absence of a menstrual period) or delay of menarche (rst menstrual period). Other complications of anorexia include osteoporosis, low body temperature, lethargy, slow heart rate, dry skin, brittle nails, development of ne body hair called lanugo, and infertility. In bulimia, repeated forcing of food from the stomach to the esophagus can cause esophageal ulcers, bleeding, bleeding gums, gingivitis, dental caries (cavities), and an absent gag reex. The subsequent uid and electrolyte imbalance can result in cardiac arrhythmia.

Asthma
ICD-9-CM code: 493.0 (childhood asthma; use 5th digit) Asthma is a disorder characterized by inammation and spasm of the bronchi, increased mucus secretions in the bronchi, and narrowing of the airway. Asthma affects about 15% of all children in the United States, making it the most common chronic disease in children and the most common disorder seen in the pediatric ofce. Specic causes of asthma vary and triggers can include cigarette smoke, cold viruses, exercise (called exercise-induced asthma), and environmental allergies. Regardless of the trigger, the patient will experience difculty inhaling and exhaling, shortness of breath, wheezing, tightness in the chest, difculty speaking, and anxiety. In some cases, intermittent episodes of severe symptoms, called asthma attacks, can occur. Coughing may also occur at the onset of an episode. Diagnosis of asthma is based on patient history and clinical ndings. Tests include spirometry, which measures the amount of air entering and leaving the lungs. Because many patients with chronic asthma exhibit normal results with spirometry, patients may also be asked to conduct a peak expiratory ow (PEF) test, which measures the exchange of air, twice per day for about 2 weeks. The patient should take the PEF test each morning upon waking and before taking bronchodilators. Although peak ow varies normally, a variability greater than 20% conrms a diagnosis of asthma.

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A patient who suffers from eczema or other allergic conditions is at greater risk for developing asthma. Because airway function tests are not always possible on small children, diagnosis may be conrmed by a positive response to treatment. Treatments for asthma include bronchodilators using an inhaler or nebulizer, anti-inammatory medications, and avoidance of common triggers. Some patients periodically suffer from asthma attacks, which are the sudden, severe inability to catch a breath and require the immediate use of an inhaler. Patients who experience more than two asthma attacks per week should be referred to a respiratory specialist. The medical assistant should demonstrate use of an inhaler or nebulizer to patients and caregivers. (For more information on how to use an inhaler or nebulizer, see Chapter 28, page 495.) Prognosis for childhood asthma is generally good, with 54% of patients outgrowing asthma after 10 years. With proper treatment, the extent of permanent lung damage is minimal.

loses things, such as school assignments, books, and tools is easily distracted is forgetful about daily activities ADHD (must exhibit at least six behaviors to a degree that is considered abnormal) is dgety and squirms does not stay seated runs or climbs excessively or has feelings of restlessness (in older children) has difculty playing quietly is often on the go or acts as if driven by a motor often talks excessively blurts out answers to questions has difculty waiting in lines or taking turns often interrupts or intrudes on others.

Behavioral Disorders
Attention decit disorderICD-9-CM code: 314.00 Attention decit hyperactivity disorderICD-9-CM code: 314.01 Attention decit disorder (ADD) and attention decit hyperactivity disorder (ADHD) are behavioral disorders. In ADD, a patient displays an inability to focus attention for short periods of time and has trouble prioritizing and completing tasks. In ADHD, the patient also has trouble focusing and finishing tasks and, in addition, has trouble sitting still for long and prefers to be moving around. Although the disorder can be familial, no genetic factor has yet been identified; boys are 10 times more likely to suffer from ADD or ADHD than girls. Signs of ADD and ADHD include an inability to organize school supplies, books, and personal items and trouble prioritizing time. In addition, the patient with ADHD is unable to sit still and is excessively active. Diagnosis of ADD or ADHD involves a patient interview by a pediatrician or psychologist, noting the following ndings:

There is no known cure, but medication and counseling can help the child focus. Medications may include atomoxetine (Straterra) or the combination drug dextroamphetamine and amphetamine (Adderall). The physician may recommend restricting food additives if they are found to contribute to the childs hyperactivity. Symptoms of ADD and ADHD usually subside or completely disappear with age.

Autism
ICD-9-CM code: 299.0 Autism is a bioneurological developmental disability. Males are four times more likely to suffer from autism than females. Autism is usually not diagnosed until age 3 or later. The National Autism Association reports that 1 child in 150 is affected by autism. The cause of autism is unknown. However, recent studies have suggested there may be a link between autism and thimerosal, a mercury compound used as a preservative in childhood vaccines. Symptoms of autism can include:

ADD (must exhibit at least six behaviors to a degree that is considered abnormal) often fails to give close attention to details or makes mistakes in schoolwork has difculty sustaining attention in tasks seems not to listen fails to follow instructions or nish work is unorganized has difculties with schoolwork or homework

failure to make eye contact repetitive behaviors such as rocking delayed language development poor cognitive function extreme agitation with changes in routine preference for solitary play activities indifference or lack of attachment to people.

Diagnosis of autism is based on behaviors dened in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). To meet the criteria, the patient must exhibit at least two symptoms of impaired social interaction, at least one symptom of impaired communication, and at least one symptom of repetitive behavior.

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Early intervention by a referral to specialists will initiate therapies that can increase the childs speech development and interactions with others. The medical assistant should be aware of the signs of autism and note such observations for the pediatrician, who can make referrals for testing and treatment as appropriate.

advances in treatment for complications, people with Down syndrome can live into their 40s or 50s. However, people with Down syndrome are at increased risk for developing Alzheimer disease after age 40.

Constipation
ICD-9-CM code: 564.0 Constipation is a condition in which a person has hard stools that are difcult to expel. Defecation is commonly painful and infrequent. Constipation occurs in approximately 2% of the general population but is most prevalent in children. Women and elderly persons also suffer more bouts of constipation than young men. Children and adolescents who suffer from chronic constipation are probably not eating enough ber or drinking enough water. Medications can also cause constipation. Signs and symptoms include hard, dry stools that are hard to pass and an infrequent urge to defecate. Because babies and young children are not able to communicate sensations of pain or difculty passing stool, the parent or caregiver may notice the child straining and turning red when trying to defecate. The parent may also note the child holding his abdomen or complaining of a bellyache. Stools that the child is able to pass may be small lumps that look like nuts. The medical assistant can encourage the child with constipation and his parent to make changes to the childs diet to relieve constipation. (See Dietary changes to relieve constipation, page 658.) If dietary changes are inadequate, the physician may prescribe a stool softener. The medical assistant must advise the parent to avoid giving too much stool softener to the child, because it could cause diarrhea and dehydration. Most children with constipation respond favorably to dietary changes and normal bowel function returns. In some cases, constipation can lead to hemorrhoids or anal ssures (tears around the skin of the anus due to stretching of the sphincter muscle). Rectal bleeding may occur from hemorrhoids and anal ssures. The medical assistant should instruct the parent or caregiver to bring the child to the pediatrician if she notices blood in the childs diaper or underwear. In severe cases, constipation can lead to a bowel obstruction. If the bowel obstruction ruptures, surgical repair is necessary.

Down Syndrome
ICD-9-CM code: 758.0 Down syndrome, or trisomy 21, is a common chromosomal disorder that causes delays in physical and intellectual development. It occurs in 1 out of every 800 children born each year and occurs in all populations, regardless of race, sex, or socioeconomic status. Down syndrome is caused by an error in cell division during conception that results in the presence of an extra (or part of an extra) 21st chromosome. It is also related to advanced maternal age at the time of pregnancy. The risk of conceiving a child with Down syndrome for mothers who conceive at age 40 is more than seven times higher than mothers who conceive at age 35. Down syndrome causes distinctive physical characteristics, including:

small head with a at facial prole mouth that tends to hang open large tongue with a high arched palate slanted eyes with irises that contain Brusheld spots hypotonia (weak muscle tone) congenital heart defects (common).

Patients with Down syndrome will likely suffer from other health problems, including:

cognitive impairment (varies in degree) sexual development delayed or incomplete (common) visual problems such as cataracts and strabismus hearing problems decreased resistance to infection high risk of developing leukemia.

Infants are diagnosed with Down syndrome at birth due to its distinctive physical characteristics. There is no cure for Down syndrome. Treatment aims to monitor development and address complications. Because a child with Down syndrome experiences developmental delays, an accurate record of her individual development is vital. Accompanying physical problems, such as heart defects and vision or hearing impairments, should be treated along with the regular well-baby and well-child visits. It is extremely important for patients with Down syndrome to receive vaccinations because they are more susceptible to infection. When age appropriate, the medical assistant or parent can explain the importance of hand washing and proper hygiene to the patient. In the past, life expectancy for people with Down syndrome was severely limited. However, with early intervention and

Failure to Thrive
ICD-9-CM code: 783.41 Failure to thrive (FTT) is a condition of insufcient weight gain according to standardized growth charts. Children experience irregular growth patterns, gaining height and weight in irregular intervals, commonly called growth spurts. So long as toddlers are growing and developing, there is little cause for concern. However, infants who do not gain sufcient weight will not develop normally. Although the

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Patient Education

delay. The length of time of the abuse or neglect impacts the long-term outcome.

Dietary Changes to Relieve Constipation

The medical assistant should teach the pediatric patient and his parent or caregiver about foods that cause constipation and others that help alleviate it.

Cerebral Palsy
ICD-9-CM code: 343.9 Cerebral palsy (CP) is a disorder of the brain that affects posture, balance, and movement. According to a March 2008 study by the CDC, CP occurs in 1 of every 278 children. The study also found that boys have a higher risk for CP as do African Americans and children from low- or middleincome families. The cause of CP is an injury to or error in development of the areas of the brain that control posture, balance, and movement. The cause may be:

Foods to encourage
apples oranges high-ber cereals high-ber, whole-grain bread apple juice or prune or plum juice water

Foods to Avoid
bananas pudding cheese rice white bread

congenital due to: genetic disorder that is present at birth infection during pregnancy (meningitis) jaundice in the neonate Rh incompatibility acquired due to: brain injury (head trauma at birth or after) infection in neonate (meningitis).

exact incidence of FTT is not known, approximately 10% of children under age 2 who have parents with psychological problems and low socioeconomic status exhibit FTT. The FTT category includes infants whose weight is under the third percentile. The most common cause of failure to thrive is inadequate nutrition. Colicky babies, mothers who used alcohol or had poor nutrition during pregnancy, and new mothers who experience fatigue and postpartum depression can all contribute to FTT. Causes can also include cleft palate, which affects the infants ability to suck, or malabsorption disease, which compromises the bodys ability to absorb formula or breast milk. Social and economic factors that can promote FTT include poverty, drug and alcohol abuse, depression, abuse, and immature parents. To identify a child with feeding problems, the medical assistant can use the PEACH survey. (See Identifying feeding problems.) The medical assistant can help an infant with FTT by reporting suspected abuse, neglect, or drug abuse to social services and offering resources for nancial assistance. Most states have programs for food stamps or nutritional assistance. Prognosis for the child with FTT depends on the cause. Infants who have malabsorptive disease treated with diet modication or cleft palate that is surgically corrected have good outcomes. FTT due to abuse and neglect can lead to permanent lack of growth and possible long-term developmental

CP is characterized by a wide variety of symptoms, including lack of muscle control, muscle weakness, spastic muscles, delayed development, mental retardation, and hearing and vision problems. The disorder appears within the rst few years of the patients life and does not worsen over time. The pediatrician can diagnose the patient with CP based on physical examination ndings. Lack of muscle tone, or oppy baby syndrome, is an indication of CP. The pediatrician can refer patients to physical, speech, and occupational therapy to maximize potential function. The pediatrician still provides routine care to the patient, while the patient benets from therapies specically designed for his needs. The prognosis for CP is very individualized. With supportive treatments such as medications, surgery, and assistive devices, each patient with CP can reach her individual potential. Some complications of CP include seizures, which affect 50% of children with CP, mental retardation, learning disabilities, and ADHD.

Eczema
ICD-9-CM code: 692.6 Eczema, or atopic dermatitis, is an inflammatory skin disease. Patients with allergies or family history of asthma, allergies to foods, and outdoor allergies are more susceptible to developing eczema. Pediatricians diagnose eczema in about 1 in 10 children in the United States, usually within the infants rst few months of life. It is somewhat more prevalent in Asian Americans and African Americans.

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Identifying feeding problems

The medical assistant can help identify feeding problems in children from birth to age 5 by using the Parent Eating and Nutrition Assessment for Children with Special Health Needs (PEACH) survey. Parents who have a child who is not reaching developmental milestones and gaining adequate weight can also use the PEACH survey to identify nutritional deciencies that might be affecting the childs overall health. The survey contains 17 yes or no questions. Each question with a yes answer is assigned a score from 1 to 4. A total score of 4 or more indicates a probable nutritional problem.

PEACH Survey
Head Start Agency: Date: Ling Su Chen Childs name: Date Address: Phone 14 Roberts Ave, Blueville CT 06000
of birth: #:

10/15/09 12/22/07 860-555-8752

Please circle YES or NO for each question as it applies to your child. Circle the points for each yes. 1. Does your child have a health problem (do not include colds or flu)? If yes, what is it? YES NO

cerebral palsy

X too thin, or 2. Is your child: small for age, too heavy? (If you check any of the above, please circle YES.) YES NO 3. Does your child have any feeding problems? If yes, what are they? YES NO difficulty swallowing
4. Is your childs appetite a problem If yes, describe: YES NO

3 3

she gets hungry, although sporadically

5. Is your child on a special diet? If yes, what type of diet? YES NO 6. Does your child take medicine for a health problem (do not include vitamins, iron, or fluoride)? Include name of medicine(s). YES NO 7. Does your child have food allergies? If yes, to what foods? YES NO 2

strawberries
8. Does your child use a feeding tube or other special feeding method? If yes, explain: YES NO 9. Circle YES if your child does not eat any of these foods: milk, meats, vegetables, fruits. (Check all that apply.) YES NO 10. Circle YES if your child has problems with sucking, X swallowing, chewing, or gagging. (Check all that apply.) YES NO 11. Circle YES if your child has problems with X loose stools, hard stools, throwing up, spitting up (Check all that apply.) YES NO 12. Does your child eat clay, paint chips, dirt, or anything else that is not food? If yes, what? YES NO 13. Does your child refuse to eat, throw food, or do other things to upset you at mealtime? If yes, explain: YES NO 14. For infants unter 12 months who are bottle fed: Does your child drink less than 3 (8-ounce) bottles of milk per day? YES NO 15. For children over 12 months (Check if applies and circle the YES). Is your child not using a cup? Is your child not finger feeding? YES NO 16. For children over 18 months: Does your child still take most liquids from a bottle? YES NO 17. Circle YES if your child is not using a spoon. YES NO Total points for YES answers = 4

3 2

1 1

2 2

14

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The cause of eczema is unknown; however, there are several possible triggers, including food, environmental irritants, and stress. The rash appears as a vesicular rash on the face, neck, elbows, or behind the knees and ears. Diagnosis of eczema is based on physical examination of the rash. Treatment is directed at reducing the frequency and number of eruptions by avoiding triggers. Topical corticosteriods, such as hydrocortisone (Dermacort), and oral antihistamines, such as diphenhydramine (Benadryl), fexofenadine (Allegra), and cetirizine (Zyrtec), are used to control itching. If secondary staphylococcal infection occurs (due to scratching), the physician may prescribe oral antibiotics. The medical assistant can instruct the parents on how to monitor the patients skin and record possible triggers by keeping a diary. If avoidance of triggers clears the skin, the parents or caregiver can treat the child at home. The medical assistant should instruct parents to contact the physician if the child:

Prognosis depends on the likelihood of progression of the curvature. Patients who have not yet reached skeletal maturity are more likely to have progressive curvature. Severe, uncorrected scoliosis can compromise respiration, due to compression of the diaphragm on one side. Fertility in females may be compromised if the rib cage will not allow uterine expansion in late pregnancy.

Obesity
ICD-9-CM code: 278.00 Obesity is dened as a body mass index (BMI) over 30. (For more information on body mass index, see Chapter 37, page 777.) Childhood obesity has become more and more prevalent over the past 30 years. In the United States, about 30% of children age 5 and older are obese. Causes of obesity in general vary and can include lifestyle factors as well as endocrine disorders. However, in childhood obesity, endocrine disorders are rarely the cause. Instead, a diet high in sugar and fat combined with a lack of exercise are the clear causes. The medical assistant can give the parents, caregivers, and child nutritional guidelines for health and weight management and a list of community resources. She should also encourage families to help children lose weight by engaging in exercise, limiting television watching and computer time, and limiting intake of foods with little nutritional value or high sugar and fat content. Although obesity in itself is not a disorder with a prognosis, the complications associated with it can limit life expectancy if they remain unaddressed. For example, type II diabetes, high cholesterol, and hypertension, which were once complications of obesity seen only in adults, are now seen in children.

cannot sleep or is distracted from his daily routines complains that his skin is extremely painful scratches and causes bleeding or possible infection does not nd relief from self-care, such as avoidance of triggers and use of unscented lotions.

Childhood eczema commonly clears with age. More than half of children with eczema will completely recover by their teenage years. Complications of eczema include Staphylococcus infection, which may be caused by the patient scratching the skin, leaving open areas in the skin where bacteria can colonize.

Scoliosis
ICD-9-CM code: 737.30 Scoliosis is an abnormal lateral (side) curvature of the spine. The condition usually appears in adolescence, during periods of rapid growth. School nurses commonly screen for scoliosis and refer patients to their physician. About 2% to 3% of Americans have a curvature greater than 10 degrees. Curvature greater than 20 degrees affects 1 in 2500 Americans. Scoliosis is more common in adolescent girls and occurs in males most commonly in infancy. A pediatrician, chiropractor, or osteopath will usually perform the assessment using physical examination. The practitioner observes the patient from the back while she bends forward at the waist. A positive nding for scoliosis is observed when a discrepancy in hip and shoulder height is observed upon forward bending. Treatments can include asymmetrical exercises to stretch and strengthen and application of a brace, cast, traction, or electrical muscle stimulation. Severe scoliosis may require surgical correction.

Lead Poisoning
ICD-9-CM code: 984.9 Lead poisoning, or plumbism, is a chronic disorder caused by poisoning by ingestion or inhalation of lead-contaminated paint, soil, or dust. According to the CDC, approximately 2% of children between ages 1 and 5 contract lead poisoning. Children of lower socioeconomic status are at greater risk of contracting lead poisoning. Because lead competes for absorption with many vitamins and minerals, such as iron, calcium, zinc, vitamin C, and vitamin D, the malnourished child will absorb more lead due to low intake of these nutrients. In addition, the empty stomach of a hungry child will absorb more lead if it is consumed. In the body, lead interferes with minerals, such as iron, calcium, and zinc. It replaces these minerals and disrupts their normal function. In the bloodstream, lead replaces iron in the hemoglobin of RBCs, making them unable to carry oxygen to tissues. In bone, lead interferes with the

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absorption of the calcium needed to make bone cells. Decreased zinc absorption causes immune suppression. Signs and symptoms of lead poisoning include recurrent episodes of diarrhea, irritability, and fatigue. Because these symptoms are similar to those of iron deciency anemia, the two are commonly confused. In fact, iron deciency anemia and lead poisoning are often diagnosed together in children of low socioeconomic backgrounds. Diagnosis is based on blood sample analysis for lead (PbB). Lead levels greater than 60 to 70 micrograms/dl of whole blood indicates poisoning. Treatment includes chelation therapy, which involves injection of a chelating agent that binds to lead, making it water soluble so the child can excrete it in urine. Because children with lead poisoning usually have an iron deciency, iron supplementation typically accompanies chelation therapy. In addition, the identied sources of lead in the childs environment should be removed to prevent further poisoning. (See Lead poisoning prevention.) Prognosis is based on the childs lead levels and how long the child ingested lead before diagnosis and treatment. Outcomes vary from severe, such as permanent reduction in IQ and permanent brain damage that can affect nerves and muscles, to mild, which can include complete recovery that could take months to years. In addition, lead poisoning further suppresses the childrens immune system, leaving them little protection from infectious diseases.

Phenylketonuria
ICD-9-CM code: 270.1 Infants born with phenylketonuria (PKU) have an inability to properly use protein, specically the amino acid called phenylalanine. It is estimated that 1 in every 70 persons is a carrier for PKU and that the disorder affects 1 in every 15,000 to 20,000 infants born in the United States. Normally, when a person eats proteins, her body breaks down the proteins into separate amino acids. In a patient with PKU, one of the enzymes that changes phenylalanine into another amino acid, tyrosine, is missing. As a result, the amount of phenylalinine accumulates in the blood. This increase in phenylalanine in the blood prevents the infants brain from growing and developing normally. In addition to increased levels of phenylalanine, other symptoms of PKU include skin rash, irritable behavior, and a musty body odor. A PKU test, mandated by most states, is typically performed before the baby leaves the hospital but may be done after discharge or if the newborn was delivered at home. A simple blood test diagnoses the disorder. Early diagnosis of the disorder allows parents to put the child on a special diet that is very low in phenylalanine, including phenylalanine-free formula, careful tracking of intake of fruits and vegetables and cereals, breads, and pastas, and elimination of foods that are high in protein, such as dairy products, beans, nuts, meat, eggs, and sh. In addition, as the PKU patient ages, she should avoid the articial

Patient Education

Lead Poisoning Prevention

The Centers for Disease Control and Prevention (CDC) recommends that health care providers continue their traditional role of providing anticipatory guidance on lead poisoning as part of routine well-child care, assessing the risk of exposure to lead, conducting blood lead screenings in children, and treating children who have elevated blood lead levels (BLLs). In addition, the CDC urges health care and social service providers to expand their roles to keep abreast of research data that clarify the relationship between lead exposure and neurocognitive development in children. They can also strongly advocate for children and foster lead exposure prevention by helping facilitate implementation of specic strategic plans to eliminate childhood lead poisoning in their local and state communities. Health care and social service providers are highly effective child advocates, and their active participation in the process provides the expertise and leadership needed to reach this goal. The CDC recommends health care and social service providers to: provide culturally appropriate education to all pregnant women and families with young children about the principal sources of lead and ways to reduce exposure target outreach, education, and screening programs to populations with the greatest risk of lead exposure become aware of, and actively support, lead poisoning elimination efforts in the community express concern to federal, state, and local policy and decision makers that children live in a lead-safe environment, actively support legislation and regulatory initiatives, and advocate for lead-safe, affordable housing by supporting appropriate legislation become aware of and comply with lead screening policies issued by Medicaid or state and local health departments ensure training of staff members engaged in housing renovation or rehabilitation in lead-safe work practices.

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sweetener aspartame, which breaks down into two amino acids, including phenylalanine. The length of time phenylalanine levels remain high is directly proportional to the extent of brain damage and disability. Thus, untreated PKU will cause progressive mental retardation. However, because most cases are identied with neonatal screening, the more serious complications of PKU are rarely seen.

If a medical assistant does not feel comfortable picking up and holding infants, she should practice using a doll at rst and then ask relatives or friends if they would allow her to pick up and hold their infant. The medical assistant must convey condence to the patient as well as the parent or caregiver. In the pediatric ofce, the medical assistant may assist with examinations, perform immunizations and basic laboratory tests, and assist the physician with procedures.

Pediatric Procedures
The medical assistant working in a pediatric ofce must be able to listen well, speak clearly, and have a solid understanding of a childs normal growth and development in order to effectively interact with pediatric patients and their parents or caregivers. Because pediatric patients may be fearful of the medical ofce, the medical assistant should try to minimize fear and promote an atmosphere of trust and comfort. For example, when the medical assistant explains procedures to the child and speaks at the childs level of understanding, the child will be relaxed and more likely to cooperate during the interview, examination, or procedure. When asking questions regarding the patients health, she should address questions to the child and parent or caregiver, including both in the conversation. If the patient is very young, the medical assistant may want to ask the parent or caregiver what she thinks the problem is. When a parent or caregiver states, Something is just not right, the medical assistant should take note and listen attentively as the parent or caregiver explains the symptoms she is noticing in the child. The parent or primary caregiver is the best judge of the daily activities of the child and is better able to notice when something different is happeningeven if changes are subtle. When directing questions to an older child, the medical assistant should encourage the patient, not the adult, to answer the questions if possible. As the pediatric patient ages, usually around age 12, the medical assistant may nd it necessary to speak with the patient alone. The medical assistant should always be truthful with a child regarding any examination or procedure. If a procedure may be painful, she should share that information with the child and the parent or caregiver, assuring them that she will be there for support and encouragement. It may help to encourage the child to express his concerns. In addition, allowing the child to touch and hold pieces of equipment to be used, such as a stethoscope, can create an environment of safety, promoting a healthy relationship between the pediatricians ofce and the patient. When explaining examinations or procedures, the medical assistant should avoid using medical terms and abbreviations that the patient and parent or caregiver may not understand.

Assisting with Examination

In assisting with the pediatric examination, the medical assistant will obtain vital signs, plot a patients growth on a chart, and screen for vision and hearing as well as assist the pediatrician with his examination.

Vital Signs
Measurement of vital signs for a child is the same as for an adult, with slight changes in equipment to account for the smaller size of the patient. However, normal values for pediatric vital signs change as the patient grows from infancy through adolescence. Height and weight scales and blood pressure cuffs for a child function in the same manner as those for an adult but are fitted to the pediatric patient. The medical assistant will measure pediatric vital signs routinely at each ofce visit. As with adults, pediatric vital signs include height, weight, temperature, respirations, and pulse and also include head circumference. (For more information on the procedure for vital signs measurement, see Chapter 21, page 319.) Blood pressure is not usually assessed until the child is approximately 3 years old. This practice may vary with pediatricians and individual patients. Special examinations may require a blood pressure reading, such as an examination for summer camp or a sports physical.

Height
Equipment for measuring height must be accurate, stable, and xed. The medical assistant should measure the height, or length, of a child less than age 2 with the child lying down in the supine position, which enables a more accurate measurement. Standard growth charts developed for younger children account for this type of measurement. The medical assistant should ensure that the examination paper on the table is clean and then lay the child down on the paper. Using a pen, she should rst make a mark on the examination paper at the crown of the childs head. Then, after ensuring that the childs leg is fully extended and that the child hasnt moved from the initial mark, quickly mark the paper at the heel of the childs foot. The medical assistant should then ask the parent or caregiver to pick up the child and then measure between the marks on the paper.

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Children older than age 2 can stand erect against a standing scale or ruler mounted on the wall. The medical assistant should be sure to have the patient remove his shoes before taking the measurement. (See Figure 33-5.) Because accuracy is essential, the medical assistant should measure again if she is unsure of her initial measurement. She should record the length or height of the patient in inches and centimeters in the patients medical record.

Weight
The medical assistant should weigh the infant without a diaper. If it is necessary to weigh the child with a diaper, the medical assistant should subtract the weight of the diaper after weighing the child. The medical assistant should ask children older than age 2 to stand on a scale. The older child can remain clothed for weight measurement, although his shoes should be off. Because weight gain in older children is more gradual and usually measured only yearly, the amount that clothing would add to the measurement is negligible. (See Figure 33-6.) Some children may refuse to stand on the scale. If a child is unwilling, the medical assistant should ask the parent or caregiver to hold the child in her arms, note the weight of both of them, weigh the parent alone, and then subtract the difference to arrive at the childs weight.

FIG 33-6 Measuring pediatric weight. (A) Measuring an infant. (B) Measuring an older child.

FIG 33-5 Measuring pediatric height for a child over age 2.

(See Help with pediatric vital signs, page 664.) As with height, accuracy is essential, so the medical assistant should weigh the child twice if necessary to be sure. She should record the childs weight in pounds and kilograms in the patients medical record and on the growth chart. (See Plotting growth, page 664.) Regardless of the patient, the medical assistant should balance and check the scale for accuracy before every use. In addition, the medical ofce should coordinate professional calibration of all the scales annually.

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Temperature
Body temperature can be measured in Celsius (C) or Fahrenheit (F). Methods of obtaining temperature will vary greatly from office to office. Digital and electronic thermometers are commonly used in pediatrics as well as other areas because they are easy to use and provide a quick reading. The American Academy of Pediatrics (AAP) has discouraged the use of mercury thermometers since 2001. The medical assistant must be sure to use the correct thermometer for the specific route by which she needs to obtain a temperature. Routes for obtaining pediatric temperature include axilla (armpit), oral (mouth), tympanic (ear), and rectal (rectum). It is important for the medical assistant to understand the equipment, so, if necessary, she

Front ofceBack ofce connection

Help with Pediatric Vital Signs

The clinical medical assistant may need help from the administrative medical assistant to obtain accurate pediatric vital signs if a child is uncooperative and the parent or caregiver does not wish to help. Some ofces establish a special phrase or code word to use to indicate that the back ofce needs additional help. For example, the clinical medical assistant might discreetly say to the administrative medical assistant, Staff for room two, or even simply, Assist in room two. Using these types of phrases will enable the clinical medical assistant to avoid using negative words, such as difcult patient, within earshot of the patient in the examination room or others in the reception area. All staff members of the pediatric ofce should work together to make the patients visit as pleasant as possible and give the physician the necessary information to make accurate decisions regarding the patients health.

should read the manufacturers instructions for the type of thermometer she uses. To measure axillary temperature, the medical assistant places the thermometer under the infants or childs arm in the armpit area, or axilla, holding it tightly in place with the arm held against the patients body. She should hold the thermometer in this spot for approximately 1 minute. The axillary method is best for infants older than age 3 months. If the axillary temperature is 99.0F or higher, the medical assistant should recheck the temperature by using the rectal method for accuracy. She should then document the patients temperature by recording the number and stating that she obtained the temperature using the axillary method. To measure oral temperature, the medical assistant places an oral thermometer into the patients mouth. She should place most oral thermometers under the tongue or in the cheek for 30 seconds to 1 minute and instruct the child to close his lips around the probe without biting down. The child must be old enough to understand these instructions, usually around age 4 or 5. The medical assistant should hold the thermometer in place until the reading is complete, approximately 1 minute (some types are less than 1 minute). She should record the patients temperature in the medical record, including that she obtained the temperature using the oral route. The medical assistant should not try to obtain an oral temperature if the patient cannot hold the thermometer in his mouth, mouth sores are present, the patient has a history of seizures, or the patient cannot breathe through his nose. The medical assistant obtains a tympanic temperature by placing a tympanic thermometer into the ear canal. The AAP does not advise using this method for children under age 2. The thermometer measures the heat from the tympanic membrane (eardrum). When using this method in a child, the medical assistant must straighten the ear canal by pulling the pinna (outer cartilage) of the ear down and back. She should then hold the tympanic thermometer in place until a reading appears on the screen or she hears a beep,

Plotting growth
The medical assistant must use a standardized growth chart to record a patients height and weight and another chart for head circumference. These charts were developed based on an average of height, weight, and head circumference for breast-fed and formula-fed infants and children in the United States. The charts are age and sex specic. The medical assistant should always double-check the measurements before plotting them on the chart. The physician uses this information to compare the patient to other children of the same sex and age. From this comparison, the physician can determine if the child is achieving average growth. To plot the patients measurements, the medical assistant must use the appropriate graph for the patients sex and age group. For example, the following chart shows the growth of a boy from birth to age 3 (36 months). The medical assistant has plotted the boys height at age 36 months as 3712'' and his weight as 31 lb, 8 oz. There is space to record head circumference on the chart; however, the medical assistant should not graph that measurement.

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Plotting growthcontd
Samuel Henry 9832

5 5 6 0
1/7/04 2/20/04 3/10/04 4/5/04 5/4/04 6/30/04 7/28/04 9/24/04 1/11/05 4/8/05 7/11/05 1/9/06 1/12/07 6 wks 2 mos 3 mos 4 mos 6 mos 7 mos 9 mos 12 mos 15 mos 18 mos 24 mos 36 mos 6 lb, 2 oz. 7 lb, 2 oz. 7 lb, 14 oz. 8 lb, 12 oz. 10 lb, 0 oz. 13 lb, 10 oz. 16 lb, 3 oz. 18 lb, 0 oz. 20 lb, 2 oz. 23 lb, 0 oz. 24 lb, 11 oz. 26 lb, 7 oz. 31 lb, 8 oz. 20 1/2 21 1/2 22 22 1/2 23 7/8 26 27 1/4 28 30 31 32 1/8 35 37 1/4

36
13 13 1/2 14 15 15 1/2 16 1/2 16 1/2 17 18 18 1/4 18 1/2 18 1/2 19 1/4

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depending on the device used, and record the patients temperature in the medical record, including the method used. The tympanic method may be uncomfortable for the patient if he has an ear infection and it is not recommended if there is a large amount of cerumen (yellowish waxy substance secreted in the ear canal, also called earwax) present in the canal. The medical assistant obtains a rectal temperature on infants under 3 months of age and when requested by the physician. This method requires a rectal thermometer, which she inserts into the patients rectum. The rectal route is the most accurate temperature reading for children under age 2 years. However, because most patients do not like this method, many ofces use alternatives. The medical assistant should wash her hands and apply gloves before starting this procedure. To measure rectal temperature, the medical assistant must place the patient in a prone or side-lying position and add lubricant to the thermometer to ease insertion. She should insert the thermometer slowly, without force, to approximately 1'' (2.5 cm). She should continue to hold the thermometer in place for a specied amount of time, usually about 1 minute. She must never leave the child unattended while checking rectal temperature. She should then remove the thermometer and note the reading, wipe away excess lubricant, and document the patients temperature, being sure to record the rectal route. Rectal temperature greater than 100.5F in children less than 3 months of age requires immediate attention. The medical assistant should not use the rectal route if the patient has diarrhea, hemorrhoids, or any other disorder than may make this procedure uncomfortable. (See Pediatric temperatures by route.)

Patient Education

Pediatric Temperatures by Route

The medical assistant can explain to parents and caregivers of small children that the route of measurement will affect the normal range for a childs temperature. Here are the normal ranges for each route: axillary94.5 to 99.1F (34.7 to 37.3C) oral95.9 to 99.5F (35.5 to 37.5C) tympanic94.5 to 99.1F (34.7 to 34.3C) rectal97.9 to 100.4F (36.6 to 38C). Fever in children is classied as temperature of 100.5F (36.6C) or higher. The medical assistant should instruct parents and caregivers on how to accurately obtain their childs temperature. In addition, she should warn parents about some methods that garner questionable results, including fever strips placed on the forehead and other types of disposable thermometers, which are not as accurate.

Normal pediatric respiratory rates

Because a childs normal respiratory rate varies as he grows, the medical assistant must know the normal values for infants, children, adolescents, and adults. These values include: neonates and infants30 to 60 breaths/minute children ages 1 to 7 years18 to 30 breaths/minute older children ages 8 to 18 and adults12 to 20 breaths/minute.

Respirations
When the infant is resting calmly, the medical assistant should measure respirations by watching the rise and fall of his chest and abdomen. During inspiration, the chest rises and, during expiration, it falls. One inspiration and expiration count as one respiration. Respirations are sometimes difficult to count in neonates and infants because these rates are more rapid than an adults. Average respirations for an adult are 12 to 20 breaths (respirations) per minute, and normal respirations for an infant or young child can be 30 to 60 breaths/minute. (See Normal pediatric respiratory rates.) If the patient is crying or fearful, the results may be inaccurate. If necessary, the medical assistant should attempt to calm the patient or ask the parent or caregiver to try to calm the patient. She should count respirations for 1 full minute and record the number in the patients medical record.

Pulse
Pulse, or heart rate, is commonly described as the lub dub identifying sounds made by the valves in the heart as

the chambers relax and contract. Heart rate in neonates and infants is higher than in older children and adults. The average pulse in adults is 60 to 72 beats/minute and the average pulse in infants and young children can be 100 to 160 beats/ minute. The medical assistant must count the pulse in pediatric patients for 1 full minute. (See Normal pediatric pulse rates.) She must also monitor the rhythm of the pulse, noting if it is regular or irregular. To measure the pulse of a patient under age 5, the medical assistant should measure the apical pulse with a stethoscope. The apical pulse site is located at the apex of the heart at the fth intercostal space to the left of the sternum. The medical assistant may need to count rib spaces for accuracy and placement of the stethoscope by palpating the patients chest. The medical assistant can measure the pulse in children over age 5 by palpating the radial or brachial artery and counting for 1 minute. She should then record the number

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Normal pediatric pulse rates

The normal resting pulse rate for children varies from birth to adolescence. Normal resting pediatric pulse rates include: neonates130 to 160 beats/minute infants110 to 130 beats/minute children ages 1 to 780 to 120 beats/minute children over age 7 to age 1880 to 90 beats/minute.

in the patients medical record along with the rhythm and method of measurement.

Blood Pressure
Blood pressure measurement is routine in pediatric patients after age 3. Blood pressure is measured in millimeters of mercury (mm Hg). The measurement is uncommon in the neonate unless the pediatrician suspects an abnormality. Blood pressure in children is lower than in adults. As a child grows in age and size, normal values increase and, eventually, approach normal adult values, which are 120 to 139/80 to 89 mm Hg. (See Normal pediatric BP values, page 668.) To obtain the blood pressure of a pediatric patient, the medical assistant must make sure the blood pressure cuff is the appropriate size. Using the wrong size may cause the blood pressure reading to be falsely high or low. To measure blood pressure, the medical assistant can use a digital or an aneroid sphygmomanometer. (See Figure 33-7.) The medical office may have a wallmounted device in each examination room or a stand that the medical assistant can move from one room to another. If the medical assistant is uncertain about how to use the equipment, she should read through the manufacturers instruction manual. Because a young child may be frightened of the equipment and what it will do, the medical assistant should explain to the patient that the cuff will give their arm a hug and then the hug will lessen while she listens with her stethoscope. She should make sure the patients arm is resting and the patient is relaxed. If the medical assistant has difculty obtaining a blood pressure measurement, she can use a handheld Doppler ultrasound device, which measures the blood ow in the major arteries and veins of the arms or legs. She must place the Doppler probe over the artery where she would normally place the stethoscope to magnify the sounds, making them easier to hear. After she measures the blood pressure, the medical assistant should record the number in the patients medical record, being sure to include which of the patients arms she used. B

FIG 33-7 Pediatric sphygmomanometers. (A) Aneroid. (B) Digital.

Head Circumference
The medical assistant should measure head circumference at every well-child examination starting at birth and continuing until age 3. Typically, the medical assistant should measure head circumference last, because most infants and children become upset when the medical assistant places the measuring device around their heads, which makes accurate measurement of temperature, pulse, respirations, and blood pressure difficult. The medical assistant should measure at least twice for accuracy, asking the caregiver or another medical assistant for help if needed to stabilize the

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Normal pediatric BP values

The normal resting blood pressure (BP) rate for children varies from birth to adolescence. Normal resting pediatric BP rates include: birth to age 195/70 mm Hg toddler to school-age child100/70 mm Hg children ages 6 to 13110/74 mm Hg children ages 14 to 18120/76 mm Hg.
20/100 20/200

20/70

childs head. She should place the measuring tape on the most prominent points of the head, including the forehead and occipital bone. The medical assistant should record the measurement in inches and centimeters. She should also make a copy of the height, weight, and head circumference for the parent or caregiver and encourage her to keep a record at home.

20/50

20/40

Vision Screening
To perform a pediatric vision screening test, the medical assistant will use the Snellen eye chart. The pediatric Snellen chart has pictures for the patient to identify or the letter E pointing in different directions. (See Figure 33-8.) The medical assistant must ask the patient to stand 20 from the chart and should conduct the test by asking the patient to identify the largest item and then progress to the smallest. The medical assistants patience with the child during the examination will promote cooperation. If the child views the examination as fun or a game, he will be interested and involved in the testing. Early diagnosis and treatment of vision problems will help the child with schoolwork and participation in activities. If the child requires corrective lenses for vision problems, the pediatrician will refer the patient to an optometrist. Durable corrective lenses that resist breakage and scratches are best for children so they can participate in sports and other activities without worry or risk of injury from broken lenses.

20/30 20/20 20/10

FIG 33-8 Pediatric Snellen charts.

Hearing Screening
The medical assistant may perform a hearing screening in the pediatric ofce or at a school. Hearing testing for infants and small children who cannot follow specic instructions involves assessment using visual reinforcement audiometry (VRA). In this test, the child sits on the parents lap in the center of the testing room with speakers having toys mounted inside to the right and left of the child. When the child responds correctly by turning toward the source of a sound, the tester can animate the toy in that speaker as a positive reinforcement for responding to the sound. As the

child becomes conditioned to seeing the animated toy when he hears the sound, he will indicate hearing ability by turning to the toy whenever he hears the sound (before the animation). Older children who can follow instructions are tested using the same audiometer as adults. (For more information on audiometry testing, see Chapter 36, page 745.) Early diagnosis of hearing problems is important for the childs performance in school and her interactions with friends and family. Some hearing decits are related to infection and can be treated and resolved. Other hearing problems may not be reversible; however, treatment with a hearing aid may enable the child to overcome the disadvantages of hearing loss.

Well-Child Examination
Well-child examinations should occur at regular intervals to assess growth and development. The goals of a well-child examination are to:

establish a trusting relationship between the pediatric patient, his parents or caregivers, and health care professionals

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promote health through education and immunizations prevent problems and diseases provide early detection of problems if present.

Well-child examinations are also a time to reinforce healthy behaviors and provide caregivers with education regarding nutrition, safety, sleep, development, and discipline. (See Teaching wellness and prevention.) During the well-child

examination, the pediatrician will do a head-to-toe physical examination, including general appearance, eyes (basic examination), ears, muscle tone, reflexes, spinal alignment, and immunization evaluation. In preparation for the physicians examination, the medical assistant must ask some questions regarding the patients current health status and lifestyle. Some medical offices have a standard form the

Patient Education

Teaching Wellness and Prevention

The pediatricians ofce is a place where the medical assistant can educate caregivers and children on wellness and prevention strategies to promote optimal growth and development for every child. New parents need accurate information regarding nutrition, safety, and prevention of illness and injuries. Even experienced parents need education on new guidelines and prevention strategies. When providing patient education for a child and her family, the medical assistant should ensure that the discussion takes place in a safe environment where conversation is relaxed and unhurried. The medical assistant must listen carefully to the concerns and questions of pediatric patients and their caregivers. Adolescents may not want a parent present during the examination or history taking. The medical assistant and pediatrician should honor such wishes, and the medical assistant can reassure adolescents that the staff will maintain strict condentiality. Here are some important topics to cover when advising patients and caregivers on safety and accident prevention: Infant and child cardiopulmonary resuscitation (CPR)The American Red Cross offers courses in infant and child CPR as well as rst aid. The medical assistant can direct parents to their communitys hospital or re station for classes. Car seat safetyThe medical assistant can refer parents to the American Academy of Pediatrics for information on car seat installation and safety. Also, some local police or re stations offer annual car seat safety clinics. Bike helmetsHead injuries from falls from a bicycle can be devastating, even fatal. The medical assistant can suggest to parents that they can lead by example and wear helmets to cycle with their children. Outlet safetyThe medical assistant should instruct parents or caregivers to cover outlets with a plastic plug cover and avoid leaving exposed electrical cords where children could trip or pull down an appliance such as an iron. Fire safetyThe medical assistant should encourage parents to make sure there are adequate numbers of smoke detectors in the home and ensure that all smoke detectors have working batteries. She can suggest that parents discuss and practice with their children evacuation procedures in case of re as well as a safe place to meet outside. The well-prepared child is less likely to panic in case of an emergency such as a re. Accidental poisoningThe medical assistant should provide the phone number for the Poison Control hotline (at the CDC in Atlanta, Georgia) and instruct parents and caregivers to call if they suspect their child has ingested a poisonous substance. She should tell them to follow instructions from poison control. She should also emphasize that the parent should never induce vomiting before calling poison control. Some poisons are caustic and can cause burning of the esophagus if vomited. Babysitting safetyThe medical assistant can advise parents on general babysitting guidelines, such as leaving a contact number where they can be reached and leaving other emergency numbers, such as the pediatricians number or a neighbors number near the phone. In addition, she can explain that many communities offer babysitting certication to teens and adults as well as infant and child CPR, basic rst aid, and prevention of injuries and choking. Safe and nutritious snacksThe medical assistant should advise parents to cut grapes in half, cut hot dogs lengthwise rather than in circles, and ensure that all foods for their infant or toddler are cut into small, bite-sized pieces to prevent choking. Basic rst aidThe medical assistant should advise parents to keep a supply of bandages, gauze pads, and antibiotic creams for administering rst aid to children. She should also remind parents to wash wounds and seek medical attention for deep cuts, burns, or suspected broken bones. If a child develops a fever after injury, the parent should bring the child to the ofce for examination because he could have an infection. The medical assistant should emphasize that a child who suffers a head injury must always undergo examination by a physician.

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medical assistant can use as a guide to ask all necessary questions of the parent or caregiver. (See Well-child examination questions.) Well-child examinations should typically occur at 2 or 3 days after birth, 2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 2 years, then once per year from ages 2 to 5, and then at ages 8 and 10. (See Neonatal special considerations.) Some variation can occur with individual pediatricians and the individual needs of the patient.

Apgar Score
The rst neonatal examination is done immediately following birth in the hospital. The pediatrician performs a headto-toe assessment of the neonate 1 minute following birth and then again at 5 minutes following birth. During this examination, the physician uses the Apgar scoring system to evaluate ve distinct categories of the neonate:

muscle tone color

Well-child examination questions

At the beginning of the well-child examination, the medical assistant must ask the pediatric patient or caregiver some questions. Some of the most common questions to ask include: Is the baby breastfeeding or using formula? If using formula, what brand? If the child is older than 6 months, what types of food is he eating?
Well-Child Examination Age in weeks or months: 4 months Height: Nutrition Breast milk Formula Solid foods: baby food or table food 261/4 Weight: 14 lb, 12 oz Head circumference: 163/4

What does the child drink? How often does the child have a bowel movement? What are the childs sleeping habits? The following form is one example of a standard form used to obtain such information during the well-child examination.

Vitamins: Poly Vi Sol one dropper per day Well water or city water: city Bowel movements: 4 x day Sleep patterns: waking to nurse every 2 to 3 hours Family/living situation: stay at home mother, father, 3-year-old sibling Siblings: one brother, 3 years old Pets: cat Second-hand smoke: Father smokes, only outside Activities: Reaches for toys, shakes rattle; studies toys in hand; puts everything in mouth; plays with fingers; laughs, giggles; recognizes mom and dad; knows mom is there when out of sight; turns in response to noise; smiles and coos in response to talking; rolls from side to side; pulls head and chest off floor when on stomach; supports head when sitting; kicks legs; focuses clearly on toy and faces 4/28/09; 10:30 a.m. ----------------------------------------------- S. Gonzales, CMA

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respirations heart rate response to stimuli.

Each of the ve categories is given a score of 0, 1, or 2. The Apgar score is expected to increase from the

1-minute exam to the 5-minute exam for healthy neonates. The physician may need to know the Apgar scoring of a neonate, contained in the neonates hospital medical record, during the follow-up visit when the neonate is several days to several weeks old. (See Apgar scor.)

Neonatal special considerations

When seen in the pediatric ofce, the very young infant requires some special attention to the umbilical cord and circumcision aftercare.

Circumcision Care
A circumcision is a surgical procedure to remove the foreskin, or prepuce, which is the loose fold of skin that covers the penis. It is commonly performed for medical, religious, or cultural reasons. It may be done by a pediatrician a day after the babys birth or it may be performed by a rabbi in a ceremony known as a bris. The medical assistant may need to instruct parents on cleaning the penis after the procedure. After circumcision, the area should be gently washed daily with soap and water. After cleaning, an antibiotic ointment may be applied to prevent infection. Depending on the surgical technique, there may or may not be a healing incision. If there is an incision, the parents must change the wound dressing with each diaper change. The medical assistant should instruct parents on how to change the dressing. The infant may be fussy while the wound is healing; the pediatrician may prescribe an analgesic ointment for pain control. The penis should heal in 7 to 10 days.

Umbilical Cord Care

During a neonatal examination, the medical assistant should inspect the umbilical cord to ensure that it is shrinking and is not infected. Parents were once instructed to clean the umbilical stump with alcohol or hydrogen peroxide. However, new research suggests that the stump will actually heal faster if left alone. If the area becomes sticky with blood, the MA can instruct the parent to clean the umbilical cord with soap and water. To dry the area, the parent can hold a clean absorbent cloth around the stump and dry the area with a hairdryer on a low setting. The medical assistant should instruct the parent to alert the pediatrician if there is a foul odor around the cord or if the baby has a fever, as these are signs of infection. The umbilical cord should shrink in size and become progressively dried out until it eventually falls off. Most babies umbilical cords fall off within the rst 3 weeks of life.

Apgar score
The Apgar score, developed by Dr. Virginia Apgar in 1952, is named after Dr. Apgar; a mnemonic using the letters of her name helps medical professionals remember the ve categories assessed in this scoring system: Activity (muscle tone) Pulse (heart rate) Grimace (reex irritability) Appearance (color) Respiration (respiratory effort). The following table outlines the Apgar score scale used to score a neonates overall health based on these categories.

Sign
0 Muscle tone Heart rate Reex irritability (response to ick on sole) Color Respiratory effort Flaccid Not detectable No response Blue, pale Absent 1

Score
2 Active motion of extremities Over 100 Cry Completely pink Good, crying Some exion Below 100 Grimace, slow motion Body pink, extremities blue Slow, irregular

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Denver Developmental Screening Tool

The pediatrician may also perform a developmental assessment using a test such as the Denver II Developmental Screening Tool (DDST) for children from age 1 month to age 6 years. Although children develop at varying rates, failure to develop or slowed development in one or more of the categories is used to identify developmental delays. Infants and children identied as developmentally delayed can benet from early diagnosis and treatment. The DDST measures four aspects of development:

gross motor skills to evaluate the childs coordination of large muscle groups. The infant at 3 to 4 months is evaluated for head and neck control and the ability to roll over and bear weight on his legs. The 10-month-old should be able to stand holding on to an object for balance, pull himself to a standing position, and get to a sitting position. The 3-year-old child should be able to balance on one foot for 1 second and do a broad jump. language to evaluate the childs ability to comprehend language and, later, use language. The 3- to 4-month-old should be able to vocalize ooh, aah, laugh, or squeal. The 10-month-old should be able to babble with varying syllables and may say dada or mama. At age 3 years, the child should be able to name pictures and an adult should be able to understand at least half of his speech. ne motor skills to evaluate the childs control of ne motor muscles and hand-eye coordination. The 3- to 4-month-old should be able to follow an object to midline with his eyes and then follow past midline as well as grasp a rattle. The 10-month-old should be able to thumb-nger grasp, bang two blocks held in his hands, and, possibly, put a block into a cup. The 3-year-old can make a tower of 8 blocks, wiggle his thumbs, and, possibly, draw a circle. personal and social skills to evaluate the childs socialization and self-condence. The 3- to 4-month-old should smile responsively and begin to smile spontaneously. The 10-month-old can wave good-bye, indicate his needs and wants, and play pat-a-cake. The 3-year-old will name his friends, wash his hands, and put on clothing.

height, weight, vital signs, and urinalysis. The physician will listen to the heart and lungs, palpate the abdomen, and examine the eyes and ears to rule out disorders that would put the athlete in danger, such as a heart murmur, decreased lung function, or organomegaly (enlargement of visceral organs that indicates some form of pathology). The physician will also observe the childs gait (manner and style of walking) to see if he has problems with coordination or injury to the back or lower extremities. She will also ask the patient to bend forward from the waist to rule out scoliosis, a lateral (side) curvature of the spine. If the child has asthma, the physician will determine the severity of the asthma by asking the patient how often he uses his inhaler. If the risk of an exercise-induced asthma attack is severe, the physician cannot clear the child to participate in sports. The medical assistant may be required to record ndings while the physician examines the child. The sports physical examination form must be signed by the physician or his agent (medical assistant or nurse) prior to the childs participation in sports. (See Sports physical season.)

Sick-Child Examination
Sick children make up about 50% of the pediatricians ofce schedule. During cold and u season, most of the daily schedule may concern sick children. The medical assistant will measure the sick childs vital signs and ask questions regarding the onset and symptoms of the illness. A thorough health history of the current illness is important when a child is ill. The pediatrician will then do a thorough examination, based on the health history and other factors. Some ofces have a standard form the medical assistant can ll out for a sick-child examination. (See Sick-child examination questions.) The administrative and clinical medical assistants should be aware of the needs of sick children in the examination and reception areas. (See Comforting sick children in reception, page 674.)

Front ofceBack ofce connection

The cooperation of the child is important for accurate test ndings. If abnormal results are obtained, the child should be screened again in 1 to 2 weeks. The parent should be instructed to make sure that the child is fed and well rested for the rescreening.

Sports Physical Season

In many communities, schools require sports physical examinations prior to the start of the new school year. The administrative medical assistant who schedules appointments should discuss with the physician and clinical staff what the best scheduling strategies might be for this busy time. Offering an evening of only sports physicals or a Saturday sports physical examination clinic may alleviate the burden of working these examinations into busy days.

Sports Physical Examination

Schools and private sports clubs require children to undergo a physical examination before participating. Schools will send an examination form to students for completion by the pediatricians ofce. The medical assistant can perform and record results for many of the tests required, including

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Sick-child examination questions

At the beginning of the sick-child examination, the medical assistant must ask the pediatric patient or caregiver some questions. Some of the most common questions to ask include: How long have you noticed a change or difference in your child? Is the child eating and drinking? Does the child have diarrhea? Has there been a change in the childs sleep patterns? Have you given the child any medications? Is there anyone else in the household who is ill? The form shown here is one example of a standard form used to obtain such information during the sick-child examination.

Sick-Child Examination Form Childs age in weeks or months: Height: 38 Weight: 101.8 F 4 years Head circumference: NA

43 lb

Temperature:

Eating What? milk, macaroni and cheese, grapes Drinking What? water, will only take small sips Nausea: yes, today and last night Vomiting How many times? 2x Diarrhea How many times? none

When last? Last night 5:30 p.m., no breakfast, he felt too sick, did sip water When last? 9 a.m.

When last? 1 a.m. this morning When last? NA

Date of injury or first sign of illness: Last night 6 p.m., after dinner cried, complained of tummy hurts Sleep pattern: usually sleeps well, mother reports 8 p.m. to 6 a.m. sleeping is routine. Last night he was up crying at 10 p.m.; vomited, midnight, crying, 1 a.m. and vomited again 4/14/08; 9:50 a.m. --------------------------------------------------------------- S. Gonzalez, CMA

Reporting Abuse
The Child Abuse Prevention and Treatment Act (CAPTA) of 1996 requires physicians in all 50 states to report suspected child abuse and neglect. The act was originally passed in 1974 and has been amended several times. Every state has a hotline for reporting abuse and neglect that is available to anyone who suspects that a child is in danger. In 2002, 1.8 million cases of child abuse were reported; 896,000 were conrmed as abuse, affecting boys and girls equally. Approximately 1,400 children died in the United States in 2002 as a result of abuse and

neglect; of those, 1,000 were under age 4. Approximately 900 of the fatalities were due to neglect. Children from birth to age 3 years are at the highest risk for abuse. Unfortunately, 80% of the abusers are the childs parents, and 58% of all abusers are female. The presentation of any symptoms of abuse warrants immediate reporting to state authorities. The medical assistant must follow the guidelines of her state. If the pediatrician and medical assistant feel that the child is in imminent danger, they may call social services to the ofce to remove

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Front ofceBack ofce connection

Comforting Sick Children in Reception

The administrative medical assistant working at the front desk can offer a sick child and her parents a treatment room or private area of the waiting room for their comfort. Doing so will separate sick children from well children and prevent the spread of infection. Tissues, access to a bathroom, and a cup of water may also comfort the sick child and her caregiver. The administrative medical assistant should also notify the clinical medical assistants of the sick child so that they can try to obtain a treatment room quickly, make sure the child is comfortable in the room, and keep waiting time for the physician to a minimum.

phobias sleep disturbance bedwetting sexual knowledge inappropriate for the childs age. Physical signs of sexual abuse include:

sexually transmitted diseases (STDs) bruising tearing in the rectum or vagina vaginal discharge or pruritis.

Neglect
Signs of neglect include:

the child from the abuser immediately. Representatives from child protective services can work with the physician to determine the likelihood of continued abuse and identify the best interests of the child. They may place the child with relatives or in foster care. Alternatively, they may order the abusive family member be removed from the home and, possibly, incarcerated. Protective hospitalization may be required for children with severe injuries. The medical assistant should be sure to note in the patients chart any signs or symptoms of abuse and neglect, including signs of physical abuse, sexual abuse, or neglect. She should then notify the physician of these signs.

malnutrition fatigue lethargy lack of appropriate clothing lack of hygiene failure to thrive.

Immunizations
Routine childhood immunizations are state mandated and required for children who attend public schools. When a patient comes to the ofce for immunizations during a wellchild examination, the medical assistant should provide the parent with a recommended immunization schedule and a vaccine information sheet (VIS) for each vaccine administered during that visit. (See Immunization schedule.) The VIS explains the safety and efcacy of the vaccine as well as possible adverse reactions and when to contact a physician if the parent is concerned. The pediatrician is obligated by law to provide parents with a VIS statement that outlines the risks and benets associated with vaccines. (See VIS, page 676.) Some states also have informed consent laws that require a parents signature before administration of a vaccine.

Physical Abuse
Signs and symptoms of physical abuse include:

skin lesions that look like they were produced by an object or by a hand slap long, bandlike bruises from a belt small, round burns from cigarettes symmetrical scald burns from being intentionally immersed in hot water bite marks bald patches on the scalp from hair being pulled bone fractures, especially in children who do not yet walk (a sign of throwing the child or hitting him with great force) a baby that is comatose or stuporous and, possibly, has retinal hemorrhages (from being vigorously shaken) childs excessive fear of the parent or caregiver.

Vaccine Registry
Some states use a database for recording and displaying immunization information for children within that state or region. For example, the Regional Early Childhood Immunization Network (RECIN) is a vaccine database for the northern Wisconsin area. Each child should receive 17 to 18 doses of vaccine by age 2. Because a child may go to different providers to get immunizations, it can be difcult to ensure that the child is getting the proper immunizations at the proper time. A vaccine registry is a way of accessing patient vaccination information outside the pediatric ofce. The medical assistant should enter vaccination information, including the patients name, the date of the vaccine, and any reaction to the vaccine into the common database. If the parent brings the child to a different provider, the new ofce can access the database. This system helps ensure that children do not receive extra doses of the same vaccine or miss a vaccine. The medical assistant should

Sexual Abuse
Most commonly, sexually abused children are ashamed of the abuse and are told by the abuser not to tell anyone. This combination of fear and shame makes diagnosis difcult. Behavioral changes can include:

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Immunization schedule
An immunization schedule enables the medical ofce to inform parents and caregivers of the immunization recommendations of the Centers for Disease Control and Prevention (CDC). The CDC gives specic guidelines for the age at which a child should receive a vaccine as well as how many times he should receive the vaccine. Although the CDC strongly recommends that parents or caregivers follow these guidelines, parents may elect to delay a vaccine for any reason, including illness or allergy. Many pediatricians also routinely delay administration of a vaccine if the child is ill. The complete immunization schedule includes ranges for catch-up immunizations for children who were incompletely immunized as well as recommendations for high-risk populations. The following table lists the general immunization schedule. Many immunizations are given in several doses over a period of time. Multiple doses are indicated in the table by a number in parentheses.

Age Range
Birth 1 to 4 months 2 months

Immunization
Hepatitis (Hep) B (1) Hep B (2) Rotavirus (Rota) (1) Diphtheria and tetanus toxoids and acellular pertussis (DTaP) (1) Haemophilus inuenzae type B conjugate (Hib) (1) Pneumococcal conjugate vaccine (PCV) (1) Inactivated poliovirus (IPV) (1)

4 months

Rota (2) DTaP (2) Hib (2) PCV (2) IPV (2)

6 months

Rota (3) DTap (3) Hib (3) PCV (3)

6 to 18 months

Hep B (3) IPV (3)

12 to 15 months

Hib (4) PCV (4) Measles, mumps, rubella (MMR) (1) Varicella (1)

15 to 18 months 12 months to 23 months 6 months to 5 years 4 to 6 years

DTaP (4) Hep A (1 and 2*) Inuenza (yearly) DTaP (5) IPV (4) MMR (2) Varicella (2)

11 to 12 years

Tetanus and diphtheria toxoids and acellular pertussis (Tdap) HPV (1, 2, and 3**) MCV4

*Separated by at least 6 months ** Administered to females only with 2 months separating rst and second dose and 6 months separating second and third dose

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VIS
The medical assistant must provide a vaccine information sheet (VIS) each time for each vaccine administered at the time of vaccination. Doing so ensures that the parents or caregivers understand the risks and benets as well as what complications to look for, including a rash and swelling, and when to seek medical attention for a severe reaction.

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serious alle rgic reactio n include di hoarseness ff iculty brea or w heezing, thing, hives, palene fast heart be ss, weaknes at or dizzin s, a ess within a an few hour few minutes s after the sh to ot. A high fe if it occurs, sk y from ng vaheseine?e re at ans age, as loMMR ver or seizur would happ cc are th T e, en 1 or 2 w nd dose What shou eeks after th rst dose. A vaccine, get the seco e shot. ld I do? like 28 mys after the fi Call a do serious prob astany daedicine, is capaget MMR vaccine: le d? ctor, or get lems, such as ould also bl e of caus ing r, who was vaccinate the person to sh se or olde The risk of away. Why get a doctor rig MMR vacc ts vere allergic reace ns of Some adul years of ag diseases.deat ht an caus 18 serio at tio . se e serious h, is extrem erally,ineyone ingld getus least one do ey have Tell your docto ar Gen y small. 56, shou el harm, orthat th d rubella r what happ an happened, an ened, the da n show , mumps, ter 19 ca Getting MM born af Measles d when the te and tim e less they e . , ey R vaccR vais ine, un Ask your vaccination it diseases runny noseany of th doctor, nurse w MM ine cc h ccines or the ese three di ther mucvasafer than getting sh , cough, , or health de as given. 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Man atio ct the immunhealth departments e cl g. these dise the immunude: ith drCos that affen program. . ong-term se ug ntact th ks or longer vaccinatin izures, com eated w e e stopped wee Centers fo w a, r2 ermanent br ing tr r Disease Co - ed co (C fo ain damage or lowerIs be nsciousn steroids, DC): ch as s ntrol and Pr es system, su evention get MMR of cancer Call 1-800-232-4636 s should hen? or drug nd Who (1-8er)-CDCith w What if th er Has any ki wthe x- rays ent INFO) treatmVisit National d disord00 ine and vacc evvaccinreacte is a mod-erIs takior cancer www count (a blooImmunizatio ere e: ate ng ion? w plat elet.cdc.gov/nip Over . . . n Programs website of MMR at er had a lo t 2 doses ould I look - Has ev should ge Children for? s of age -15 month 12 ag ua e. The first at 6 years of l conditions, such U.S. DEPA as a serious cond at 4RTME igh fever or and the se allergic Centers for NT OF HEALTH behavior ch & HUMA Disea anges. 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research her local area to see if a common vaccine database is available.

Objections to Vaccination
Some parents or caregivers may have religious, cultural, or medical beliefs that cause them to object to immunizations.

If a parent or caregiver will not allow the child to be vaccinated, the physician has no legal authority to administer the vaccine. In such an instance, the medical assistant should still provide the parent with the vaccine information sheet and tell her that the vaccines are available if she changes her mind.

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Pediatric Laboratory Tests

The most common laboratory tests performed in pediatrics are urinalysis, hemoglobin and hematocrit, and rapid Strep tests.

Urinalysis
Obtaining a urine sample from a child can be challenging. A child may be uncooperative or unable to urinate. Depending on the age of the patient, the medical assistant can ask the parent or caregiver to go into the bathroom with the child

and collect the specimen. She should convey instructions for a clean-catch or midstream urine specimen collection to the parent or child depending on the childs age and maturity level. (For information on specimen collection, see Chapter 44, page xxx.) If a physician orders a urine sample from an infant who is too young to use the toilet, the medical assistant must obtain the sample using a collection bag. This procedure requires the cooperation of the parent or caregiver. (See Procedure 33-1: Collecting a urine specimen from an infant.)

PROCEDURE 33-1

Collecting a urine specimen from an infant

Task Collect an uncontaminated urine specimen from an infant. Conditions Nonsterile disposable gloves Antiseptic wipes Sterile water and sterile gauze squares Pediatric urine collection bag Sterile urine specimen container and label Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully collect a urine specimen from an infant. Performance Standards 1. Wash your hands to ensure infection control. 2. Assemble the equipment and supplies and check the order in the patients medical record. 3. Greet the patient and caregiver. Explain the procedure to the caregiver and answer any questions. 4. Apply gloves. 5. Position the infant in the supine position and remove the diaper. Ask the caregiver to position the infant with legs apart. 6. Clean the childs genitalia thoroughly with the antiseptic wipes to prevent contamination of the urine sample. a. For a girl, clean the urinary meatus from front to back using a separate wipe for each side. Use a third wipe to clean directly over the urinary meatus, again from front to back to prevent contamination from the anal area. Rinse the area thoroughly with sterile water and a sterile gauze. Dry the area with sterile gauze to enable an airtight seal between the collection bag and the patients skin. b. For a boy who is uncircumcised, retract the foreskin of the penis slightly. Clean the area around the meatus and urethral opening with an antiseptic wipe. Use a fresh antiseptic wipe to clean the scrotum. Rinse the area thoroughly with sterile water and a sterile gauze. Dry the area with sterile gauze to enable an airtight seal between the collection bag and the patients skin. 7. Prepare the urine collection bag by removing the peelapart packaging and the paper backing to expose the adhesive strip around the sponge ring of the bag.

Remove the paper backing to expose the adhesive strip.

Continued

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PROCEDURE 33-1contd

8. Attach the collection bag rmly to the infant to prevent leakage and contamination. a. For a girl, place the round opening of the bag so as to cover the upper half of the external genitalia, centering the opening of the bag above the urinary meatus. b. For a boy, position the bag so that the childs penis and scrotum are projected through the opening of the bag. The loose end of the bag should hang down toward the infants feet. A

9. Place a clean diaper under the child. 10. Offer the caregiver water in the infants bottle to stimulate urination or ask the mother to breastfeed the infant if he does not take a bottle. 11. Ask the caregiver to stay with the infant until he voids. 12. When the infant has voided a sufcient volume of urine, wash your hands, apply gloves, and gently remove the urine collection bag. Use care in removing the bag to avoid irritating the infants skin. 13. Clean the genital area with antiseptic wipes and rediaper the child. 14. Pour the urine from the collection bag directly into a sterile urine specimen container. 15. Label the specimen container. 16. Record the procedure in the patients medical record to ensure a complete, accurate medical record.
Date 10/15/09; 9:52 a.m. Urine collected in pedi bag. -----------------S. Gonzales, CMA

17. Remove gloves and wash your hands.

Attach the bag rmly to the infant to collect the urine as the child voids.

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Hemoglobin and Hematocrit

The hemoglobin and hematocrit (H&H) test measures values of these substances in the patients blood. The test, routinely performed to diagnose possible anemia, involves a capillary puncture to obtain a blood specimen. The medical assistant will routinely perform a capillary puncture in the pediatric ofce, so familiarity with this procedure is essential. (For more information on performing a capillary puncture, see Chapter 41, Phlebotomy, page 867.) Because the patient may feel discomfort, or pinching, during a capillary puncture, the patient may cry and want the comfort of his parent or caregiver. The medical assistant can offer the child stickers, a pencil, or a small toy as a reward for good behavior and cooperation. The medical assistant should never offer candy as a reward because it conveys a disregard for proper nutrition and good health.

then vegetables, and then fruits. This progression is gentler for the baby and will not create a dislike for the taste of vegetables in favor of the sweetness of fruits. Common foods added from 6 months on include:

weeks 1 to 3cereals, such as rice, oats, and wheat weeks 4 to 6vegetables, such as green beans, peas, sweet potato, and carrots weeks 7 to 9fruits, such as applesauce, strained pears, and peaches.

Age 1
At age 1, the child can transition from breast milk or formula to whole milk. The American Academy of Pediatrics (AAP) strongly urges parents to give children under age 2 whole milk, rather than reduced fat or nonfat milk. The reduction in fat and calories will not meet the caloric requirements of growing babies. At age 1, the child should be eating a variety of nutritious foods, such as:

Rapid Strep Test

The rapid Strep test determines the presence of the Streptococcus pathogen. This test diagnoses Strep throat, a common pediatric ailment, and is easily carried out in the pediatric ofce. Even so, obtaining a throat culture from a child can be a challenge. The patient is most likely in pain and may not want to cooperate with testing. To obtain a sample, the medical assistant must swab the back of the patients throat, avoiding the teeth and cheeks to prevent contaminating the specimen. Because the results are available quickly, the physician can prescribe the appropriate treatment before the child leaves the ofce. (For information on obtaining a throat culture for rapid Strep testing, see Chapter 45, page 935.)

whole wheat crackers cheese applesauce bananas scrambled or hard-boiled eggs mashed potatoes variety of bite-sized green, yellow, and orange vegetables chicken cut into very small pieces crumbled hamburger.

Ages 2 to 5
At ages 2 to 5, the child should be feeding herself and making some food choices. The medical assistant can discuss with parents trying to keep only healthy foods in the home so that the child can make good choices. The preschooler can explore nutritious foods and help in meal preparation. Parents should still be sure to cut food into small pieces to avoid a choking hazard. Foods that are appropriate for this age group include:

Nutritional Counseling
In addition to prevention and treatment of illness, the pediatric medical ofce can offer patients and caregivers information on proper nutrition to support growth and development. Good nutritional habits learned in childhood can promote good health throughout the patients entire life.

Birth to 6 Months
From birth to age 6 months, an infant should receive breast milk or formula exclusively. Studies have shown that introducing solid foods before 6 months leads to an increased risk of food allergies.

6 Months to 1 Year
From age 6 months to 1 year, breast milk or formula should still make up most of an infants diet. However, at 6 months, the parent or caregiver can begin introducing solid foods. New foods should be added one at a time for a period of 3 or 4 days for each. In this way, if the child exhibits a sign of allergy, such as a rash, the caregiver can quickly identify the new food as an allergen and eliminate it from the childs diet. Most pediatricians recommend introducing cereals,

milk, yogurt, cheese chicken, eggs, beans, sh, meat vegetables of a variety of colors (green, yellow, and orange) variety of fruits (such as grapes, apples, oranges, bananas, and pears) bread, cereal (unsweetened or with minimal sweeteners) rice, and pasta.

School-Age Children
Parents of school-age children, from ages 5 to 12, should continue offering healthy foods and allowing the child to make good choices. The child may want to explore cuisines from other cultures, add seasonings to foods, and make more of her own food choices. Children can be included in menu

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planning, the preparation of meals, and cooking with supervision. The child will become increasingly aware of what her peers are eating, so parents should continue to discuss with their child the reasons for making healthy food choices. In addition, parents can use the USDA food pyramid for young children (ages 6 to 11) to help explain healthy food choices. (See Figure 33-9.)

Adolescents
Teenagers, ages 13 to 19, tend to be busy with school and activities and healthy eating habits may decline. The teenager will begin eating more meals outside of the home, and the parent will have less control of her diet. The parent can lead by example, choosing healthy foods for herself and continuing to buy healthy foods to serve at home. Parents can encourage teens to plan and cook meals and invite friends to create healthy meals together.

Vitamin and Mineral Supplements

During infancy, childhood, and adolescence, growth and development require vitamins and minerals to support the

many changes in young bodies. Healthy food choices can provide all the essential vitamins and minerals. Thus, education about healthy foods is essential. However, the pediatrician may also recommend a vitamin and mineral supplement to ensure that the child is getting the necessary nutrients. The medical assistant should discuss vitamin and mineral supplementation with children and parents when discussing healthy nutrition. The AAP recommends breastfed infants receive iron supplements at 4 months of age and then supplements or iron-fortified cereal at 6 months of age because iron stores from breast milk are depleted at that age. Iron supplementation can continue until age 1, when the childs diet should contain enough iron for his needs. Many pediatricians also recommend vitamin D supplementation during infancy, especially in northern states where sunlight during the winter is limited. The medical assistant should also document in the patients chart the name and dosage of any supplements the child is taking. (See USRDA of vitamins and minerals.)

FIG 33-9 USDA food pyramid for young children.

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USRDA of vitamins and minerals

While pediatricians should always recommend healthy food choices as the best source of vitamins and minerals, children commonly require supplementation. Many pediatricians recommend a multivitamin and multimineral supplement to ensure that the patient receives the necessary nutrients for good health. Children who refuse to eat a variety of foods, or picky eaters, are especially in need of vitamin and mineral supplementation. Many varieties of vitamin and mineral supplements are available in pharmacies, health food stores, and supermarkets. If the pediatrician recommends supplements for a patient, the medical assistant should record what supplements the patient is taking in the medical record. The following table lists the United States recommended daily allowances (USRDA) of vitamins and minerals for infants, children, and males and females ages 9 to 18.

Vitamin or Mineral

Infants
birth to 6 months 6 to 12 months

Children
1 to 3 years 4 to 8 years 9 to

Males
14 to 18 years 13 years

Females
9 to 13 years 14 to 18 years

Vitamins Thiamine (mg/day) Riboavin (mg/day) Niacin (mg/day) Biotin (mcg/day) Pantothenic acid (mg/day) Vitamin B6 (mg/day) Folate (mcg/day) Vitamin B12 (mcg/day) Vitamin C (mg/day) Vitamin A (mcg/day) Vitamin D (mcg/day) Vitamin E (mcg/day) Vitamin K (mg/day) Minerals Sodium (Na) (mg/day) Chloride (Cl) (mg/day) Potassium (K) (mg/day) Calcium (Ca) (mg/day) Phosphorus (P) (mg/day) Magnesium (Mg) (mg/day) Iron (Fe) (mg/day) Zinc (Z) (mg/day) Iodine (I) (mcg/day) Selenium (Se) (mcg/day) Copper (Cu) (mcg/day) Manganese (Mn) (mg/day) Fluoride (Fl) (mg/day) Chromium (Cr) (mcg/day) 120 180 400 210 100 30 0.27 2 110 15 200 0.003 0.01 0.2 370 570 700 270 275 75 11 3 130 20 220 0.6 0.5 5.5 1000 1500 3000 500 460 80 7 3 90 20 340 1.2 0.7 11 1200 1900 3800 800 500 130 10 5 90 30 440 1.5 1.0 15 1500 2300 4500 1300 1250 240 8 8 120 40 700 1.6 2 21 1500 2300 4700 1300 1250 360 15 9 150 55 890 1.6 3 24 1500 2300 4500 1300 1250 240 8 8 120 40 700 1.6 2 21 1500 2300 4700 1300 1250 360 15 9 150 55 890 1.6 3 24 0.2 0.3 2 5 1.7 0.1 65 0.4 40 400 5 4 2.0 0.3 0.4 4 6 1.8 0.3 80 0.5 50 500 5 5 2.5 0.5 0.5 6 8 2 0.5 150 0.9 15 300 5 6 30 0.6 0.6 8 12 3 0.6 200 1.2 25 400 5 7 55 0.9 0.9 12 20 4 1.0 300 1.8 45 600 5 11 60 1.2 1.3 16 25 5 1.3 400 2.4 75 900 5 15 75 0.9 0.9 12 20 4 1.0 300 1.8 45 600 5 11 60 1.0 1.0 14 25 5 1.2 400 2.4 65 700 5 15 75

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Chapter Summary

The medical assistant working in the pediatric ofce can educate parents and children about health, safety, prevention of illness, transmission of illness, and nutrition. Well-baby and well-child visits are an opportunity to monitor the growth and development of infants and children or to diagnose developmental delays as early as possible to start intervention. Vision and hearing screening in the pediatric ofce enables early diagnosis of vision and hearing decits to initiate treatment as soon as possible. Medical assistants and other staff should work together to ensure that sick children do not wait in the reception area if at all possible, to avoid potentially infecting healthy children. When children are diagnosed with an illness by the pediatrician, the medical assistant can educate patients and parents in the treatment of their illness. Routine childhood immunizations are state mandated and required for children who attend public schools. Immunizations are administered to patients in the pediatric ofce with the consent and understanding of the vaccines by the parent or guardian. Common pediatric laboratory tests include urinalysis, hemoglobin and hematocrit, and rapid Strep tests. CAPTA requires physicians in all 50 states to report suspected child abuse and neglect. The medical assistant should be sure to note in the patients chart any signs or symptoms of abuse and neglect, including signs of physical abuse, sexual abuse, or neglect. In addition to prevention and treatment of illness, the pediatric medical ofce can offer patients and caregivers information on proper nutrition to support growth and development. While pediatricians should always recommend healthy food choices as the best source of vitamins and minerals, children commonly require supplementation.

a. bicycle helmet safety and head injury prevention b. car seat safety, tting car seats, local resources for getting a car seat tted properly c. good nutrition for infants, toddlers, and adolescents. d. children with ADD and ADHD, including school strategies and so forth e. drug and alcohol abuse education for adolescents f. preventing teen pregnancy and sexually transmitted diseases g. choking hazards for babies and infants, including feeding guidelines as well as infant CPR h. preventing and responding to poisoning; childproong the home

Case Studies
1. Yotchi Tanaka is a new mother who has come into the ofce with a thermometer that she does not know how to use. She has questions regarding the equipment and technique necessary to obtain an accurate temperature for her child. What should the medical assistant do? 2. The medical assistant measures a 3-year-old female patient and plots the measurements on the standardized growth chart. The caregiver of the child notices that the patients measurements are under all the lines on the chart. She asks the medical assistant what is wrong with her child. How should the medical assistant respond?

Resources

Team Work Exercises

1. Divide into groups of four to six students each. Each group should research one of these vaccines: Hib, MMR, Hep B, HPV, or varicella. Each group must create a computerized presentation or a poster that discusses the benets and risks of the vaccine. Students can role-play the medical assistant and parent discussing a vaccine. 2. Divide into groups of three to five students each. Research and create patient education brochures for a pediatric ofce, including these topics:

American Academy of Pediatrics car seat safety guidelines: www.aap.org/family/carseatguide.htm American Red Cross infant and child CPR and rst aid offerings by area: www.redcross.org/services/hss/courses CDC lead poisoning recommendations: www.cdc.gov/ nceh/lead/ACCLPP/recommend.htm CDC vaccine information statements: www.cdc.gov/vaccines/ Child welfare information for all 50 states: www .childwelfare.gov/systemwide/laws_policies/state/index.cfm Denver Developmental Materials: www.denverII.com Ear infection quiz for parents and caregivers: www .mayoclinic.com/health/ear-infections/QZ00026 Immunization schedule from the CDC: www.cdc.gov/ vaccines/recs/schedules/downloads/child/2007/child-schedulecolor-print.pdf Information on pediatric health: www.aap.org, www .mayoclinic.com/health/healthy-baby/FL99999, and www .mayoclinic.com/health/childrens-health/CC99999 Whitney, E.N., and Rolfes, S.R.: Understanding Nutrition, 11th ed. Boston: Wadsworth Publishing Company, 2005. Wardlaw, G.M., and Smith, A.M.: Contemporary Nutrition, 7th ed. New York: McGraw Hill, 2009.

CHAPTER

Geriatrics
Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell key terms describe the impact of an aging population on the American health care system list nine myths commonly associated with aging and explain why each is a myth discuss the effects of aging on each of the body systems differentiate between dementia, delirium, and depression identify self-care measures that may be taken to prevent or minimize the risk of developing dementia demonstrate in a role-playing scenario the techniques that should be employed when communicating with the patient who has dementia identify self-care measures that may be taken to prevent or minimize the risk of developing osteoporosis describe a plan for increasing safety and preventing accidents in the home of an elderly individual compare and contrast cataracts, glaucoma, and macular degeneration describe the medical assistants role in providing care for elderly patients describe why pain management for geriatric patients should be a priority list medications commonly used for pain management in the elderly patient and identify specic considerations for each.

34
CAAHEP Competencies
General Competencies Professional Communications
Recognize and respond to verbal communication Recognize and respond to nonverbal communication Digestive System Urinary System Reproductive System Endocrine System Musculoskeletal System Sensory System

Legal Concepts
Identify and respond to issues of condentiality

Medical Terminology Related to Geriatrics Common Geriatric Diseases and Disorders

Dementia Alzheimer disease Bone Disorders Osteoporosis Osteoarthritis Sensory Disorders Presbyopia Cataracts Glaucoma Macular degeneration Presbycusis

Patient Instruction
Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention Identify community resources

ABHES Competencies
Professionalism
Maintain condentiality at all times

Communication
Adapt what is said to the recipients level of comprehension Adapt for individualized needs

Special Needs of the Geriatric Patient

Communication Strategies Safety Promotion Mobility aids Home safety Pain Management Extended Care and End-of-Life Issues In-home and home health care Assisted living Nursing center Extended care campus End-of-life issues

Administrative Duties
Locate resources and information for patients and employers

Instruction
Instruct patients with special needs Teach patients methods of health promotion and disease prevention

Chapter Outline
The Aging Population Ageism Physiological Changes of Aging
Integumentary System Nervous System Cardiovascular System Respiratory System

Chapter Summary Team Work Exercises Case Studies Resources

683

Key Terms
ageism

The Aging Population

Aging is inevitable, but how people age is variable. Everyone ages at a different rate and in a different way, so discussions about the needs of the aging population must take those variables into account. American society has commonly thought of the age of 65 as the start of older adulthood. However, some people look and behave relatively young into their 60s, 70s, or even 80s, and others look and behave old as early as age 40 or 50. Some factors impacting aging include genetics, lifestyle, diet, activity and exercise, and coping strategies. The effects of aging on a persons health has a huge impact on that persons quality of life. In general, the U.S. population is aging. In 2000, there were 35 million age 65 or over (12.4% of the population). This number is expected to double to 70 million by the year 2030. In addition, the segment of the population known as the frail elderly (over age 85) is also increasing in size. The major reason for this increase is the aging of the baby boom generation, which includes those born between 1946 and 1964. The aging of the U.S. population is having a profound impact on the American health care system. As people age, their need for health care resources also increases. With the total numbers of individuals age 55 and older projected to increase by over 200% in some states by the year 2025, the health care industry can expect to experience ever-increasing demands in the coming years.

Form of prejudice and discrimination against individuals because of their age

assisted living

Residential facilities with minimal health care, common dining and social activities, and usually transportation assistance
home health care agency

Private company that employs nursing assistants and nurses who make home visits to provide patients with limited nursing services
hospice care

Program that provides special end-of-life care for terminally ill patients
in-home care

Care provided in the home by spouses, family, close friends, or paid, live-in caregivers
neuritic plaque

Accumulation of bundled bers surrounding normal and damaged nerve cells in the brain
neurobrillary tangles

Tangles of neurobrils that make up part of the nerve cell body

nursing center

Facility in which custodial and nursing care are provided to individuals who need assistance with activities of daily living; also called a nursing home
palliative care

Medical care aimed at alleviating disease symptoms, rather than providing a cure
postmenopausal

Period occurring after permanent cessation of menstruation

Ageism
American culture in general values the qualities of youth and beauty. In fact, some may say that it places too much emphasis on such things, while the experience and wisdom gained from long life is commonly dismissed as unimportant or obsolete. In some situations, the bias toward youth results in ageism, a form of prejudice and discrimination against people because of their age. An example of ageism against the elderly is the preferential interviewing, hiring, and promoting of younger workers over equally qualied older workers. Such prejudice is similar to racism, sexism, and other forms of discrimination and is illegal as well as unethical. Because of the impending impact of an aging population on the American health care system, medical assistants will be increasingly involved in providing health care services to elderly patients. Therefore, the medical assistant should assess her own attitude and potential bias toward elderly patients. She can begin such an assessment by considering myths associated with aging, including the perception that all elderly people end up needing

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institutional placement. In fact, less than 5% of elderly persons live in institutional settings, and the other 95% live more independently. In some cases, they live in their own residence individually or with a spouse. In other cases, they live semi-independently with family members, friends, or caregivers. (See Aging myths.)

Integumentary System
Skin changes create some of the most visible signs of aging. These changes are accelerated by environmental exposure to the suns ultraviolet rays and pollution. Skin cells reproduce more slowly, causing the skin to thin and become more vulnerable to tearing and other types of injury. Thus, when treating an elderly patient, the medical assistant must take care to use tape, bandages, and other products that are as gentle on the skin as possible. Once injured, the elderly persons skin is slower to heal, especially if he also suffers circulatory or immune system impairment. The skin loses moisture, elasticity, and strength due to changes in elastin bers, which provide elasticity, and collagen bers, which provide strength. Age spots develop due to changes in pigmentation and a variety of skin lesions may develop. Most of these lesions are benign; however, cancerous lesions may also occur. Thus, the

Physiological Changes of Aging

As a person ages, his physical body undergoes changes to all systems. Therefore, the health care needs of an aging person change over time. The medical assistant can become more effective in understanding and meeting the needs of aging patients by learning about the changes these patients experience.

Aging myths
This table lists the most common myths and the facts associated with aging

Myth
All elderly people become senile.

Truth
Memory becomes less acute with advancing age and it takes longer for elderly individuals to recall information. However, most continue to have good cognitive function.

All elderly people become incontinent.

Most elderly people maintain control over their bowel and bladder. Incontinence should never be considered a normal part of aging.

All elderly people are set in their ways and incapable of learning or changing.

Older adults learn more slowly, due to physical limitations affecting vision, hearing, and energy level. They may need more time to process information but are fully capable of learning.

Disease and disability are an unavoidable part of aging.

Elderly people are more vulnerable to some physical ailments; however, most report their health as good or excellent.

Elderly people have no interest in or desire for sex.

A large percentage of elderly people report continued participation and enjoyment in sexual relationships.

Continued interest in sex among elderly people is abnormal and should be discouraged. Elderly people are unproductive and a burden on society.

Sexuality is not age-dependent and is a healthy dimension of the whole person, regardless of age. Many people continue paid work well past retirement age. After retirement, most continue contributing time and energies to their families and their communities through a wide variety of activities.

Most elderly people end up living in long-term care institutions. Elderly people have more experience with pain and have, therefore, developed an increased tolerance for pain.

Less than 5% of the elderly live in institutional settings. Experience with pain does not create an increased tolerance for pain. Regardless of age, all individuals deserve to have their pain evaluated and managed appropriately.

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medical assistant should educate patients about the warning signs of skin cancer. (For more information on skin cancer education, see Chapter 25, Dermatology, page 411.) Changes to the dermal layer of the skin include decreased vascularity, which decreases a persons ability to regulate body temperature, resulting in increased vulnerability to heat and cold. An elderly persons skin also has less active sweat and sebaceous glands, which results in dryer skin that is more vulnerable to injury. Fat deposits in the face decrease and increase in the abdomen and thighs of women. Hair on the head begins to thin and turn gray, while hair on the eyebrows, nose, and ears in men becomes longer and coarser. Women may begin to develop more facial hair. Fingernails become more brittle and may split and toenails may thicken.

resistance to blood ow, thus increasing blood pressure and forcing the heart to work even harder. Atherosclerosis (buildup of cholesterol plaques inside of arterial walls), also more common in elderly patients, contributes further to the developing stiffness and narrowing of vessels and results in hypertension, a major contributor to cardiovascular disease, the leading cause of death in the elderly. Over half of elderly patients have some form of hypertension, including systolic hypertension, diastolic hypertension, or both. Hypertension increases the risk of vascular and cardiac events, such as stroke and heart failure.

Respiratory System
Respiratory function in aging adults changes in several ways. The thorax changes shape and loses exibility due to calcication of ribs and changes in the thoracic vertebrae. Kyphosis, an exaggerated curve of the upper thoracic spine that is sometimes called hunchback or Potts curvature, is a common age-related change that affects respiratory function. The development of osteoporosis, a condition characterized by loss of bone mass throughout the skeleton, further contributes to degenerative changes in the vertebrae and thorax. Respiratory muscles also lose strength, resulting in a weaker cough and the need to work harder to cough and even to breathe. Because the cough reex is an important protective mechanism, a weakening cough reex puts elderly individuals at increased risk for respiratory problems. In addition, as a person ages, her lung tissue loses elasticity and capacity due to changes in capillaries and alveoli. All of these changes result in less effective movement of the chest wall, an overall decrease in gas exchange, and an increased risk for pneumonia and other respiratory disorders.

Nervous System
As aging progresses, the number of neurons in the nervous system decreases and the brain gets smaller. Dendrites begin to shrink, which can slow message transmission. Therefore, an elderly patient may nd that information retrieval takes longer, slowing their ability to recall facts or events. Reaction time also slows somewhat. In spite of these changes, loss of brain cells is minimal, and elderly people are still capable of learning new information. Experts suggest that optimal mental function can be preserved by keeping the brain actively stimulated. Such activities might include reading, taking classes, playing board games and trivia games, and doing crossword puzzles. Some experts believe ingestion of antioxidants, such as vitamin E and ginkgo biloba, has benecial effects. However, patients should only take such supplements after consultation with a physician, because ginkgo biloba interacts with some medications and too much vitamin E causes toxicity. Other activities that promote cardiovascular health, such as exercise, also positively affect the brain by providing optimal circulation. Avoidance of destructive habits and other risk factors also helps preserve brain health and mental function.

Digestive System
In general, elderly persons are at increased risk for gastrointestinal (GI) disorders, such as gastroesophageal reux disease (GERD), peptic ulcer disease (PUD), and diverticulitis. As individuals age, the digestive system loses some of its muscle tone and elasticity. Thus the digestive tracts smooth muscle wall, which is responsible for peristalsis, becomes less effective. As a result, an elderly person is more vulnerable to constipation. Also, many medications commonly taken by elderly patients also contribute to this problem. Elderly patients are also more vulnerable to nutritional deciencies as they experience less tolerance for certain foods. As a result, they are more likely to develop problems with diarrhea and atulence. As a person ages, the stomach produces less hydrochloric acid, which aids digestion, and less intrinsic factor, which is a compound made in the stomach necessary for vitamin B12 absorption. These decreases lead to vitamin deciencies. Some medications also contribute to nutritional deciencies by impairing the digestion,

Cardiovascular System
In an aging patient, the cardiovascular system suffers the effects of decreased cardiac output, arteriosclerosis, and atherosclerosis, which combine to contribute to hypertension, cardiovascular disease, and stroke. The aging heart beats less forcefully because it loses strength and mass with age as well as from disease or adverse effects of medication. A less forceful heartbeat results in decreased cardiac output and, therefore, decreased energy and stamina. In addition, the heart tries to compensate for decreased cardiac output by increasing the heart rate. Such an effect is more pronounced during physical exertion, anxiety, or illness. Compounding the problem is the age-related loss in vessel wall elasticity caused by arteriosclerosis. Stiffer vessel walls provide more

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absorption, or utilization of certain nutrients. Elderly persons, especially those who live alone, are prone to poor eating habits and, as a result, may be decient in important vitamins and minerals. Many are hesitant to drink adequate quantities of uids because of fears of incontinence, nocturia, or being a burden to others. As a result, they are commonly dehydrated, which further contributes to constipation and decreased kidney function and slows waste excretion, which increases the risk of toxicity. Oral medications may impact elderly persons differently due to changes in GI function. In older patients, liver function decreases, which slows the metabolism of medications and toxins. Oral medications traveling more slowly through the intestines can, in some cases, result in increased absorption of these drugs. In addition, medications may interact with one another, resulting in a decrease or increase in their desired effects. Thus, elderly patients may be at greater risk for drug toxicity.

Urinary System
Elderly men commonly develop benign prostatic hyperplasia (BPH), which is an enlargement of the prostate gland. BPH results in urinary symptoms of frequency, urgency, nocturia, hesitancy, and difficulty maintaining a urine stream. It also increases the risk of urinary retention and incontinence and increased incidence of urinary tract infection (UTI). Incidence of prostate cancer also increases with age and is the second leading cause of cancer death in men over age 50. In general, bladder capacity decreases as a person ages. This decreased capacity leads to increased urinary frequency during the day and night for men and women. This disrupts sleep patterns and overall quality of sleep. Elderly women sometimes suffer from forms of overactive bladder, including various types of incontinence. The number of functioning nephrons in the kidneys decreases as a person ages. Thus, kidney function decreases. Decreasing effectiveness of the cardiovascular system also impacts kidney function, because decreased blood ow to the kidneys inhibits their ability to lter and excrete wastes effectively. As a result of these changes, the half-life of some medications may increase, causing a risk of drug toxicity. However, in most cases, the kidneys have a great capacity to continue normal or near normal function late into life.

decreases in size and loses elasticity. The ovaries, uterus, and cervix also decrease in size. Vaginal dryness occurs as secretions decrease. In men, spermatogenesis (formation of mature functional spermatozoa) continues late into life. However, in addition to an enlarging prostate, men nd that erections take longer to develop and may be less rm than in the past. Erectile dysfunction (ED) may develop from various causes, including medication, arthritis, and arteriosclerosis. Gynecomastia (breast enlargement) may develop as a result of adverse effects of medication, obesity, or hormone changes. Men as well as women are at greater risk for breast cancer. Desire for and participation in sexual activity may continue late into life for women and men. Health care providers should view this behavior as normal and healthy. In some cases, decreased sexual activity may result from illness, disability, adverse effects of medication, loss of a partner, or decreased interest. The medical assistant must be sensitive to such issues and should encourage patients to discuss issues of concern with the physician.

Endocrine System
As individuals age, changes in the level and activity of some hormones may occur. These changes impact each body system regulated by certain hormones. The muscular system is affected by a decreased level of growth hormone, resulting in decreased muscle mass as well as an increased tendency to store fat. Decreased calcitonin and parathyroid hormone levels affect calcium and phosphate levels in the skeletal system, leading to an increased likelihood of osteoporosis. Decreased aldosterone leads to decreased efciency in salt and water conservation, increasing the risk of dehydration in elderly patients. A decrease in thyroid hormones slows the metabolic rate and increases sensitivity to cold and heat. Decreased insulin production or less effective insulin use leads to hyperglycemia and an increased risk of type 2 diabetes. Decreased glucocorticoid levels lead to a decrease in the ability to deal with stress and a weakened immune system, possibly leading to increased sensitivity to pain and increased vulnerability to infection. A slight decrease in testosterone production in males may lead to diminished libido and changes in erectile function. Decreased estrogen and progesterone in females leads to loss of elasticity and density of breast and vaginal tissue and decreased size of the ovaries, uterus, and cervix.

Reproductive System
In women who are postmenopausal (the period after permanent cessation of menstruation), a number of changes develop as a result of decreased estrogen and progesterone levels. The breasts lose underlying muscle mass and tone and the breast tissue loses elasticity and density. These changes result in smaller breasts that tend to droop. The vagina also

Musculoskeletal System
A person experiences decreased muscle mass and strength as he ages. Bone mass decreases as bones lose minerals. This decrease is compounded by decreased physical activity, especially weight-bearing activities that stimulate bone growth. Postmenopausal women are at greater risk for loss of bone

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mass than men (50% over age 50). However, both men and women may develop osteoporosis. Osteoarthritis occurs as joints begin to deteriorate with erosion of cartilage and bone.

Sensory System
A decrease in all ve senses is common in aging; however, it is not clear if this effect is due to physiological changes of aging or changes associated with injury, surgery, medications, or chronic disease. Many elderly persons nd that, as they age, food does not taste as good. With age, active taste buds decrease in number and lose their sensitivity to salty, sweet, sour, and bitter avors. This decrease in the sense of taste most commonly begins after age 60. In addition, aging also causes a decrease in the sense of smell, which is a significant part of being able to taste and enjoy food. A decrease in the sense of smell occurs most commonly after the age of 70 and may be due to loss of functional nerve endings in the nose. As a result, some elderly patients tend to oversalt their food in an effort to make it taste better. Others lose interest in eating and, as a result, develop nutritional deciencies. Many structures in the body, including skin, muscles, and internal organs, have receptors that detect touch, temperature, pressure, or pain. These receptors send signals to the brain for processing and interpretation. Elderly persons seem to experience decreased perception of such signals. In any case, elderly persons generally experience greater difculty differentiating temperatures, which may put them at risk for heat- and cold-related injury, such as frostbite and burns. Decreased sensitivity to pressure puts elderly patients at greater risk for developing pressure ulcers. On the other hand, because of their thinning skin, frail elderly patients sometimes notice increased sensitivity to light touch. One of the most signicant challenges in caring for aging patients is communication due to hearing or vision loss.

With advancing age the tympanic membrane in the ears begins to thicken and the delicate structures of the inner ear begin to deteriorate. This may also begin to affect a persons sense of balance, leading to an increased risk of falls. Because many elderly patients suffer some type of hearing or vision loss, the medical assistant must adapt her communication techniques to accommodate these differences. In addition, she must be aware of the impact of these difculties on the patients quality of life. Some adapted communication strategies the medical assistant can use for patients with vision loss include using large print educational materials. In addition, the medical assistant should make sure the reception area, hallways, and examination rooms have good-quality, nonglare lighting. Doing so will help elderly patients with task completion and safe ambulation. Communication strategies the medical assistant can use for patients with hearing loss include keeping her voice low-pitched and facing the elderly patient so that the patient can read her lips. In addition, the medical assistant should attempt to minimize environmental noise when possible.

Medical Terminology Related to Geriatrics

Terms used in the medical office will include those related to geriatrics, including diseases common to elderly patients and procedures regularly performed as part of regular care for elderly patients. To be effective in her role, a medical assistant must become well versed in the language and vocabulary of geriatrics. The following tables list common medical terminology related to geriatrics.

Table 34.1 | Element

Word Elements
Meaning Example
ankylosis (ang-k-LO-ss)

Meaning

Combining Forms ankyl/o stiffness; bent, crooked Abnormal condition of stiffening or crookedness (of a joint) ger/o geront/o presby/o rhytid/o Prexes awithout, not anacusia (an-a-KU-se-a) Without hearing (total deafness) old age wrinkle geriatric (jer-e-AT-rk) gerontologist (jer-on-TOL-o-jst) presbyacusis (pres-be-a-KU-ss) rhytidoplasty (RIT--do-plas-te) Pertaining to the elderly Specialist in the study of aging Age-related hearing loss Surgical repair (removal) of wrinkles

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Table 34.1 | Element

bradySufxes -asthenia -penia -porosis -stenosis

Word Elements
Meaning
slow

Example
bradykinesia (brad-e-k-NE-se-a)

Meaning
Slow movement

weakness, debility decrease, deciency porous narrowing, stricture

myasthenia (m-as-THE-ne-a) osteopenia (os-te-o-PE-ne-a) osteoporosis (os-te-o-por-O-ss) arteriostenosis (ar-te-re-o-ste-NO-ss)

Muscle weakness Deciency of bone mass Porous bones Narrowing of an artery

Table 34.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to geriatrics with a pronunciation guide and brief denition for each. Term
age-related macular degeneration MAK-u-lar de-gen-er-A-shun Alzheimer disease ALZ-h-mer anacusis an-a-KU-ss cataract KAT-a-rakt dementia de-MEN-she-a glaucoma glaw-KO-ma kyphosis k-FO-ss osteoarthritis os-te-o-ar-THRI-ts osteoporosis os-te-o-por-O-ss presbyopia prez-be-O-pe-a presbycusis prez-b-KU-ss psychosis s-KO-ss Progressive, irreversible decline in mental function marked by memory impairment and decits in reasoning and judgment Group of eye diseases characterized by increased intraocular pressure, resulting in atrophy of the optic nerve Condition marked by exaggeration of the posterior curve of the thoracic spine; also called hunchback A type of arthritis marked by progressive cartilage deterioration in synovial joints and vertebrae Loss of bone mass that occurs throughout the skeleton when more bone is resorbed than laid down Permanent loss of accommodation of the lens of the eye that occurs when people are in their mid-40s Progressive loss of hearing with aging

Denition
Age-related degeneration of the macula (part of the retina) with resulting loss of central vision Chronic, progressive, degenerative cognitive disorder

Total deafness

Opacity of the lens of the eye as a result of aging, trauma, or disease

Mental disorder marked by loss of contact with reality, evidenced by delusions, hallucinations, disorganized speech patterns, and bizarre or catatonic behaviors

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Table 34.3 |

Abbreviations

In geriatrics, as in other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed in this table save time and effort in documentation and written communications. Abbreviation
ADLs AD AMD, ARMD BMD BPH

brain infection, and head injury. In addition, some other disorders are commonly confused with dementia because the signs and symptoms are similar. (See Conditions confused with dementia.)

Alzheimer Disease
ICD-9-CM code: 331.0 Alzheimer disease is the most common form of dementia. It usually occurs in patients over age 65 but may occur as early as age 40. It currently affects approximately 4 million Americans. However, experts estimate that by the year 2050, the number may increase to 14 million. This disorder costs nearly $100 billion each year in direct and indirect health care costs. The cause of Alzheimer disease is not yet fully understood. However, some contributing factors have been identified, including genetics, some viruses, previous brain injuries from head trauma or minor stroke, and immunologic factors. (See Preventing Alzheimer disease, page 692.) Characteristic changes in the brain of those affected by Alzheimer disease include cerebral atrophy and degenerative changes to neurons. These changes include neuritic plaques, which are accumulations of bundled bers surrounding normal and damaged nerve cells in the brain, and neurobrillary tangles, which are a distortion of neurobrils that make up part of the nerve cell body. Patients with Alzheimer disease also experience a signicant decrease in levels of neurotransmitters, such as acetylcholine. The course of Alzheimer disease has been divided into three stages:

Term
activities of daily living Alzheimer disease age-related macular degeneration bone mineral density benign prostatic hyperplasia, benign prostatic hypertrophy

CABG CAD CPAP decub. DNR ED HTN LTC OA

coronary artery bypass graft coronary artery disease continuous positive airway pressure decubitus (ulcer); bedsore do not resuscitate erectile dysfunction hypertension long-term care osteoarthritis

Common Geriatric Diseases and Disorders

As a person ages, he becomes more vulnerable to certain diseases and disorders. Some of the most common include dementia, bone disorders, and vision disorders.

Stage I is characterized by progressive short-term memory loss. Stage II is characterized by deterioration of intellectual ability, personality changes, speech and language problems, impaired judgment, and continued worsening of memory as well as possible paranoia, delusions, hallucinations, seizures, and depression. Stage III marks the patients total dependence on others for care and can also include paranoia, delusions, hallucinations, seizures, and depression.

Dementia
Dementia is a neurological disorder characterized by chronic, progressive, irreversible decline in mental function. It is marked by deficits in reasoning and judgment. It progressively impairs a persons ability to participate in occupational and social activities. About 20% to 40% of those affected by dementia are over age 85. Although there are numerous causes of dementia, Alzheimer disease is responsible for over 60% of dementia cases. The other 40% of dementia causes include Parkinson disease, Huntington disease, stroke, toxicity from excessive alcohol or drug use, severe deficiency of vitamin B12 and folate,

Diagnosis of Alzheimer disease is made by ruling out other disorders, including delirium and depression. There is no cure for Alzheimer disease. Medications such as donepezil (Aricept) and tacrine (Cognex) temporarily enhance cognitive function by preventing the breakdown of acetylcholine. However, the effects of these medications decrease after several months. Antidepressant and antipsychotic medication may be used when depression and hallucinations are present. Other treatment measures are the same as for all types of dementia and aim to maximize function and provide safety and comfort. Patients with early dementia may respond to

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Conditions confused with dementia

Dementia is sometimes confused with other states, including delirium and depression. Adverse effects of medications are also sometimes mistaken for signs of dementia. Therefore, careful evaluation is necessary to rule out other pathologies and determine an appropriate treatment plan. By comparing features of delirium and depression, one can differentiate them from dementia. The following table outlines each disorder along with its denition; onset, course, and duration; and its effects on memory, thought processes, perception, psychomotor behaviors, and sleep patterns.

Disorder and Denition

Dementia Neurological disorder characterized by chronic, progressive, irreversible decline in mental function

Onset, Course, and Duration

Onset: slow Course: long, progressive Duration: years

Effects
Memory: short-term memory loss in early stages and remote memory loss in later stage Thought processes: impaired judgment, difculty with word nding, difculty performing a familiar task Perception: usually intact Psychomotor behaviors: usually normal in the early stages Sleep patterns: impaired and fragmented

Delirium Acute reversible state of agitated confusion marked by disorientation, hallucinations, or delusions

Onset: sudden Course: short, uctuates and commonly worsens at night Duration: hours to days, usually less than 1 month

Memory: possible impairment of immediate and recent memory Thought processes: distorted and disorganized, easily distracted from tasks Perception: distorted with delusions and hallucinations Psychomotor behaviors: distorted with delusions and hallucinations Sleep patterns: impaired, with day and night cycles commonly reversed

Depression Mood disorder marked by loss of interest or pleasure in living

Onset: slow Course: slow Duration: weeks to years

Memory: variable effect with episodes of poor memory mixed with clear memory Thought processes: intact with a bleak outlook; ability to focus on task at hand (with some possible impairment); apathetic Perception: usually intact Psychomotor behaviors: usually intact Sleep patterns: impaired; may sleep too little or too much, commonly involving early morning awakenings

efforts to reorient them to time and place. However, this strategy becomes less effective as dementia progresses. Support resources for patients with Alzheimer disease and their families are available, including adult day services, respite care, support groups, and home health care services. In addition, the medical assistant can provide tips on making the home environment safer for the patient with Alzheimer disease or other forms of dementia. (See Home safety for patients with dementia, page 692.)

Because a change of routine and environment increases confusion and may increase agitation in the patient with Alzheimer disease, the medical assistant must learn to interact with such patients in a calm, clear, thoughtful manner. She should provide simple instructions one step at time and avoid rushing or forcing the patient. (See Communicating with patients with dementia, page 692.) Education and emotional support for family members and caregivers of such patients are also essential.

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Patient Education

Communicating with patients with dementia

When communicating with patients suffering from Alzheimer disease or other types of dementia, the medical assistant should be sure to learn these important dos and donts.

Preventing Alzheimer Disease

The medical assistant can share these tips with her patients so they can preserve and protect their brain function to help prevent Alzheimer disease: Avoid tobacco use. Avoid use of illicit drugs. Avoid lead exposure. Avoid chronically high levels of stress. Maintain a healthy blood pressure. Manage diabetes effectively. Follow all recommended measures to prevent heart disease (which help protect the brain, too). Pursue educational or mentally stimulating activities. Exercise regularly. Participate in social activities.

Dos
Provide for physical discomfort before anything else. Physically approach the patient in an unhurried, gentle manner. Speak in an unhurried manner using a clear, calm voice. Keep sentences short. Give instructions one step at time and focus on one subject at a time. Allow the patient time to process his response if one is needed. Look for cues of increasing anxiety or agitation, such as tensing of the body, or expressions of fear or distress. If the patient becomes agitated, move away from him and let the caregiver or family member provide comfort and reassurance. Verify important information with the caregiver or family member because the patients memory and judgment are not reliable. If you wish to make conversation, ask about events in the distant past, because the patient is more likely to recall such events.

Patient Education

Home Safety for Patients with Dementia

The medical assistant should share these safety tips with family members and caregivers of patients with Alzheimer disease or other forms of dementia: Keep doors and windows locked. Install safety latches on cabinets and drawers that contain objects such as knives. Install protective gates at the top and bottom of stairs. Supervise the ingestion of all medications. Keep car keys in a locked cupboard. Place nightlights throughout the home, especially in the bedroom and bathroom. Keep walkways clear.

Donts
Do not ask the patient unnecessary questions. Do not remind the patient of his bad memory; simply repeat things as needed. Do not argue with the patient. Do not try to physically force the patient to do anything. Do not overwhelm the patient with too much information or complex instructions. Do not expect the patient to remember you from one visit to the next. Do not ask or expect the patient to recall recent events (unless the question is being asked to further evaluate the patients memory).

Life expectancy for patients with Alzheimer disease is variable but averages 8 to 10 years from the onset of symptoms. Death is not due to Alzheimer disease itself but its complications. These complications most commonly include pneumonia, infection of various types, and injury associated with falls and immobility.

Bone Disorders
Common bone disorders in geriatric patients include osteoporosis and osteoarthritis.

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Osteoporosis
ICD-9-CM code: 733.00 Osteoporosis is a condition characterized by loss of bone mass throughout the skeleton. It affects an estimated 8 million American women and 2 million American men. Those of northern European or Asian descent and those with a family history of osteoporosis are at increased risk. Osteoporosis puts a person at greater risk for vertebral and hip fractures. Osteoporosis is caused by loss of bone density as more bone is resorbed (removed) than developed. Contributing factors for osteoporosis include a drop in hormone levels after menopause; a diet poor in calcium, magnesium, and vitamin D; immobility and sedentary lifestyle; thyroid hormone excess; corticosteroid use; use of some anticonvulsant medications; and alcohol and tobacco use. Patients with osteoporosis are commonly asymptomatic until bone fractures, such as vertebral and hip fractures, occur. Subsequent immobility exacerbates the condition. Thoracic vertebral changes can cause kyphosis, vertebral compression fractures, or even vertebral collapse with subsequent pain and disability. Loss of bone density in the vertebrae causes changes in posture and decreased height. (See Figure 34-1.) Diagnosis of osteoporosis usually does not occur until the patient suffers a related injury, such as hip fracture. Diagnosis is based on x-rays, bone scans, CT scans, and dual-energy x-ray absorptiometry (DEXA) scans, all of which reveal decreased bone density. Treatment is aimed at preventing or minimizing further bone loss and disability. It includes dietary modication, mineral and vitamin supplements, estrogen replacement, weight-bearing exercises, and medications to foster bone density. Medications to treat osteoporosis include calcitonin nasal

spray (Miacalcin), raloxifene (Evista), risedronate (Actonel), ibandronate (Boniva), and alendronate (Fosamax). Treatment for injury and disability from osteoporosis includes surgery, physical therapy, and analgesics and muscle relaxants for pain. Even so, the most effective treatment for osteoporosis is prevention. (See Osteoporosis risk factors and preventive measures.)

Osteoarthritis
ICD-9-CM Code: 715.90 Osteoarthritis is the most common form of arthritis, a condition of joint inammation characterized by pain, stiffness, redness, swelling, and deformity. Arthritis affects approximately 43 million Americans and is more common in women than in men. Incidence of arthritis increases with age. Osteoarthritis is caused by erosion of the joints cartilage and eventual erosion of the bone surface. The joints most commonly affected are the shoulder, elbow, hip, wrist, nger, knee, ankle, and toe. Bone spurs may develop, causing increased pain with movement. (See Figure 34-2.)

Osteoporosis risk factors and preventive measures

Good self-care, including preventive measures, is the best way to minimize osteoporotic changes. Such preventive measures should begin in childhood. This table contains a list of the most common risk factors for osteoporosis along with preventive measures.

Risk Factor
Immobility or sedentary lifestyle

Prevention
Regular weight-bearing exercise such as walking (3060 minutes 34 times per week) and weight lifting

Diet poor in calcium, magnesium, and vitamin D Thyroid hormone excess Decrease in sex hormones Excessive alcohol use

Consistent intake of adequate amounts of calcium, magnesium, and vitamin D

Timely, appropriate treatment of hyperthyroidism Hormone replacement therapy

Eliminating or minimizing alcohol consumption

Tobacco use Medications such as corticosteroids and phenytoin (Dilantin)

Eliminating tobacco use Determining the smallest therapeutic dose of such medications in consultation with a physician and carefully weighing the risks and benets

FIG 34-1 Changes in posture and height from osteoporosis.

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A
Patellar surface of femur

Femur Posterior cruciate ligament

Osteoarthritis is not life-threatening but commonly impairs quality of life by causing chronic pain and decreasing mobility. For some patients it is a mild annoyance; for others, it may force them to leave work and severely limit everyday activities such as walking.

Sensory Disorders
Common geriatric sensory disorders include presbyopia, cataracts, glaucoma, macular degeneration, and presbycusis.
Lateral meniscus Medial meniscus Anterior cruciate ligament Fibula Tibia

Presbyopia
ICD-9-CM code: 367.4 Presbyopia is age-related loss of visual acuity. Age-related visual changes occur in nearly everyone as they age and become noticeable around the age of 40. The estimated incidence of presbyopia is extremely highwell over 100 million Americans. Visual acuity diminishes with age from a variety of factors, including damage to the retina, changes to the lens and cornea, and reduced pupil size. A common symptom of presbyopia is a reduced ability to accommodate for change in distance and, especially, close detail. Other changes include increased sensitivity to light and glare, decreased ability to see in the dark, and decreased ability to discriminate between shades of colors, such as greens and blues, and among pastel colors. Decreased secretions from lacrimal (tear) glands results in drying and irritation of the eye. Diagnosis is based on the patients complaint of increased eye fatigue and difculty focusing on ne print or difculty with tasks that require visual acuity, such as threading a needle. Standard vision screening tests are used, such as having the patient read text from a card held 14'' to 16'' away. These tests reveal difculty focusing on near objects. Treatment for presbyopia is usually corrective lenses. There is no cure for presbyopia, and it typically progresses to increased vision loss. However, progression is slow and most patients are able to carry out activities of daily living with the use of corrective lenses.

Healthy knee

B
Exposed bone

Eroding cartilage

Eroding meniscus

Bone spurs

Arthritic knee FIG 34-2 The degenerative changes of osteoarthritis.

Cataracts
Diagnosis is based on physical examination ndings, description of symptoms, and radiological studies. X-rays and, possibly, MRI studies reveal eroded cartilage, narrowing of the joint space, and bone spur formation. Although there is no cure for arthritis, treatment with medication, such as corticosteroids and analgesics, can commonly minimize symptoms and slow disease progression. Other treatment measures include weight loss, joint protection, exercise, and heat or cold application. If joint deterioration is severe, joint replacement surgery may be necessary. Physical and occupational therapy is common with or without surgery. Regardless of the treatment strategy, the goal is to promote function, comfort, and safety. ICD-9-CM code: 366 Cataracts are the gradual clouding of the eyes lens. They are extremely common, affecting more than 40% of people between ages 52 and 64, 60% of those ages 65 to 74, and 91% of those ages 75 to 85. Nearly 6 million Americans are affected by cataracts. In addition, cataracts are the leading cause of blindness worldwide. Cataracts may be caused by age-related deterioration. Other contributors include traumatic injury, drug toxicity, diabetes, and prolonged, high-dose corticosteroid therapy. Signs and symptoms include blurred vision, halos around lights, blue or yellow tint to the visual eld, light sensitivity, and a white-appearing pupil. Diagnosis is based on visual

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examination of the patients eyes with an ophthalmoscope, which reveals the milky opacity, or clouding of the lens. Treatment for cataracts involves surgical removal of the lens and replacement with an articial lens. There are two types of surgery. The extracapsular cataract extraction (ECCE) involves removal of the lens while leaving most of the lens capsule intact. High-frequency sound waves (phacoemulsication) may be used to break up the lens prior to extraction. Intracapsular (ICCE) surgery is rarely done and involves removal of the entire lens including the capsule. In either case, the lens is removed and replaced by a plastic lens. Because only local anesthetic is required, it can be a day procedure. Most people (95%) who undergo surgery to treat cataracts recover completely within 3 to 4 weeks and enjoy vastly improved vision. Potential complications include endophthalmitis (inflammation of the intraocular cavities, including the aqueous or vitreous humor), posterior capsular opacification (clouding of the posterior capsule), and retinal detachment.

Glaucoma
ICD-9-CM code: 365.10 (primary or chronic open-angle), 365.2 (acute angle-closure) Glaucoma is a group of disorders in which increased intraocular pressure (IOP) results in atrophy of the optic nerve, leading to loss of peripheral vision and eventual blindness. There are several types of glaucoma, the most common being chronic (primary open-angle), which develops slowly with no warning signs. Glaucoma is the second most common cause of blindness in the world, with an estimated incidence of 65 million, including between 2 and 3 million Americans. It affects people in all age groups, although the elderly are at increased risk. African Americans have a much higher incidence than Caucasians. The cause of glaucoma varies with the type. In all types, damage to the optic nerve occurs, usually due to abnormally increased intraocular pressure (IOP). However, there is also a form of glaucoma in which IOP is normal, called normal tension or low tension glaucoma. The cause of this type of glaucoma is not known. Normally, aqueous humor is produced and circulates through the anterior eye chamber and then drains out through a tiny channel called Schlemms canal. In healthy eyes, the production and ow is continuous and normal pressure is maintained. However, when drainage is impeded, IOP increases, damaging the optic nerve. As the optic nerve degenerates, blind spots develop in the visual eld. The cause of acute (closed-angle) glaucoma is a blockage of outow of aqueous humor, which causes a rapid increase in IOP. This form is usually associated with a very narrow drainage angle of Schlemms canal, which makes it prone to blockage. Risk factors for this type of glaucoma are aging

and farsightedness. Triggers for angle closure include anything that causes the pupils to become dilated, including darkness, stress, certain medications, and excitement. Chronic (primary open-angle) glaucoma is caused by aqueous humor draining too slowly, leading to increased IOP, although the exact cause is unclear. Acute angle-closure glaucoma commonly has a rapid onset, and loss of vision may occur within 1 day. Those with chronic primary open-angle glaucoma are commonly asymptomatic until signicant peripheral vision is lost. It affects both eyes, although vision loss may initially progress more rapidly in one eye. The attack may be triggered by darkness. Signs and symptoms include severe eye pain, blurred vision, eye redness, seeing light halos, and nausea and vomiting. For all types of glaucoma, the physician will carefully examine the eye with an ophthalmoscope for optic nerve damage. The optic disk of the eye is where the nerve bers join at the back of the eyeball. An optic disk damaged by glaucoma takes on an indented appearance, called cupping. Other signs of damage include changes in disk color and contour. The physician also evaluates the eye to detect whether the angle of the eye where drainage occurs is open, narrow, or closed. Doing so helps determine the diagnosis and appropriate treatment. In primary open-angle glaucoma, ophthalmoscopy reveals an open angle and obvious optic nerve damage. A perimetry (visual eld) test reveals peripheral vision loss. IOP measurement with a tonometer will reveal 22 mm Hg or higher, which indicates a high risk for glaucoma. Pachymetry, in which ultrasound waves measure cornea thickness, rules out other disorders that involve a thick cornea, rather than optic nerve damage. Gonioscopy and tonography determine how rapidly uid drains from the eyes. Treatment of glaucoma includes reduction of IOP by reducing production of aqueous humor or making the outow more efcient. Either treatment involves the use of eye drop medication, such as the miotic pilocarpine (Isopto Carpine, Pilocar) and the beta blocker timolol maleate (Timoptic). Other treatments include systemic medications, which also act to decrease production of aqueous humor or increase efciency of outow. Laser surgery may be used to open the uid channel and enhance drainage. If these treatments are not effective, microsurgery may be done to create a drainage hole so that uid can escape. Acute angle-closure glaucoma is an emergency in which blindness can develop rapidly. Therefore, emergency treatment includes use of medication to reduce IOP and, typically, iridotomy. In iridotomy, the surgeon uses a laser to create a small hole in the iris to allow aqueous humor to ow into the anterior chamber of the eye where it can then ow out through Schlemms canal. There is no cure for glaucoma and any vision loss that develops is permanent. Left untreated, glaucoma causes

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blindness. Even with treatment, approximately 10% of patients still lose their vision. However, the prognosis for those who get early diagnosis and treatment is very good and further damage can usually be prevented or minimized. Glaucoma is a chronic condition that can change over time. Therefore, ongoing management and regular medical checks are important.

Macular Degeneration
ICD-9-CM code: 362.50 Macular degeneration, sometimes called age-related macular degeneration (ARMD), is a disorder involving deterioration of the macula of the retina, located at the back of the eye, resulting in progressive vision loss in the center of the visual eld. It is categorized as atrophic (dry) or exudative (wet). Macular degeneration is a common cause of blindness in persons over age 55. It is more common among Caucasians than other ethnic groups and is more common in women than men. With atrophic macular degeneration, the macula develops irregular pigmentation but there is no scarring, hemorrhage, or exudates. With exudative macular degeneration, hemorrhage or uid accumulation occurs and causes elevation of part of the macula and eventual scarring. Contributors include inammation, injury, or infection. Risk factors include advancing age, genetics, obesity, cigarette smoking, cardiovascular disease, high cholesterol, hypertension, nutritional deciencies, light eye color, and ultraviolet light exposure. Atrophic macular degeneration usually manifests slowly and painlessly. The exudative form progresses more quickly, causing rapid vision loss, although color and peripheral vision may remain intact. In either case, vision loss occurs and may develop faster in one eye than the other. Tasks requiring sharp vision become difcult and then impossible. Legal blindness, dened as vision that is less than 20/200 may occur. Diagnosis is based on inspection of the macula of the retina with an ophthalmoscope (an instrument used to examine the interior of the eye), revealing tiny yellow deposits under the macula called drusen. Vision testing identies vision loss. Other possible tests include angiography, tomography, and funduscopy. Angiography evaluates the blood vessels in the eye for bleeding or evidence of neovascularization (abnormal proliferation of blood vessels beneath the retina). The optical coherence tomography test helps identify retinal thinning or thickening or abnormal presence of uid. Funduscopy reveals pigment changes and tiny hemorrhages. Other noted changes may include scarring, atrophy, retinal detachment, and lipid exudates. An Amsler grid may identify visual distortion that occurs rapidly in exudative macular degeneration. Scotomas (central blind spots) may be present in atrophic macular degeneration. There is no cure for macular degeneration. However, vitamin therapy has been found to slow disease progression.

Recommendations include daily supplements of betacarotene, vitamin E, vitamin C, zinc oxide, and copper. Patients should consult with their ophthalmologist regarding specic dosage amounts. Treatment of exudative macular degeneration may prevent or delay blindness. In addition to vitamin therapy, a combination of laser and photo therapy may be used. Photodynamic laser therapy (PDT) involves the intravenous injection of the light-activated drug verteporn (Visudyne), which helps direct a laser to the problematic vessels for destruction. However, it is expensive and may cause scarring. Repeated treatments may also be necessary. Those who have lost central vision may nd adaptive devices helpful, including corrective lenses, magniers, telescopic lenses, and use of computer monitors. Prognosis depends on the type of macular degeneration involved. In most cases, mild to moderate vision loss is experienced over time. Blindness occurs from retinal detachment or scarring in some cases. Ninety percent of such cases involve exudative disease. Atrophic disease causes mild to moderate vision loss but rarely causes blindness.

Presbycusis
ICD-9-CM code: 388.01 Presbycusis is progressive, age-related hearing loss that typically begins after age 55. It usually affects both ears equally and begins with loss of high-pitched sounds. An estimated 4 million Americans currently are deaf or have profound hearing loss. Incidence of hearing loss increases with age and as many as 50% of individuals over age 75 have hearing loss. Internationally, incidence varies widely. However, incidence is higher in westernized countries than in others, possibly due to industrial noise. Presbycusis is a type of sensorineural hearing loss caused by traumatic injury to tiny hair cells in the inner ear; bacterial or viral infections, such as meningitis or mumps, that damage hair cells or the auditory nerve; and Mnires disease. Other factors contributing to presbycusis include stress and genetics. Underlying physical disorders that affect circulation to ear structures, including diabetes, hypertension, and atherosclerosis, may also be a factor. Early hearing loss is usually not detected until family or friends notice the person increasing the volume on the television or radio and requesting them to repeat things they have said. Individuals with presbycusis may complain that others mumble too much or speak too quietly. They have greater difculty hearing when background noise is present. First lost is the ability to hear high-pitched sounds and s, sh, and ch consonant sounds. For this reason, they may nd a mans lower-pitched voice easier to hear and understand than a womans voice. They may also complain of tinnitus, which causes abnormal hissing, ringing, or roaring sounds in one or both ears, compounding their hearing difculties. Diagnosis is based on otoscopic examination of the ear, a variety of hearing tests and other tests such as CT scan and

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MRI, which may rule out structural abnormalities, masses, or lesions that can cause hearing loss. The Weber and Rinne tuning fork tests help differentiate between conductive and sensorineural hearing loss. Presbycusis is diagnosed when other possible causes of hearing loss are ruled out. Sensorineural hearing loss is permanent; thus, the physician will prescribe hearing aids and other devices to help the person with activities of daily living. A variety of strategies and technological devices are currently available to improve hearing and understanding. Many individuals benet from hearing aids and amplication devices used with telephones. Some technology makes sounds more clear with or without the use of hearing aids. In addition, some patients may benet from learning lip reading. There is currently no cure for presbycusis. However, with appropriate diagnosis and treatment, most patients can maintain a high quality of life using hearing aids or other devices that improve their ability to hear and understand the sounds around them. (See Hearing loss and condentiality.)

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Hearing Loss and Condentiality

Condentiality is a challenge when the medical assistant communicates with a patient who has moderate to severe hearing loss. Because the medical assistant may have to speak loudly so the patient can hear her questions, she risks violating his condentiality by enabling others in the ofce to hear as well. This is an issue for the administrative medical assistant, who may need to conrm information about insurance, address, and telephone number when the patient checks in at the reception desk. It is also an issue for the clinical medical assistant, who must ask questions about symptoms, allergies, and other personal health information. Accurate information is critical, so medical assistants should challenge themselves to be creative in nding condential ways to obtain it. Here are some suggestions to consider: Conrm information, such as insurance, address, and telephone number over the telephone when the appointment is made. Show the information in writing (using large print) to the patient for his conrmation or correction. Take the patient into a private room where the door may be closed to conrm or obtain information. Face the patient so he can see your lips and facial expressions. Speak at an adequate volume in a low-pitched voice without shouting. Enunciate clearly and speak in an unhurried manner. Use visual aids, such as photos or illustrations when appropriate.

Special Needs of the Geriatric Patient

To effectively interact with geriatric patients and their caregivers, the medical assistant must be able to communicate clearly and understand the physical and psychological challenges of the older adult. When asking questions about the patients health, she should be sure to speak clearly and consider any sensory decits the patient might have, including vision and hearing loss. She should use various communication strategies to ensure that the patient understands her questions and obtain accurate responses. If the patient suffers from dementia, the medical assistant should try to direct her questions to the patient and caregiver, including them both in the conversation. She should also be alert for opportunities to explain safety promotion for the elderly patient living at home. For patients who are acutely ill or have chronic, degenerative illness, the medical assistant should be alert for signs of caregiver burnout as well as the need for support and assistance, including home health care, assisted living, long-term care, and hospice. In addition, the medical assistant may provide information and referrals regarding nutrition and end-of-life issues.

Communication Strategies
Communication with elderly patients requires patience and sensitivity on the part of the medical assistant. Some elderly individuals are too embarrassed to admit that they dont hear well. Consequently they may not understand what has been said. Health care providers may erroneously assume the older person is confused, forgetful, or suffers from dementia when the real problem is faulty communication. The medical

assistant can make accommodations for sensory decits by adjusting the pace and volume of her speech. Clear enunciation will also help the listener hear and understand what she says. She must also allow adequate time for the older patient to process information and formulate a response. Last, but not least, the older patient must be treated with respect and dignity. The medical assistant should refer to the patient by his last name and use the appropriate title, such as Mr., unless the patient instructs her to do otherwise. It is never appropriate to refer to the patient with a term of endearment, such as sweetie or honey. Although the medical assistant may do so with good intentions, the message conveyed is one of disrespect and talking down to the patient.

Safety Promotion
An important part of the medical assistants role when providing care for elderly patients is the promotion of

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independent function and safety. To help the patient maintain a level of independence, the medical assistant can advise him on the use of tools, including mobility aids and assistive devices (hearing aids and corrective lenses), to compensate for sensory decits. To help promote the patients safety, she can provide guidelines for modifying his home environment to reduce hazards and promote safe function. (See Safety: Everyones concern.)

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Safety: Everyones Concern

Keeping patients safe in the medical ofce should be the concern of every staff member regardless of her job description. Patients with strength, agility, mobility, and sensory decits are at signicantly higher risk for injury than the general population. Thus, the medical assistant and others must evaluate their work area daily to identify and remove potential hazards and obstacles. Administrative and clinical medical assistants should work together cooperatively on a daily basis to ensure every patients safety, including following these guidelines: Conrm that there are no obstructions in walkways, stairs, and wheelchair ramps. Make sure patients have access to entryways and doorways and that patients with disabilities can easily open them. Arrange seating in the reception area to facilitate easy navigation by patients with disabilities and those using mobility aids. Determine that there is adequate lighting in all rooms. Allow patients to sit in chairs or remain in wheelchairs when possible, rather than asking them to climb onto examination tables. Safely assist patients onto examination tables if they must do so. Never leave a patient with dementia, severe weakness, or disability alone. Verify that oors in all areas are clean, dry, and uncluttered. Never push, pull, or rush a patient when walking, sitting, standing, or transferring between chairs and examination tables. Never assist a patient by pulling on her arms or shoulders. Instead, use a second person and a gait belt, if necessary, to help with patient transfers. Be willing to interrupt what you are doing to help a patient or coworker with safety issues.

Mobility Aids
Elderly patients commonly use mobility aids, such as canes, walkers, and motorized scooters, on a temporary or permanent basis to compensate for weakness from disease, impairment caused by injury or disability, and general functional decline. The medical assistant may have the responsibility of tting the patient with a mobility aid and teaching her to use it. (For more information see Chapter 35, Orthopedics,page 707.) Crutches are not an appropriate mobility aid for very elderly patients because such patients do not typically have the upper body strength required to use them. Inappropriate use of crutches by a frail older adult increases the risk of further injury. More appropriate choices for such patients include walkers and canes, depending on the level of aid needed, as determined by the physician or therapist. The medical assistant must make sure the device is tted correctly for the patient and that she knows how to use it safely. After the medical assistant demonstrates correct use, she should ask the patient to perform a return demonstration. Doing so enables the medical assistant to observe the patient and provide feedback and correction as needed.

Home Safety
Home safety is a critical issue for elderly adults because of the risk of injury from falls. An estimated 30% of elderly individuals who live independently in their own homes fall at least once each year. Of those, approximately 5% will suffer a bone fracture. In addition, the risk increases with age. There are many factors that contribute to the risk of fallrelated injury. The medical assistant should review home safety with elderly patients as well as family members or caregivers. General considerations include the patients degree of mobility, mental status, home setting, and close proximity to potential help. (See Safety hazards at home.) In some cases, elderly adults are afforded an extra measure of security by wearing some type of device that allows them to call for help if they fall. Although such a device does not prevent falling or injury, it may help provide more immediate assistance and prevent some complications associated with a delay in treatment. In addition to injury from falls, elderly patients are at increased risk for adverse effects from medication errors. Because many elderly patients take multiple medications, including prescription and over-the-counter (OTC)

medications, and some suffer from cognitive impairments, a patient can easily become confused regarding when medications should be taken. Such confusion can lead to medication errors and, possibly, illness or death. The medical assistant can help reduce the risk of such complications by providing education to elderly patients about ways to prevent medication errors. (See Preventing medication problems, page 700)

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Safety hazards at home

In addition to taking safety measures in the medical ofce, the medical assistant can provide strategies to the elderly patient to decrease the risk of falls and other injuries at home. The following table lists many hazards faced by elderly patients as they deal with sensory decits, illness, decreased mobility, and increased use of medications as well as solutions to prevent the adverse effects of each.

Hazard
Vision and hearing impairment

Solution
Referral for vision and hearing evaluation and treatment (corrective lenses and hearing aids) Keeping corrective lenses accessible at night, such as at the bedside Ensuring adequate lighting, especially at night

Postural hypotension Musculoskeletal disorders, such as arthritis or generalized weakness

Standing slowly to allow time for blood pressure adjustment Appropriate evaluation and treatment to maximize function General self-care measures to maximize energy and functional ability, such as regular exercise and gentle stretching

Altered balance

Use of cane or other mobility aid for stabilization Using well-tting shoes and house slippers with nonskid soles

Impaired bladder function, such as incontinence, nocturia, and urgency Medication adverse effects

Evaluation and treatment of the disorder, if possible Sleeping near a bathroom or keeping a commode at the bedside at night Reviewing medications with the health care provider to determine whether adjustments can be made to minimize adverse effects Learning about prescribed medications to become aware of potential adverse effects, such as sedation and postural hypotension, and using appropriate safety strategies, such as sitting on the bedside for a moment before rising, taking medications at bedtime when possible, and avoiding driving or similar activities

Medication errors

Labeling medications with large, easy-to-read print Placing scheduled medications in a daily or weekly organizer, according to day and time

Household hazards, such as throw rugs, stairs, bathtubs, poor lighting, and wet oors

Evaluating the home environment for potential hazards and rearranging or removing them Placing nightlights in high-risk areas Installing handrails in hallways and on stairs Installing grab bars around the bathtub, shower, and toilet Keeping emergency numbers posted by the telephone Replacing the telephone with one that has larger, easy-to-read numbers and a volume adjustment knob

Cognitive impairment

Educating family members and caregivers about precautions regarding fall prevention, including wearing shoes with nonskid soles, eliminating household hazards, and keeping often needed items, such as reading glasses and tissues, within reach Reducing environmental hazards, as listed above Using a bed or chair alarm, which is a device that will emit a loud sound if the individual gets out of his bed or chair unassisted

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Patient Education

Preventing Medication Problems

Nearly a quarter of a million elderly patients are hospitalized each year because of the adverse effects of combining prescription medications with over-the-counter (OTC) medications or taking medications improperly. In an effort to prevent or minimize such adverse events, the medical assistant should encourage elderly patients and their caregivers to take these precautions: Use nonpharmacologic methods rst to try to treat a problem, such as treating pain with heat or cold therapy, insomnia with warm milk or progressive relaxation, or anxiety with relaxation or exercise. Talk with your health care provider before using any OTC medications and read the labels of such medications for warnings about interactions. Avoid combination OTC products when possible. Read and follow instructions on the medication label. Avoid using OTC remedies for longer than recommended. Consult with your health care provider if a condition does not improve or worsens.

quality of life possible to all patients, including elderly patients. The medical assistant can better understand pain management strategies by learning which medications are most effective for which forms of pain. (See Medications for managing pain.) In addition, the medical assistant should be familiar with specic considerations for the elderly patient using these medications. (See Pharmacokinetic variations in older adults, page 702.)

Extended Care and End-of-Life Issues

One of the main challenges of the medical assistant working with geriatric patients is to provide correct, timely information on resources for extended care, or care beyond the primary care offered by a medical ofce, and care at the end of a patients life. (See Community resources for elder care, page 703.) Garnering the support of family, friends, and the community is essential for patients to experience a high quality of life in their elder years. As a person ages and cannot take care of himself without support and aid, he and his spouse or family must consider options for extended care, including in-home care and home health care, assisted living, and nursing centers.

In-Home and Home Health Care

Most elderly persons prefer to remain in their own homes for as long as possible. In-home care, or care provided by spouses, family, and close friends who act as caregivers, commonly makes such a preference possible. However, ongoing care can become a hardship for families as a persons care needs increase. Thus, many families eventually choose to enlist the services of a paid in-home caregiver. Some families hire a live-in caregiver who may have some health care training. In these cases, the family usually locates and trains the caregiver on their own and pays them privately or enlists the services of a home care agency that provides the caregivers. However, some families choose to enlist the services of home health care agencies, which are located in most communities and are sometimes afliated with local hospitals. These agencies employ nursing assistants and nurses who make home visits. During these visits, the home health nurse or nursing assistant may provide such nursing services as home infusion of antibiotics and education for patients or family members regarding wound care. However, these agencies do not provide round-the-clock care or assist with all activities of daily living. In addition, because the number of visits and the type of services allowed by insurance or Medicare are limited, long-term use of such services can become extremely expensive for the patient or family.

Pain Management
Many elderly patients experience some form of pain on a daily basis due to acute illness or injury or chronic disease. Such pain can severely limit the patients ability to function socially, maintain independence, obtain good-quality sleep, and enjoy a high quality of life. Unfortunately, health care providers do not always provide adequate pain management for elderly patients. Some reasons for this gap in care include the providers or patients fear of adverse effects or addiction, more appropriately called psychological or physical dependence, and general misconceptions about pain and pain behaviors. A common yet misguided belief is that elderly patients feel less pain than younger individuals. However, there is little evidence that age impacts pain perception. Elderly patients may have a compromised ability to communicate what they are feeling, which may lead others to mistakenly assume that they feel less pain. In fact, significant evidence indicates that elderly patients suffer from increased pain from illness and injury, including arthritis and various forms of neuropathy. Therefore, all health care providers, including medical assistants, should place a high priority on adequate evaluation and treatment of pain in order to maximize function and quality of life for elderly patients. Health care providers are obligated to do everything possible to relieve suffering and promote the highest

Assisted Living
If an elderly person is no longer able to live independently and home health care is not possible, she may wish to consider

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Medications for managing pain

The following table lists medications used to manage pain in the elderly, along with the form of pain for which they are commonly prescribed as well as any special considerations for geriatric patients.

Medication
analgesics acetaminophen (Tylenol)

Form of Pain
Most forms of mild to moderate pain

Considerations
Little or no anti-inammatory property Nonirritating to the stomach Should be used cautiously in patients with liver impairment Possible kidney damage with prolonged use Additive analgesic effect when coadministered with opiates, possibly allowing a lower opiate dose

salicylates aspirin (Bayer)

Mild to moderate inammatory pain, such as arthritis

Should be used cautiously in patients with history of ulcer disease, GI bleeding, alcohol abuse, or kidney or liver impairment Increased risk of adverse reactions and lower toxicity levels, indicated by tinnitus (ringing in the ears) Possible adverse interactions with many drugs, including anticoagulants, some anticonvulsants, and antibiotics Greater risk of allergic reaction in those with asthma Should be taken with food to minimize gastric irritation, a common adverse effect Enteric coated form should not be crushed Additive analgesic effect when coadministered with opiates, possibly allowing a lower opiate dose

Nonsteroidal anti-inammatory drugs (NSAIDs) ibuprofen (Motrin, Advil) ketorolac (Toradol)

Mild to moderate inammatory pain, such as arthritis pain

Should be used cautiously in patients with a history of ulcer disease, GI bleeding, alcohol abuse, or kidney or liver impairment Commonly causes gastric irritation Numerous drug interactions possible with such drugs as anticoagulants, digoxin, insulin, and antihyperglycemics Risk of gastric or duodenal ulceration leading to GI bleeding Should be started at lower dose because of the higher sensitivity to adverse reactions in geriatric patients Increased risk of allergic reaction in patients with asthma or aspirin allergies Should be taken with food to minimize gastric irritation Additive analgesic effect when coadministered with opiates, possibly allowing a lower opiate dose Concurrent aspirin or acetaminophen use contraindicated before consulting a health care provider

Opiates acetaminophen and hydrocodone (Vicodin) hydromorphone (Dilaudid) acetaminophen and oxycodone (Percocet) morphine (MS Contin)

Most forms of moderate to severe pain

May cause constipation (most common adverse effect) Risk of physical dependence and tolerance when used regularly Risks of sedation, drowsiness, and respiratory depression with short-term use that lessen with long-term use and development of tolerance Reduced initial dosage recommended for geriatric patients

Continued

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Medications for managing paincontd

Medication Form of Pain Considerations
Additive depressant effect when combined with other central nervous system (CNS depressants), such as alcohol, sedatives, and opiates Additive analgesic effect when coadministered with nonopioid analgesics, possibly allowing a lower opiate dose Antidepressants amitriptyline (Elavil) doxepin (Sinequan) imipramine (Tofranil) nortriptyline (Pamelor) Chronic pain, such as neuropathy caused by diabetes (in low doses) Should be used cautiously because of the higher sensitivity to adverse reactions in geriatric patients Risk of exacerbation of urinary retention in men with benign prostatic hyperplasia (BPH) Anticholinergic adverse effects (blurred vision, urinary retention, dry eyes, dry mouth, constipation) and drowsiness Contraindicated for use with or within 2 weeks of use of monoamine oxidase inhibitors (MAOIs) Additive CNS depressant effects when combined with other CNS depressants Monitor baseline ECGs in those with a history of heart disease because of risk of irregular heart rhythm Contraindicated in narrow-angle glaucoma Anticonvulsants phenytoin (Dilantin) gabapentin (Neurontin) Chronic pain, such as neuropathy caused by trigeminal neuralgia and peripheral neuropathy Risk of drowsiness Should not be taken within 2 hours of antacids

Pharmacokinetic variations in older adults

This table summarizes the pharmacokinetic variations (absorption, distribution, metabolism, and excretion) of drugs in elderly patients based on route or drug form.

Route and Drug Form

Oral (tablets, capsules)

Effect
Drier mucous membranes may cause capsules and tablets to adhere to the side or roof of the mouth instead of being swallowed, which impairs absorption and may cause ulceration. Decreased acid production in the stomach slows absorption of drug.

Rectal, vaginal (suppositories)

The drug may require more time to melt in this form. Decreased circulation in rectal and vaginal mucosa may slow absorption. The patient may expel the drug before it dissolves for many reasons, including sphincter laxity, poor muscle tone or control, or the urge to defecate.

Subcutaneous, intramuscular (injectable solution)

Loss of skin elasticity may cause medication to leak back out of the injection site. Decreased circulation may decrease absorption.

Topical (ointments, creams, lotions, powders)

Skin changes, such as atrophy, scarring, or thinning and loss of subcutaneous tissue may increase or decrease the intended localized effect.

All routes other than topical

Reduced kidney function extends the half-life.

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Community resources for elder care

Medical assistants may need to help their elderly patients identify community resources that can help them with living arrangements, personal care, and other needs. The following resources are available in most communities and can be located by checking the local telephone directory: adult care facilities, such as assisted living facilities and nursing homes retirement communities for elderly persons with minimal health-related issues senior and aging organizations for support and group activities chore services for house cleaning and maintenance respite services, which provide support to caregivers and patients, by providing resources for caregivers, as well as elder day care, which gives the caregiver some free time and gives the patient social interaction in a safe environment senior activity centers for group activities and lifelong learning adult protective services for protection from fraud and abuse Department of Social and Health Services for legal and social assistance housing authority for assistance with housing Social Security Administration for nancial assistance in retirement and for those with disabilities state legislature for help with resources for state aid and other services Veterans Administration for help with health care and housing costs for veterans.

more intensive care on a short-term basis, such as in a hospital or rehabilitation facility, to return to the facility when that care is complete as long as the persons needs have not increased beyond the scope of the facility.

Nursing Center
A common misconception is that all elderly persons eventually end up in a nursing center, formerly called a skilled nursing facility (SNF) and commonly referred to as a nursing home. In fact, the vast majority of elderly persons are able to maintain a more independent living situation for the duration of their lives. A nursing center provides care for residents who need ongoing medical care on a long-term basis. Staff members include nurses and nursing assistants who meet the residents health and personal needs, including help with medications, dressing, bathing, toileting, and eating. Other staff members may help with social activities, nutrition, and various therapies. Most nursing centers are designed like hospitals, with private or semiprivate rooms with a bath but no kitchen or living areas.

Extended Care Campus

Facilities that provide various levels of assistance on the same campus are a growing trend in extended care. Such a facility includes retirement apartments, assisted living services, and LTC services. Retirement apartments are available for persons who are able to continue living independently but desire more social interaction with their peers as well as fewer responsibilities for maintaining their own home. These facilities typically offer community dining options to such residents in addition to the kitchen facilities in their private apartment. They also offer the services of a visiting nurse, who can check in on residents from time to time to help with simple tasks, such as organizing weekly medications or blood pressure screening. If a resident experiences a decline in health and needs a greater degree of assistance, she may move to the assisted care facility on the same campus. Because she is able to maintain relationships with those in the larger facility as well as some of the staff, she may more easily transition to the new care setting than she would if moving to a different facility with new caregivers and residents. If, after living in the assisted care facility for a time, her health continues to decline to the point that LTC services are necessary, she can make the transition to the LTC facility on the same campus. This transition, again, may feel less traumatic because she would remain within the same larger community.

an assisted living situation. Most assisted living facilities, commonly called adult family homes, are privately operated. Many accept only private-pay clients. They are regulated by state agencies, however, and must meet certain criteria for health and safety. Older assisted living facilities are laid out as in a dormitory or hotel, with many small suites with a living space and bedroom, shared bathrooms, and shared dining areas. Newer facilities typically contain more private apartments with small kitchenettes, private bathrooms, and private living areas but still include shared dining areas. Most assisted living facilities offer elderly persons several prepared meals each day as well as many social events and other activities. In addition, they may facilitate transportation to and from shops, supermarkets, doctors ofces, and so on. These facilities commonly allow a person who needs

End-of-Life Issues
An older person, especially one with chronic illness, may also desire to plan for the eventuality of his death. The medical assistant can help the patient with this planning by providing information about living wills, also called an advance

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directive. In addition, the medical assistant should be aware of any patient who has enacted a living will as well as the content of that will in case it contains instructions regarding treatment that she might administer. For example, if a patient has instructed in a living will that he does not wish anyone to provide lifesaving care, commonly called a do-notresuscitate (DNR) order, she is legally bound to withhold that care. If she provides that treatment, she can be sued for battery. (For more information on legal considerations regarding end-of-life care, see Chapter 6, Legal Considerations, page 53.)

Hospice
Individuals who are facing a terminal illness may be interested in the services provided by hospice care. In its earliest forms, a hospice was a facility designed to provide care to terminally ill individuals. It has evolved into an entire philosophy of care in which death is viewed as the natural and nal stage of life. The goal of hospice care is to support patients in maintaining a high-quality, dignied, pain-free

life in their last days. It is family-centered and includes the patient and family in decision making. Family members serve as the main hands-on caregivers, supported as needed by the hospice staff. Hospice care may be provided within the home or in a variety of locations, including but not limited to hospice facilities, hospitals, or nursing centers. Hospice care focuses on palliative care, which is medical care aimed at alleviating disease symptoms and enhancing quality of life, rather than curative treatments or quantity of life. Medical and nursing care aim to relieve symptoms and provide physical, emotional, and spiritual comfort as desired by the patient and family. In addition to services by professional health care providers, most hospice organizations also train volunteer staff members to offer respite for family members and a comforting presence for the patient. Although medical assistants do not generally provide hospice care, they should be aware of its purpose and goals so they can answer questions from their elderly patients or family members. (See Common questions and answers about hospice care.)

Common questions and answers about hospice care

Medical assistants can answer some of the most common questions asked about hospice care by patients and family members, including: Is hospice care paid for by insurance and when does the patient qualify for care? Most insurance companies cover hospice care charges. Medicare covers hospice nationwide. Medicaid covers hospice in most states. Patients and family members should always check with their insurance carrier or Medicaid and Medicare representatives to get specic questions answered. Most hospice organizations accept patients who have been determined by their physician as having a life expectancy of 6 months or less. Does hospice provide round-the-clock care? No. Medicare requires that certied hospices provide a basic level of care but the specic type of services offered by hospice organizations may vary. If a hospice patient makes a physical recovery can she return to regular medical treatment? Yes. Patients whose disease goes into remission may be discharged from hospice and return to more aggressive therapy or even to their normal daily life. What can the patient expect during the hospice admission process? Initially, the hospice will contact the patients physician to verify the appropriateness of hospice care. The hospice will then ask the patient to sign consent and insurance forms similar to those when entering a hospital. Must the patient make changes within her home before hospice care begins? The hospice provider will evaluate the patients needs and make recommendations for any necessary equipment. Needs may be minimal initially and increase over time as the patients disease progresses. Will someone be with the patient at all times? Initially, the patient may have no need or desire to have someone there continuously. However, as her disease progresses and her needs increase, she may need more care. Hospice will help design and coordinate a plan of care that will meet the patients needs and involve professional caregivers, volunteers, and family members as needed. What specic services will be provided? Hospice care is provided by a team of caring individuals, including physicians, nurses, social workers, therapists, clergy, home health aides, and volunteers. Individuals provide help based on their own expertise. Hospice also provides medication, health care supplies, equipment, and other services as needed. Does hospice hasten the dying process? Hospice does not hasten dying. It views dying as a natural process and seeks to alleviate suffering while enhancing quality of life for the patient as well as family members. It does so by alleviating physical and emotional pain through medication administration, a variety of therapies (physical, occupational, art, music, and so on), dietary counseling, and other measures.

CHAP TER 34

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705

Chapter Summary

The effects of aging on a persons health have a huge impact on her quality of life. Some of the factors impacting aging include genetics, lifestyle, diet, activity and exercise, and coping strategies. Ageism is a form of prejudice and discrimination against individuals because of their age. As a person ages, his body undergoes physical changes to all systems. To appropriately meet the health care needs of their aging patients, medical assistants must understand these changes. The most common endocrine system disorder that develops secondary to aging is type 2 diabetes, which is commonly not diagnosed until after age 60. Symptoms are commonly atypical but treatment is the same as for younger patients. The aging musculoskeletal system decreases in muscle mass and strength as well as bone mass. Osteoarthritis and osteoporosis are signicant concerns for both men and women. Osteoporosis is characterized by loss of bone mass throughout the skeleton. Dementia is a neurological disorder characterized by chronic, progressive, irreversible decline in mental function and is marked by decits in reasoning and judgment. It may be confused with delirium, depression, and psychosis. Alzheimer disease is the most common form of dementia and most commonly occurs over age 65. Treatment for all types of dementia is aimed at maximizing function and providing safety and comfort. Elderly persons are prone to poor eating habits and poor uid intake. As a result, they may be decient in vitamins and minerals, are usually dehydrated, and have an overall increased risk of GI disorders, such as GERD, PUD, and diverticulitis. Elderly patients commonly must use mobility aids on a temporary or permanent basis due to weakness from disease, impairment caused by injury or disability, and general functional decline. Home safety is an issue of critical importance for elderly adults because of the risk of injury from falls. Communication with elderly patients requires patience and sensitivity on the part of the medical assistant and she must always treat elderly patients with respect and dignity. Many elderly patients experience some form of pain on a daily basis due to acute illness or injury or chronic disease. Such pain can severely limit the patients ability to function socially, maintain independence, obtain good-quality sleep, and enjoy a high quality of life.

For an elderly patient who becomes unable to continue living independently, the medical assistant may need to provide information about alternative living arrangements, such as in-home care, services provided by home health care agencies, assisted living facilities, and nursing care centers. In some cases, a range of services may be available on the same extended care campus. The medical assistant may provide information to an elderly patient about living wills, which are documents that patients can complete to indicate their wishes regarding life-sustaining measures. A person facing a terminal illness may be interested in the services provided by hospice care, which is care centered around the philosophy that death is natural and the nal stage of life. Hospice seeks to support patients in maintaining a high-quality, dignied, pain-free life in their last days and focuses on palliative care, rather than curative treatments or quantity of life.

Team Work Exercises

1. Divide into nine teams. Each team must create an educational poster based on a topic listed here. Posters will be graded on accuracy, creativity, professional appearance, and other criteria as indicated by the instructor. After the poster has been approved by the instructor, the team must contact a local organization or facility, such as a senior center, an area agency on aging, nursing home, or church. With permission from the appropriate persons, the team must post and display the poster at the identied facility. Topics include: a. home safety, including common hazards and strategies to increase safety b. osteoporosis, including the cause, prevention and management strategies, and common medications c. dementia, including the cause, risk reduction and management strategies, and common medications d. osteoarthritis, including the cause, prevention and management strategies, common medications, and surgical procedures f. cataracts, including the cause, prevention and management strategies, common medications, and surgical procedures g. macular degeneration, including the cause, prevention and management strategies, and common medications h. open-angle glaucoma, including the cause, prevention and management strategies, and common medications i. angle-closure glaucoma, including the cause, prevention and management strategies, and common medications. 2. Divide into ve teams. Each team must choose a patient from the list provided. For that patient, the team must identify resources available in the community to help the patient meet his or her needs. Then the team must create

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a plan that designates what services will be provided by which community resource, including accurate contact information. Finally, the team must describe a safety plan for the patients home. a. Mildred Osborne is a 75-year-old woman discharged home after being hospitalized with pneumonia. She was diagnosed with type 2 diabetes in the hospital and must learn more about her disease to be able to do daily glucometer testing and eat an appropriate diet. Mrs. Osborne lives with her 77-year-old husband, who suffers from severe hearing loss but is able to help with minor household chores. b. Nicholas Stednick is a 68-year-old man who recently suffered a stroke. After several days in the hospital, he spent 2 weeks in a rehabilitation unit and is now preparing to return home. His stroke left him with leftsided weakness and he currently uses a walker. He hopes to be able to transition to using a cane within the next month. He lives in a three-bedroom, one-level house by himself. His grown daughter lives in the same neighborhood and will check on him at least once each day but she has a job and family of her own. c. Sayoko Oni is a 72-year-old woman recently diagnosed with metastatic lung cancer. She lives at home with her 75-year-old husband and is determined to remain at home for whatever time she has left. Her husband wants to respect her wishes but is concerned that he will be unable to meet her health care needs and does not want her to suffer. d. Helga Ivarsen is an 88-year-old woman who was recently hospitalized after falling and breaking her hip. She underwent a total hip replacement and spent 3 weeks in a rehabilitation unit. She is now preparing to return home, where she lives with her 66-year-old daughter and 6-year-old great-grandson. She is legally blind and has severe hearing loss but is ercely independent and wants to be able to provide as much of her own self-care as possible. e. Hershel Hemminger is a 70-year-old man who has recently been diagnosed with Alzheimer disease. He suffers severe short-term memory loss and is beginning to display impaired judgment. His wife is 65 years old and wants to keep him at home with her for as long as possible. To do this, she needs help keeping him safe and must learn more about Alzheimer disease so that she can anticipate what to expect in the future.

Case Studies
1. Mr. Clancy and his wife Margaret visit the physicians ofce one morning. Mr. Clancy is concerned about his wife and asks the physician to evaluate her. He states she has been having trouble with her memory lately, her sleep patterns have been odd, and she sometimes says and does odd things. What questions might the medical assistant ask to elicit and clarify important information about Mrs. Clancys health status and behaviors? 2. Mrs. Halvorson is a 45-year-old woman who is a regular patient at Valley Clinic. She is concerned about the possibility of developing osteoporosis. She is 5' 2'' tall, weighs 105 lb, and is currently perimenopausal. Her elderly mother has severe osteoporosis, suffered a recent hip fracture, and has developed kyphosis. Mrs. Halvorson wants to know what she can do to avoid the same experience. List the type of information that the medical assistant should share with her and describe an effective method of teaching her.

Resources

Administration on Aging: www.aoa.dhhs.gov Alzheimers Association: 1-800-272-3900; www.alz.org Arthritis Foundation: www.arthritis.org Glaucoma Research Foundation: www.glaucoma.org National Council on Aging: www.ncoa.org National Institute on Aging: www.nia.nih.gov National Institute on Deafness and Other Communication Disorders: www.nidcd.nih.gov National Meals-on-Wheels Foundation: www.mowaa.org National Osteoporosis Foundation: www.nof.org

CHAPTER

Orthopedics
Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms presented in the glossary identify and locate bones of the skeleton and major muscles of the body identify and name body movements used in range of motion exercises perform procedures outlined in the chapter discuss the importance of patient education in the use of assistive devices discuss how to comfort and educate a patient with a cast, from application to cast maintenance and removal explain how the body reacts to application of heat and cold and their use in soft tissue injuries describe the physiological effects of ultrasound, TENS, and massage. Legal Concepts
Document accurately

35
Instruct patients with special needs Teach patients methods of health promotion and disease prevention Scoliosis Kyphosis Lordosis Gout Osteoarthritis Osteoporosis Rheumatoid arthritis Juvenile rheumatoid arthritis Muscle Disorders Fibromyalgia Strain Myasthenia gravis Rotator cuff tear Herniated disk Injuries to Tendons and Ligaments Anterior cruciate ligament tear Epicondylitis, medial and lateral Tendinitis Sprain

Instruction

Procedures
Transferring a patient from a wheelchair to an examination table Transferring a patient from an examination table to a wheelchair Performing ROM exercises, upper body Performing ROM exercises, lower body Assisting with gait using a gait belt Assisting a patient in ambulating with a walker Assisting a patient in ambulating with a cane Assisting a patient in ambulating with crutches Assisting with berglass cast application Assisting with cast removal Applying a triangular arm sling Administering ultrasound Teaching a patient to use a TENS unit

Orthopedic Procedures
Assisting with Examination Evaluating Muscle Strength and Range of Motion Goniometry Range of motion Fitting a Patient with a Walker, Cane, and Crutches Fitting a patient with a walker Fitting a patient with a cane Fitting a patient with crutches Casting Thermotherapy Moist heat Dry heat Cryotherapy Ultrasound Transcutaneous Electrical Nerve Stimulation

CAAHEP Competencies
Clinical Competencies Patient Care
Prepare patient for and assist with procedures, treatments, and minor ofce surgeries

General Competencies Patient Instruction

Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention

Chapter Outline
Structures and Functions of the Musculoskeletal System
Structures of the Musculoskeletal System Bone Muscle Tendons and ligaments Functions of the Musculoskeletal System Bone Muscle Tendons and ligaments

ABHES Competencies
Clinical Duties
Prepare patients for procedures Prepare and maintain examination and treatment areas Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries

Chapter Summary Team Work Exercises Case Studies Resources

Medical Terminology Related to the Musculoskeletal System Common Musculoskeletal System Diseases and Disorders
Injuries to Bones Dislocation

707

Key Terms
abduction

muscle

Tissue made up of contractile bers that produce movement Motion away from the midline of the body
adduction muscle testing

Process of evaluating muscle strength and range of motion

myofascia

Motion toward the midline of the body

ambulation

Tissue consisting of muscle and underlying fascia

pronation

Action of walking
aponeurosis

Movement of the arm so the palm is down or movement of the foot outward and up
range of motion

Flat, brous sheet of connective tissue that attaches muscle to bone or other tissues
articulation

Outer limit of joint movement

reduction

Juncture between two or more bones; also called a joint

atrophy

Manual manipulation of a bone to return it to its normal position

rotation

Decrease in mass of a muscle or organ; also called wasting

bone

Movement that turns a body part around its axis

supination

Individual unit of osseous tissue that is part of the framework of the body
circumduction

Movement of the arm so the palm is up or movement of the foot inward and up
tendon

Circular motion of a body part

contracture

Band of dense, brous tissue that attaches muscle to bone

thermotherapy

Movement that shortens or tightens a muscle

cryotherapy

Removal of heat from a body part to decrease cellular metabolism and swelling
eversion

Therapeutic application of heat used to treat various muscle injuries

ultrasound

Movement of a body part outward

extension

Application of high-frequency sound waves to warm tissues, increasing tissue extensibility and improving local blood ow
vasoconstriction

Movement that straightens a body part

fascia

Decrease in diameter of blood vessels, which decreases blood ow and raises blood pressure
vasodilation

Sheet of brous connective tissue that covers, separates, or supports muscle

exion

Dilation or enlargement of blood vessels, especially small arteries and arterioles

Movement that bends a body part

gait

Manner of walking
goniometry

Process of measuring joint movements and angles

hematopoiesis

Production and development of blood cells

hemiplegia

Paralysis of one side of the body

hyperextension

Position of maximum extension, or extending a body part beyond its normal limits
inversion

Movement of a body part inward

ligament

Band or sheet of brous tissue that connects two or more bones or cartilage
modality

Method of applying a therapy, usually a physical device

CHAP TER 35

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709

Skull

Structures and Functions of the Musculoskeletal System

The musculoskeletal system consists of muscles, bones, ligaments, and tendons. Together, these structures facilitate movement and protection for internal organs.

Cranium Face Mandible Scapula Clavicle

Structures of the Musculoskeletal System

The structures of the musculoskeletal system include the bones, muscles, tendons, and ligaments.
Humerus

Manubrium Sternum Ribs Xyphoid process Radius Ulna Carpals Ilium Sacrum Coccyx Pubis Ischium Thorax

Bone
A bone is an individual unit of osseous tissue and is part of the framework of the body. Bones are living tissues that are hard in appearance due to their calcium matrix. (See Figure 35-1.)

Pelvic girdle

Muscle
Muscles are tissues made up of contractile bers. Muscles are covered by a brous membrane called a fascia. The fascia is connective tissue that is arranged in sheets or bands and covers, separates, and supports muscle. Because the muscle and fascia are connected, these structures are commonly referred to as one structure: myofasciamuscle and fascia. There are three types of muscle tissue:

Metacarpals

Phalanges

Femur

skeletal smooth cardiac. (See Figure 35-2.)

Patella

Skeletal Muscle
Striated muscles are found in all skeletal muscles and in the tongue, pharynx, and upper portion of the esophagus. The striations, or stripes, in this type of muscle are due to the structure of the muscle, which are bundled bers surrounded by a sheath or connective tissue.
Tibia Fibula

Calcaneus

Smooth Muscle
Smooth muscle is found principally in the internal organs of the digestive tract, respiratory passages, urinary bladder, and walls of the blood vessels. No cross striations appear on these muscles. This type of muscle is arranged in sheets or layers.
Tarsals Metatarsals Phalanges

FIG 35-1 Skeletal system.

Cardiac Muscle
The muscles of the heart branch and connect, forming a continuous network. Cardiac muscles are quadrangular in shape and have a single central nucleus. The muscle cells contain striations as in skeletal muscle cells but are arranged in a branching network, not a linear bundle.

aponeurosis. This structure is at or ribbon-like and larger than a typical tendon. Ligaments are bands or sheets of strong, brous connective tissue. This tissue attaches from bone to bone across joints.

Tendons and Ligaments

A tendon is brous connective tissue structured like a cord or strap and usually attaches to a small area of bone. A tendon that attaches to a larger area of a bone is called an

Functions of the Musculoskeletal System

The musculoskeletal system, including the bones, muscles, tendons, and ligaments, functions to provide movement, protection, and a framework for the body.

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FIG 35-2 Three types of muscle. (A) Skeletal. (B) Smooth. (C) Cardiac.

Bone
Bones provide a framework for the body and protect internal organs. For example, such vital organs as the brain, heart, and lungs are protected by the skull and rib cage. Bones enable movement at joints through attachments to muscles and tendons. There are three types of bone joint, or articulation:

The muscle fascia supports and separates muscles and subcutaneous tissues, such as fat and the internal organs. The movement of muscles depends on the type of muscle.

Skeletal Muscle
Movement of skeletal muscles is under conscious control (voluntary). Skeletal muscles work with tendons and ligaments to help the body move. Examples of skeletal muscle are those that move bones, the eyeballs, and the tongue. The brain and spinal cord tell muscles to move, or contract. Nerves at motor points within the muscle tissue receive these signals from the brain and spinal cord and initiate muscle movement. (See Figure 35-3.) Skeletal muscles are required for such movement as walking. A persons gait, or the manner and style in which a person walks, is coordinated by the skeletal muscles of the back, trunk, and legs. Skeletal muscle responds to exercise by increasing in strength, size, and definition. Forceful contraction of a skeletal muscle will cause vasodilation, or dilation of blood vessels, increasing blood flow within the muscle tissue to give energy to the muscle. Conversely, if muscles are not used and blood is not directed to blood vessels within the muscle, vasoconstriction (a decrease in the diameter of the vessels) occurs. Decreased blood flow to the muscle makes forceful contraction difficult and muscle strength may be lost. If a person does not use his skeletal muscles (for example, in a

synarthrosisimmoveable joint, such as the sutures of the skull amphiarthrosisslightly moveable joint, such as a vertebra diarthosisfreely moveable joint, such as the knee joint.

Bone marrow within bone performs hematopoiesis, or the production of red and white blood cells. Bones also serve to store essential minerals such as calcium and phosphorus. When dietary intake of calcium and phosphorus is inadequate or the need for these minerals increases, as in puberty or pregnancy, the bones release their stores of calcium and phosphorus into the bloodstream for use, leaving the bone vulnerable to deterioration and possibly leading to osteoporosis.

Muscle
The primary function of muscles is to provide movement using contractile cells or fibers. Movement depends on the force of the contraction and the type of muscle.

CHAP TER 35

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Brain

Actions and names of major skeletal muscles

The major movements of the body and the muscles that provide that movement are listed below.

Movement
Closing of the jaw Closing of the jaw Flexion and rotation of the head Extension of the head and movement of the scapula Adduction and exion of the arm Abduction of the arm Flexion and supination of the forearm Extension of the forearm Flexion of the forearm Flexion, side bending,

Skeletal Muscle
Masseter Temporalis Sternocleidomastoid Trapezius

Nerve

Pectoralis major Deltoid Biceps Triceps Brachioradialis, Brachialis Rectus abdominus, transverse abdominus Gluteus maximus Gluteus medius Quadriceps femoris Sartorius

Motor points

Nerve

and rotation of the trunk Extension of the thigh Abduction and rotation of the thigh Extension of the leg Flexion of the thigh; exion and rotation of the leg Flexion of the leg and extension

Hamstring

Muscle FIG 35-3 Motor point of muscle.

of the thigh Flexion of the foot Gastrocnemius

comatose patient), the muscles will atrophy, or decrease in size. (See Actions and names of major skeletal muscles.)

Smooth Muscle
Smooth muscle is not under conscious control (involuntary) and is found in the internal organs, such as the digestive tract, urinary bladder, gallbladder, and the walls of the blood vessels. In the digestive tract, smooth muscle functions to carry food through the alimentary canal to be broken down for digestion and absorption. In the walls of the blood vessels, smooth muscle moves blood through the vessels to various parts of the body. Smooth muscle structure, arranged in sheets or layers, is determined by its function. Because movement is not directed along a single axis, the structure of this type of muscle must allow for movement in many directions. Unlike skeletal muscle, smooth muscle size and strength cannot be affected through exercise. The smooth muscles of the alimentary canal do not become stronger with an increase in eating as a skeletal muscle would with increased work, such as weight lifting.

Cardiac Muscle
Cardiac muscle, the muscle of the heart, works to pump blood through the heart and out to the body. The strong contractions of the heart muscle push blood through the circulatory system, supplying blood and oxygen to all the tissues of the body. Blood returns to the heart, which pumps it to the lungs, where it is reoxygenated, and then returns back to the heart. Like skeletal muscles, cardiac muscle

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efciency improves with use. Exercise that increases the heart rate increases the efciency of the cardiac muscle.

Tendons and Ligaments

A tendon attaches muscle to bone. A tendon does not contract or elongate upon movement of the muscle but facilitates the bones movement. In some places where an aponeurosis attaches muscle to bone, it covers such a large area of bone that it also serves as a protective fascia. Ligaments attach bone to bone across joints to limit the motion of the joint. Ligaments prevent hyperextension, which is the position of maximum extension or extension of a body part beyond its normal limits. They essentially hold the joint together, allowing the attached muscles to move bones upon contraction while preventing the joint from falling apart. (See Figure 35-4.)

Medical Terminology Related to the Musculoskeletal System

Terms used in orthopedic, osteopathic, and chiropractic physician offices will include the names of muscles, bones, and pathologies associated with the musculoskeletal system. Medical assistants in these practice settings will also become familiar with the medications, surgical procedures, and outpatient therapies, or modalities, of the various practices. The modalities employed may be therapeutic devices, such as ultrasound and transcutaneous electrical nerve stimulation, or the application of ice or heat. The medical assistant may be required to administer

FIG 35-4 Knee joint showing the bones, tendons, and ligaments that prevent this joint from falling apart.

Table 35.1 | Element

Word Elements
Meaning Example
cervicodynia (ser-v-ko-DIN-e-a) chondromalacia (kon-dro-mal-A-she-a) cleidocostal (kl-do-KOS-tal) costophrenic (kos-to-FREN-k) craniotomy (kra-ne-OT-o-me) cryotherapy (kr-o-THER-a-pe) dorsiexion (dor-s-FLEK-shun)

Meaning

Combining forms cervic/o chondr/o cleid/o cost/o crani/o cry/o dors/o, dors/i neck cartilage clavicle rib skull cold back pain in the neck softening of cartilage pertaining to the clavicle and ribs pertaining to the ribs and diaphragm incision through the cranium application of cold to a body part movement of a part or joint to bend the part toward the back ili/o ank iliosacral (l-e-o-SA-kral) concerning the sacrum and ilium

CHAP TER 35

Orthopedics

713

Table 35.1 | Element

ischi/o kines/i, kin/o kyph/o

Word Elementscontd
Meaning
ischium movement humped

Example
ischium (IS-ke-um) kinesiology (k-ne-se-OL-o-je) kyphosis (k-FO-ss)

Meaning
the lower posterior portion of the hip bone the study of muscles and body movement exaggeration of the posterior curve of the thoracic spine

muscul/o, my/o orth/o

muscle straight

myodynia (m-o-DIN-e-a) orthodontics (or-tho-DON-tks)

muscle pain area of dentistry concerned with correction of structure

oste/o ped/i, ped/o

bone foot

osteopathy (os-te-OP-a-the) podiatry (po-DI-a-tre)

any bone disease diagnosis, treatment. and prevention of conditions of the human feet

phalang/o poster/o spondyl/o stern/o tend/o, ten/o therm/o thorac/i, thorac/o vertebr/o Prexes ahyperhyposubingsuprasynSufxes -asthenia -blast

bones of the ngers and toes behind, toward the back vertebra chest tendon hot; heat chest vertebra

phalangitis (fal-an-JI-tis) posterolateral (pos-ter-o-LAT-er-al) spondylolisthesis (spon-d-lo-ls-THE-ss) sternoclavicular (ster-no-kla-VIK-u-lar) tenodesis (te-NOD-e-ss) thermotherapy (ther-mo-THER-a-pe) thoracentesis (tho-ra-sen-TE-ss) vertebroplasty (VER-te-bro-plas-te)

inammation of the ngers and/or toes located behind and at side of a part forward slipping of a vertebra pertaining to the sternum and clavicle surgical reattachment of tendon to bone therapeutic application of heat to the body inserting a needle into the chest wall surgical repair of a vertebra

without, not above, excessive under, below under, below above, excessive union, together, with

atrophy (AT-ro-fe) hyperkinesia (h-per-kn-E-ze-a) hypoesthesia (h-po-es-THE-ze-a) suboccipital (sub-ok-SIP--tal) supraclavicular (soo-pra-kla-VIK-u-lar) syndesis (sn-DE-ss)

wasting; decrease in size of an organ or tissue excessive movement dulled sensitivity to touch situated below the occiput located above the clavicle surgical xation or ankylosis of a joint

weakness, debility embryonic cell

myasthenia (m-as-THE-ne-a) osteoblast (OS-te-o-blast)

muscle weakness and fatigue cell of mesodermal origin concerned with the formation of bone

-clast

to break, surgical fracture

osteoclast (OS-te-o-klast)

device used to fracture a bone to correct deformity; large multinuclear cell formed in the bone marrow of growing bones

-desis -malacia -plegia

binding, xation softening paralysis, stroke

arthrodesis (ar-thro-DE-ss) osteomalacia (os-te-o-mal-A-she-a) hemiplegia (hem-e-PLE-je-a)

binding together of a joint softening of bone paralysis of one side of the body

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Table 35.2 |

Bone fractures

Bone fractures are common, especially to the clavicle, wrist, and ankle. The medical assistant should become familiar with the various types of bone fractures. This table lists fracture types along with a description and example of each. Fracture Type
closed or simple

Description
Bone fractured without external wound

Example

Comminuted

Bone broken into pieces

greenstick

Bone bent and partially broken (common fracture in children)

CHAP TER 35

Orthopedics

715

Table 35.2 |

Bone fracturescontd
Description
Bone broken with one end wedged into the interior of the other (crushed into the fracture)

Fracture Type
impacted

Example

incomplete

Line of fracture that does not continue through entire bone

oblique

Bone with slanted fracture of the shaft on its long axis

Continued

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Table 35.2 |

Bone fracturescontd
Description
Broken bone sticking out of an open wound or fragments of bone seen through the skin

Fracture Type
open or compound

Example

Table 35.3 |

Musculoskeletal Abbreviations

In orthopedics, as with other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed below save time and effort in documentation and written communications. Abbreviation
ACL ADL AK ALS AS BK DJD DTR JRA LLE LP LUE MD

Term
anterior cruciate ligament activities of daily living above the knee amyotrophic lateral sclerosis ankylosing spondylitis below the knee degenerative joint disease deep tendon reex juvenile rheumatoid arthritis left lower extremity lumbar puncture left upper extremity muscular dystrophy

Abbreviation
MVA NSAID ORIF OT PT RA RLE ROM RUE TENS TMJ US WNL

Term
motor vehicle accident nonsteroidal anti-inammatory drug open reduction and internal xation occupational therapy physical therapy rheumatoid arthritis right lower extremity range of motion right upper extremity transcutaneous electrical nerve stimulation temporomandibular joint ultrasound within normal limits

various modalities under the direction of the physician. To be effective in her role, a medical assistant must become well versed in the language and vocabulary that pertain to the musculoskeletal system. The following tables list common medical terminology related to the musculoskeletal system.

Common Musculoskeletal System Diseases and Disorders

There are innumerable diseases and disorders of the musculoskeletal system. In addition to bone fractures, some of

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the most common diseases and disorders include dislocation, arthritis, osteoporosis, curvature of the spine, torn ligaments and tendons in the knees or shoulders as a result of sports injuries, and injuries to the intervertebral disks of the lower back, affecting the sciatic nerve. Damage to bones, muscles, or tendons and ligaments can result in loss of function to the musculoskeletal system. Treatments are aimed at regaining normal function and controlling pain.

Injuries to Bones
In addition to bone fractures, bone pathologies can include dislocations, various forms of arthritis, osteoporosis, and abnormal curvatures of the spine. The medical assistant can offer information on treatments to reduce pain in chronic bone conditions and safety strategies to prevent bone injuries.

Dislocation
ICD-9-CM code: 830839 (code by specic site) Dislocation is the displacement of a bone from its normal articulation. Dislocation is evident upon visual inspection. An x-ray confirms the diagnosis. Treatment for dislocation includes manual repositioning by the physician in the office or, if anesthesia is required, in the operating room.

Scoliosis
ICD-9-CM code: 737.43 Scoliosis is an abnormal lateral curvature of the spine. Scoliosis is more common in adolescents because the adolescent spine is still developing. Symptoms include lateral spinal deformity with back pain. Mild scoliosis generally causes no problems and is usually not noticeable. Severe scoliosis can cause signicant back pain and, possibly, heart or lung problems because of the decreased space in the thoracic cavity on one side. Diagnosis is based on a physical examination and radiographic studies. Treatment includes bracing and asymmetrical exercise to correct muscle imbalances where one side is stronger than the other. In severe cases, surgical correction is necessary. (See Figure 35-5.)

Kyphosis
ICD-9-CM code: 737.0 (adolescent); 737.1 (acquired) Kyphosis is an outward curvature of the thoracic region of the spine. Kyphosis may be due to a congenital anomaly, disease (tuberculosis, syphilis), a malignancy, or a compression fracture. Kyphosis is most common in older women. A symptom of kyphosis is a stooped posture. Diagnosis depends on an x-ray of the spine, which reveals a curvature. Treatment includes supplemental calcium; vitamin D; medications to slow the progression of bone loss, such as Boniva and Fosimax; and pain management in the form of analgesics, massage, and acupuncture.

FIG 35-5 (A) Scoliosis, or lateral curvature of the spine. (B) Kyphosis, or increased curvature of the thoracic spine.

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Lordosis
ICD-9-CM code: 737.20 (acquired); 754.2 (congenital) Lordosis is excessive curvature in the lumbar portion of the spine, which gives a swayback appearance and prominence of the buttocks. The cause of lordosis is unknown but is thought to be congenital or associated with poor posture, back surgery, hip dysplasia, or overtraining in gymnastics. Lordosis is most commonly diagnosed in childhood; school nurses will commonly screen students for lordosis. Lordosis is an asymptomatic condition. Children complaining of back pain, pain down the legs, and changes in bowel and bladder habits should be evaluated for other conditions. Diagnosis is obtained by x-ray of the lumbar spine and physical examination, including observing the patients standing posture. Early detection and treatment prevents injury to lumbar discs and the paraspinal musculature. The goal of treatment is to stop the progression of the abnormal curve and prevent deformity. Exercises conducted at home or with a physical therapist correct postural abnormalities. If underlying hip abnormalities are the cause of lordosis, correction of hip pathology will help decrease abnormal curvature.

because it can exacerbate the condition. Patients with a history of gout can elect to take allopurinol, a medication that directly reduces the production of uric acid. Allopurinol is a lifelong medication and cannot be initiated during an attack because it will make the acute gout worse. The medical assistant should educate the patient about dietary changes that can prevent further attacks. (See Foods and gout.)

Osteoarthritis
ICD-9-CM code: 715.9 (use 5th digit to code site) Osteoarthritis is an inammation of the joints, which causes pain, swelling, redness, warmth, and limited ROM. These afictions affect the weight-bearing joints in the body. Osteoarthritis usually affects elderly patients and may be due to angina, obesity, overuse or abuse of joints in sports or strenuous occupations, and trauma. Patients with osteoarthritis complain of gradually increasing joint pain and gradually decreasing ROM in the affected joint. Diagnosis is based on x-rays, which show increasing changes in the joint surfaces and narrowing joint space. Treatment includes rest, heat, massage, acupuncture, weight reduction (if necessary), and analgesics. The main goals for treatment are relieving pain, gaining normal ROM for the joint, and preventing the osteoarthritis from getting worse.

Gout
ICD-9-CM code:274.0 (acute) Gout is a disease caused by a congenital or acquired disorder of uric acid metabolism. A family history of the disease is present in 20% of people who have gout. Risk factors for acquiring the disease include obesity; excessive alcohol consumption; diet high in purines and protein, including such foods as cream, anchovies, meats, and sh; exposure to lead; and such underlying medical conditions as renal insufciency, high blood pressure, and hypothyroidism. Medications that can cause gout in some people include diuretics, salicylatecontaining drugs such as aspirin, niacin, and cyclosporins. In the disorder, the body is unable to clear uric acid from the bloodstream and uric acid crystals deposit in the articular cartilage of joints. The knee and great toe are the joints most commonly affected. The deposits provoke an inammatory response in the affected joints, causing pain and restriction of the degree of movement, or range of motion (ROM), of the joint. The deposits commonly increase in size and burst through the skin, causing a chalky white material to appear. Affected joints will also appear red, swollen, and painful to the touch and the patient may have a fever during an acute episode. Gout is commonly chronic with episodes of acute attacks. It is most prevalent among African American males, in whom the incidence is twice that of Whites. Diagnosis is made using physical examination, patient history, and blood uric acid levels greater than 7.0 mg/dl in males and 6.0 mg/dl in females (hyperuricemia). Treatment is directed at pain relief with nonsteroidal anti-inammatory drugs (NSAIDs) and intra-articular glucocortoids to reduce inammation. Aspirin should never be used for pain relief

Osteoporosis
ICD-9-CM code: 733.00 (generalized) Osteoporosis is a loss of bone mass throughout the skeleton. It is most common in postmenopausal women but can be associated with parathyroid abnormalities that result in loss of calcium to the bone matrix. Osteoporosis may be due to increased age; immobilization; thyroid hormone excess; use of corticosteroids and some anticonvulsant drugs; consumption of alcohol, tobacco, or caffeine; and menopause. Symptoms of osteoporosis include frequent fractures, exaggerated thoracic kyphosis, decreased height, and back pain. Diagnostic blood tests for osteoporosis are serum calcium, alkaline phosphatase, estrogen level, total protein, and creatinine. A bone scan can be performed as a denitive diagnostic test. Treatment includes supplemental calcium, regular weight-bearing exercise, and bisphosphate drugs. Estrogen supplementation may also be used (for women only) but there may be some risks involved that should be assessed.

Rheumatoid Arthritis
ICD-9-CM code: 714.0 Rheumatoid arthritis is a chronic systemic inammation of the joints and synovial membranes that also involves elevated serum rheumatoid factor levels. Researchers believe that rheumatoid arthritis is triggered by an infection in people with an inherited susceptibility to the disease. Symptoms of rheumatoid arthritis include severe joint pain and joint deformity. Diagnostic blood tests for rheumatoid arthritis are

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Patient Education

Foods and Gout

The medical assistant should make sure the patient suffering from gout receives nutritional counseling about foods that will help ease gout and those to be avoided. cherries strawberries.

Good for gout

These foods will help reduce uric acid production and should be recommended for the patient with gout: mushrooms spinach asparagus cauliower

Bad for gout

These foods contain elements, such as purine, that should be limited or avoided in the patient with gout: alcohol cream meat sh pinto, kidney, and red beans.

rheumatoid factor, antinuclear antibody (ANA) test, and erythrocyte sedimentation rate (ESR). Treatment includes disease-modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine and methotrexate. Immunosuppressive agents, such as cyclosporine and azathioprine, may also be used for treatment. Gold compounds are sometimes used; however, they are usually not as effective.

physician or physical therapist will assess the strength and ROM of specic muscle groups. Severe loss of muscle function can cause paralysis. For example, a stroke can cause hemiplegia, paralysis of half of the body due to injury in the brain on the opposite side.

Fibromyalgia
ICD-9-CM code: 729.1 Fibromyalgia is chronic pain in the muscles and soft tissues due to various causes. Fibromyalgia can be found in people of all ages and is more common in women than men. Associated conditions can include sleep disorders, irritable bowel syndrome, chronic headaches, temporomandibular joint (TMJ) problems, increased chemical sensitivity, and other musculoskeletal complaints. Fibromyalgia can be triggered by an automobile accident, bacterial or viral infection, or an underlying medical condition, such as rheumatoid arthritis (RA), lupus, or hypothyroidism. Fibromyalgia is aggravated by changes in monthly hormonal variations, weather or temperature, stress, anxiety, and depression. Symptoms of bromyalgia include diffuse aches and pains all over the body. Diagnosis is made by eliminating any other cause for the symptoms and nding 11 of 18 specic points to be extremely tender to touch. Treatment includes antiinammatories, trigger point injections, nutritional and herbal support, exercise, and massage. There is no known cure for bromyalgia. (See Figure 35-6.)

Juvenile Rheumatoid Arthritis

ICD-9-CM code: 714.30 Juvenile rheumatoid arthritis ( JRA) is a chronic systemic inammation of the joints and synovial membranes, which usually involves elevated ANA. The onset of juvenile rheumatoid arthritis is usually more acute than in the adult form. Systemic effects are typically more noticeable; however, the rheumatoid nodules are absent. The systemic form of JRA, called Stills disease, forms with fever, rash, lymphadenopathy, and hepatomegaly as well as joint involvement. The second form of JRA causes polyarticular inammation similar to the adult form. The third form involves four or less joints but causes uveitis (inammation of the iris). Treatment of all forms of JRA includes DMARDs, such as hydroxychloroquine and methotrexate. Immunosuppressive agents, such as cyclosporine and azathioprine, may also be used as well as gold compounds, although they are less effective.

Muscle Disorders
Injury or disease to the muscular system can be acute or chronic and associated with underlying disease or trauma. The most common of these disorders is bromyalgia. Other common disorders include muscle strains from exercise and muscle weakness in the paraspinal musculature leading to a herniated disk. Loss of strength or ROM may be an indication of neurologic pathology. Skeletal muscle strength and ROM can be assessed manually by muscle testing, where a

Strain
ICD-9-CM code: 840-848 (code by site) A strain is trauma to a muscle and, sometimes, a tendon due to violent contraction or excessive forcible stretching. Symptoms can be moderate to severe and include pain, heat, discoloration, and localized swelling in the affected area. An x-ray rules out an avulsion fracture of the ligaments

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(called ocular myasthenia gravis). Most individuals with myasthenia gravis develop drooping of the eyelids (ptosis); weakness of eye muscles; inability to maintain a steady gaze, resulting in double vision (diplopia); extreme muscle fatigue following activity; and weakness of facial muscles. Difculty speaking (dysphasia), difculty swallowing (dysphagia), and weakness of the upper arms and legs are also common. Patients will have difculty climbing stairs and lifting heavy objects due to muscle weakness. In about 10% of cases, affected individuals may develop potentially life-threatening complications due to severe involvement of muscles used during breathing, causing myasthenic crisis. Diagnosis is made by physical examination, including muscle strength assessment. As the disease progresses, muscle strength decreases and can progressively involve more muscle groups. A test using edrophonium (Tensilon), a medication that blocks the action of enzymes that break down the neurotransmitter acetylcholine, can be used to make a denitive diagnosis of MG. Temporary improvement of muscle function after administration of edrophonium conrms the diagnosis of MG. There is no known cure for MG; treatment is directed at reducing symptoms of muscle weakness and fatigue. The medical assistant should advise patients to avoid stress and exposure to heat, because they can exacerbate symptoms. The patient may want to wear an eye patch if diplopia is problematic. Some medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon), can improve communication between nerves and muscles and decrease weakness. Surgical removal of the thymus may cause permanent remission or decrease the need for medication.
FIG 35-6 Fibromyalgia tender points.

Rotator Cuff Tear

ICD-9-CM code: 840.4 (traumatic); 726.10 (degenerative) The rotator cuff is made up of four muscles and their tendons that wrap around the front, back, and top of the shoulder joint. Together, the rotator cuff muscles help guide the shoulder through many motions and provide stability to the joint. At the ends of the rotator cuff muscles, tendons attach to the humerus. A rotator cuff tear is seen in patients of all ages; however, they are more common in older patients. As a person ages, the muscles and tendons of the rotator cuff lose some elasticity, causing an increased susceptibility to tears. Around 30% of 70-year-olds have some degree of rotator cuff tear, although not all of these people experience symptoms. In younger patients, usually a traumatic injury or excessive use of the shoulder (as seen in athletes) is the cause of a tear in the rotator cuff. The most common symptom of a rotator cuff tear is generalized pain exacerbated by shoulder movement. Depending on the severity of the tear, loss of motion and decreased strength may also occur. Diagnosis of a rotator cuff tear is based on patient history and physical examination, which will reveal loss of strength and ROM.

attachment. Treatment includes ice, rest, compression, elevation, massage, ultrasound, electrical muscle stimulation, and analgesics.

Myasthenia Gravis
ICD-9-CM code: 358.0 Myasthenia gravis (MG) is a neuromuscular disorder characterized by muscle weakness and muscle fatigue. The disease results from an abnormal immune reaction in which antibodies inappropriately attack and gradually destroy certain receptors in muscles that receive nerve impulses. The cause of myasthenia gravis is unknown but, in some cases, it is associated with tumors of the thymus gland. Patients with other immune disorders such as rheumatoid arthritis and systemic lupus erythematosus are at increased risk. Although the disorder usually becomes apparent during adulthood, symptom onset may occur at any age. The condition may be generalized, involving multiple muscle groups, or restricted to certain muscle groups, particularly those of the eyes

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Diagnosis is conrmed by an arthrogram with contrast dye injection into the joint capsule. If a tear is present, the dye will leak out of the joint capsule, conrming the diagnosis. Treatment for rotator cuff tear includes physical therapy to strengthen the muscles and maintain normal function. Antiinammatory medications and cortisone injections decrease inammation and pain. If conservative measures are ineffective, surgical repair will be necessary.

Herniated Disk
ICD-9-CM code: 722 (code by specic site and conditions) A herniated disk is a prolapse of the nucleus pulposus of a ruptured disk into the spinal canal. Patients with a herniated disk complain of back pain and extremity pain or weakness. The most common symptom of a herniated disk is sciatica, a compression of the sciatic nerve. The compression on the nerve causes irritation of the nerve and can produce pain radiating down the back of the leg as far as the ankle. The pain can be sharp and stabbing or the patient may complain of numbness and weakness in the leg. Procedures used to diagnose a herniated disk include computed tomography (CT) and magnetic resonance imaging (MRI). Treatment for a herniated disk is a laminectomy, a surgical excision of the vertebral posterior arch to remove the herniated disk or lesion. Conservative treatment may include anti-inammatories, chiropractic adjustment, physical therapy, traction, and acupuncture. Such treatments are palliative, not curative, and may offer the patient some pain relief. (See Figure 35-7.)

FIG 35-7 Laminectomy.

of the ligament followed by rest and physical therapy to strengthen and stabilize the knee joint. Knee bracing for return to contact sports is commonly utilized.

Injuries to Tendons and Ligaments

Tendons and ligaments, the tissues that hold joints together and attach muscle to bone, are commonly injured in sports-related accidents. Injuries can occur as the result of collision with another player or can be due to a chronic overuse of the joint. The medical assistant can provide information on injury prevention in athletics. (See Preventing musculoskeletal injuries, page 722.) Common injuries to the tendons and ligaments include anterior cruciate ligament (ACL) tear, tendinitis at various sites, and sprains of various ligaments.

Epicondylitis, Medial and Lateral

ICD-9-CM code: 726.32 (lateral epicondylitis); 726.31 (medial epicondylitis) Tennis elbow is trauma or overuse of the elbow, which causes inflammation along the medial side of the joint, specifically to the epicondyle. Tennis elbow is common in sports such as tennis and weight lifting. A similar condition, lateral epicondylitis, is the same injury except that it affects the lateral side of the joint. Lateral epicondylitis is also called golfers elbow because the repeated motion of driving the golf club is the most common cause. Symptoms of both conditions include tenderness, stiffness, inflammation, and pain around the elbow. Diagnosis is determined mainly through symptoms and palpation of the elbow, which is inflamed and tender on palpation. Treatment includes immobilization with a splint, strapping (strap positioned around the arm 2'' to 3'' below the elbow joint to take pressure off the wrist extensor tendons), ultrasound, friction massage, acupuncture, ice, NSAIDs, and muscle relaxants. Cortisone injections may be administered if the injury does not respond to other treatments.

Anterior Cruciate Ligament Tear

ICD-9-CM code: 717.83 The anterior cruciate ligament (ACL) is the ligament of the knee that originates on the anterior portion of the femur in the intercondylar notch, which can tear from a twisting motion. This injury is most common in athletes, especially those in basketball and skiing. It is also more common in females. Symptoms include severe pain and an inability to bear weight on the leg. Diagnosis is usually based on pain and functional instability of the knee and is conrmed by MRI or CT scan. Treatment includes surgical reattachment

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Patient Education

Preventing Musculoskeletal Injuries

The medical assistant can help her patients prevent injury by providing information on safety in their environment and while exercising.

Exercise and behaviors

The risk of injury increases during exercise. The medical assistant can advise her patient to prevent injury by including these instructions: Get proper sleep (to prevent tripping and falling). Reduce emotional stress. Stop smoking (which contributes to back injuries). Stretch muscles before working out to prevent cramping or pulling ligaments and tendons. Exercise within reason. Do not go from couch potato to marathon runner in 1 week. Apply ice to sore muscles after exercise. Eat a balanced diet to fuel muscles for exercise.

Creating an injury-proof environment

People can prevent injury by injury-proong their home and using safe behaviors, including: Making sure carpets are not loose, which could cause trips and falls. Making sure electrical cords are not in walk areas, to prevent trips. Never standing on a chair; using a step stool to change light bulbs or dust ceiling fans. Removing snow, ice, and wet leaves to prevent falls. Providing adequate lighting in all areas of the home to prevent injury.

Tendinitis
ICD-9-CM code: 726 (4th and 5th digit code by site) Tendinitis is inammation of a tendon due to overuse. Symptoms can be moderate to severe and include pain with decreased ROM in the affected area. X-rays rule out the possibility of a fracture. Treatment includes moist heat, ultrasound, electrical muscle stimulation, and strengthening ROM exercises. Corticosteroid injections may be administered if these more conservative treatments yield a poor response.

Patient Education

Treating Sprains at Home

The medical assistant can encourage patients to start treatment for a suspected sprain right away. She can advise her patients to come to the ofce, but start with RICE: R: rest I: ice C: compression E: elevation.

Sprain
ICD-9-CM code: 840848 (code by site) A sprain is a stretched or torn ligament, which causes pain and immobility. Sprains are most common in the ankle joint. Symptoms can be moderate to severe and include pain, heat, discoloration, and localized swelling in the affected area. An x-ray rules out an avulsion fracture of the ligaments attachment. Treatment includes ice to reduce swelling, circumferential compression and support with a bandage, rest and elevation, stretching exercises, ultrasounds, electrical muscle stimulation, analgesics, and antiinammatories. (See Treating sprains at home.)

health care providers, including chiropractors, osteopaths, and general practitioners, will treat disorders of the musculoskeletal system with conservative therapies and refer patients to an orthopedic surgeon for surgical correction. Orthopedic procedures conducted by various providers are directed at diagnosing and treating musculoskeletal disorders to restore normal function. Because each patient is unique, the provider and medical assistant must work with each one to attain optimal function.

Orthopedic Procedures
Orthopedics is the medical specialty that focuses on the study and treatment of the musculoskeletal system. Many

Assisting with Examination

People suffer injuries to the musculoskeletal system every day. To reach an accurate diagnosis, the physician must

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obtain a medical history, including a description of the accident or injury, and the signs and symptoms of the injury. A sports injury, car accident, fall, or other trauma can result in partial or total loss of the use of an extremity. Stroke and head or spinal cord injury can leave a patient unable to perform independent tasks. Such patients can receive care from an orthopedic surgeon, chiropractor, osteopath, physical or occupational therapist, and speech pathologist. The goal of treatment for these patients can vary but is generally focused on reestablishing normal function, strength, and movement of the affected body areas. In an examination, the medical assistant must prepare the patient by checking vital signs and obtaining a health history. She should then assist the physician as needed with undressing and positioning, remembering to take care, as the patient may be in pain or unable to move. For example, a patient with a herniated disk will need her assistance to climb onto the examination table and may be in considerable discomfort. (See Procedure 35-1:

Transferring a patient from a wheelchair to an examination table.) The clinical medical assistant can play a vital role in the care of these patients in various ambulatory and inpatient settings. During the patient examination, the physician may ask the medical assistant to help position the patient, support the patient, and document examination findings. The medical assistant should be attentive to the needs and physical limitations of the patient. (See Procedure 35-2: Transferring a patient from an examination table to a wheelchair, page 724.) Patients using crutches, canes, or walkers to ambulate may require assistance to transfer to and from examination tables. Offer help as needed, being sure to use your knees and hips for bending and not bending from the lower back. Depending on the injury, the patient may require help getting from the waiting room to the treatment room. Offering to perform simple tasks such as carrying a purse or bag can show the patient that the medical assistant is receptive to their needs.

PROCEDURE 35-1

Transferring a patient from a wheelchair to an examination table

Task Move a patient from a wheelchair to an examination table safely. Conditions Gait belt Stool with rubber tips and a handle for gripping Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully transfer a patient from a wheelchair to an examination table. Performance Standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. Explain to the patient that you will help him onto the examination table to promote patient cooperation and understanding. 3. Place the wheelchair next to the examination table and lock the brakes. Place the patient with his stronger side (if applicable) closest to the examination table to allow him to balance on that leg during transfer. 4. Place the gait belt securely (but not too tightly) around the patients waist to provide support and comfort. Tuck in the ends of the gait belt so that it does not interfere with assisting the patient.

Tuck in the ends of the gait belt so that it does not interfere with assisting the patient.

5. Move the footrests up and out of the way, and ask the patient to place his feet on the oor. 6. Position the stool in front of the examination table as close to the wheelchair as possible so that the patient does not have to take any additional steps. 7. Ask the patient to move to the front edge of the wheelchair.
Continued

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PROCEDURE 35-1contd

8. Stand directly in front of the patient with your feet hipwidth apart for a strong base. Bending at the hips and knees (to avoid straining your lower back), grasp the gait belt on both sides. Instruct the patient to use the armrests of the wheelchair to push upward if he is able. Proper body positioning while assisting a patient from the wheelchair prevents injury to you and the patient. 9. Give the patient a signal to push off with his arms and good leg while you lift the gait belt so that you and he work at the same time. 10. Tell the patient to allow you and the gait belt to support him while he moves his stronger foot to step onto the stool. Do NOT let go of the gait belt. 11. Tell the patient to pivot his back to the examination table to sit. Make sure that the patients buttocks are high enough to get onto the table. Support the patients weaker, outer leg. 12. Instruct the patient to grasp the stool handle and place the other hand on the examination table. 13. Help the patient adjust his position on the examination table as necessary; make sure that the patient is balanced and comfortable. 14. Move the wheelchair out of the way to provide room for the physician to examine the patient.

Proper body positioning while assisting a patient from the wheelchair prevents injury to you and the patient.

PROCEDURE 35-2

Transferring a patient from an examination table to a wheelchair

Task Move a patient from an examination table to a wheelchair safely. Conditions Gait belt Stool with rubber tips and a handle for gripping Standards In the time specified and within the scoring parameters determined by the instructor, the student will successfully transfer a patient from an examination table to a wheelchair. Performance Standards 1. Wash your hands. 2. Introduce yourself (if you were not assisting the patient previously) and address the patient by name. 4. 5. Explain to the patient that you will help him back to his wheelchair. Position the wheelchair next to the examination table and lock the brakes. The chair should be positioned closest to the patients stronger side so that he can transfer weight onto his stronger foot on the way down. Position the stool next to the examination table. Assist the patient into a sitting position (if not sitting already) and put the gait belt on the patient. The belt should be snug but not tight, and the excess belt should be tucked in the back. Place one arm under the patients arm and around his shoulders and the other arm under the patients knees. Pivot the patient so that his legs dangle over the edge of the examination table.

3.

6.

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7. Position your body directly in front of the patient without removing your hand from the patient. You should always make the patient feel secure. 8. Grasp the patient by the gait belt on both sides. You should position your feet apart with your knees bent for a strong base of support. 9. Instruct the patient that when you give him a signal, he should push off of the examination table and grasp the stool handle for support. Give the patient the

10.

11. 12. 13.

signal as you pull him slightly towards you so his feet come down onto the stool. Keeping both hands on the gait belt, ask the patient to step onto the oor with his strong leg. Pivot the patient so that his back is to the wheelchair. Ask the patient to grasp the armrests of the wheelchair and assist him to a seated position in the wheelchair. Lower the footrests and place his feet on them. Remove the gait belt.

In addition to helping patients in the office, the medical assistant can offer her patient and caregivers strategies to promote independent function without compromising safety. (See Independent function strategies.)

record ROM and strength results or position and comfort the patient during the physical examination. (See Muscle strength scale.)

Evaluating Muscle Strength and Range of Motion

The orthopedic, osteopathic, or chiropractic physician or a licensed physical therapist will evaluate the patients muscle strength in the upper or lower extremities and back or neck region as necessary to help in the diagnosis and treatment of the patient. The role of the medical assistant may also be to

Goniometry
Measurement of the degree of movement, or range of motion, of a joint is called goniometry. Goniometry is performed using a device called a goniometer, which is a protractor with a moveable pointer. If the joint only moves in a single direction, such as the elbow, the measurement is exion (bending) or extension (straightening). If a joint allows for more than one axis of movement, the measurement is more complex.

Patient Education

Muscle strength scale

The following table shows the scale used for evaluating muscle strength, including the response to resistance, its rating, and what this response and rating mean.

Independent Function Strategies

Disabled or elderly patients may need accommodations to help them function as independently as possible. Caregivers can promote independence by: adding side rails to a bed or bathtub to ease patient transfer using a bathtub seat and handheld shower nozzle to help patients with disabilities or decreased range of motion bathe themselves placing items in cupboards or shelves that are accessible without reaching too far using ramps and wide hallways to accommodate wheelchairs or walkers as needed buying clothing that the patient can put on and remove herself such as elastic waistbands and pullover tops. ensuring that banisters on stairways are secure and can provide support while the patient is on the stairs.

Muscle Response
No response Slight contraction of muscle Passive range of motion (ROM) when resistance is removed Active ROM against gravity or light resistance Active ROM against heavy resistance

Rating
0 1 2

Meaning
Paralysis Severe weakness Moderate weakness

3 or 4

Mild weakness

Normal strength

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(See Figure 35-8.) A goniometer can measure 10 movements, including:

abductionmoving away from the midline of the body, such as moving a straightened leg outward at the hip joint adductionmoving toward the midline of the body, such as moving a straightened leg inward at the hip joint eversionturning outward, such as moving the ankle so that the sole of the foot turns outward inversionturning inward, such as moving the ankle so that the sole of the foot turns inward

exionbending, such as moving the hand up to the shoulder by exing at the elbow extensionstraightening, such as moving the hand away from the shoulder by elongating or extending the elbow joint pronationtwisting to face downward, such as turning the wrist so the palm faces down supinationtwisting to face upward, such as turning the wrist so the palm faces up rotationmoving along an axis, such as turning the head by looking left and right

D F

A B

FIG 35-8 Goniometer measurements. (A) Abduction. (B) Adduction. (C) Eversion. (D) Inversion. (E) Flexion. (F) Extension. (G) Pronation. (H) Supination. (I) Rotation. (J) Circumduction.

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circumductionmoving in a circle, thus including multiple directions, such as the shoulder or hip joint. (Due to its complexity, circumduction requires a specialized goniometer.) (See Documenting goniometer measurements.)

Documenting goniometer measurements

These goniometers are measuring a patients elbow at extension and exion.

Range of Motion
Range of motion (ROM) of any joint will decrease without movement. Hospitalized or bedridden patients must move extremities to avoid contracture, a loss of range of motion due to lack of movement. A patient can perform ROM exercises passively; that is, the patient does not move the extremities, the medical assistant gently moves the extremities for the patient. These exercises will not only prevent contracture but also promote adequate blood ow and prevent pressure ulcers. (See Procedure 35-3: Performing ROM exercises, upper body, page 728, and Procedure 35-4: Performing ROM exercises, lower body, page 730.)

Fitting a Patient with a Walker, Cane, and Crutches

Ambulation, or walking, may be compromised due to injury, stroke, or weakness. (See Procedure 35-5: Assisting with gait using a gait belt, page 731.) Patients can use assistive devices for ambulation, such as walkers, canes, and crutches, to enjoy the freedom associated with mobility. Proper fitting and instruction in the use of assistive devices promotes safety and stability and prevents reinjury.

Extension

Fitting a Patient with a Walker

Most walkers are adjustable to accommodate various heights. The medical assistant fitting a walker to a patient should adjust the walker height so that the top of the walker is just below the patients waist, at the top of the femur. (See Figure 35-9.) After adjusting the height of the walker, the medical assistant should make sure that screws are secure so that the walker will not collapse when the weight of thepatient is applied. The patient should be able to stand with elbows bent at approximately 30 degrees when touching the hand grips. After fitting the walker, the medical assistant should instruct the patient about its use and assist him in trying to use it. (See Procedure 35-6: Assisting a patient in ambulating with a walker, page 733.)

Flexion

Here is an example of how these measurements should be documented.

Date 11/22/08; 9:30 a.m. ROM about the left elbow; Extension 170 degrees, Flexion, 25 degrees. --------------------------------------- J. Morgan, CMA

Fitting a Patient with a Cane

A patient should use a cane when he has one weak side. It is useful to patients that have generalized but minor weakness and may be used on an as needed basis by

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the patient. For example, some patients may feel comfortable at home without the cane but rely on the cane in public for extra support and to act as a deterrent to other people who may inadvertently bump into the person. Patients with poor balance may also benefit from the use of a cane. Canes can be made of wood or lighter-weight aluminum and come in three basic types:

stability to patients who may suffer from severe walking difculties. A walk cane is similar to a walker; it has four legs and a handlebar, but is unilateral and can be used by hemiplegic patients. (See Figure 35-10.)

The standard cane has a single tip and a simple curved handle or a bent grip handle. A quad cane is a four-legged cane that adds extra support by its increased contact with the oor. It provides more

Because canes are the most portable assistive device, patients may ask for canes rather than wheelchairs, walkers, or crutches. The physician must prescribe the appropriate assistive device for each patient. After tting the patient with a cane, the medical assistant should assist and instruct the patient in its use. (See Procedure 35-7: Assisting a patient in ambulating with a cane, page 734.)

PROCEDURE 35-3

Performing ROM exercises, upper body

Task Use passive range-of-motion (ROM) exercises to maintain and increase joint mobility in the upper extremities to prevent contracture. Conditions None. Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully use passive ROM exercises. Performance standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. Explain to the patient that you will be gently moving his arms, within pain tolerance and exibility of the limb, to assure him that the ROM exercises will not hurt. Shoulder exion 1. Keeping the patients arm straight and holding the arm at the wrist and elbow, lift the patients arm straight over his head until it rests at on the bed or to range-of-motion (ROM) tolerance to attain end range of motion without discomfort. 2. Bring the arm back to the patients side. Repeat according to the physicians instructions. Shoulder abduction and adduction 1. Keeping the patients arm straight by his side with the palm facing up, bring the arm out straight away from the patients body. Be sure to support the arm at the wrist and elbow for his safety and comfort.

For the patients safety and comfort, be sure to support his wrist and elbow during the ROM exercise.

2. Return the patients arm to his side and bring it across his body (adduction) to adduct the shoulder to a comfortable end range. 3. Return the patients arm to his side. Repeat according to the physicians instructions.

CHAP TER 35

Orthopedics

729

PROCEDURE 35-3contd

External and internal shoulder rotation 1. Bring the patients arm out at a right angle from his body. 2. Bend the elbow at a right angle, keeping the upper arm on the bed, and the hand straight up to ensure rotation of the shoulder. 3. Keeping the patients elbow bent at 90 degrees, gently press down on his shoulder with one hand while holding up his hand with your other hand to stabilize the shoulder and facilitate rotation of the joint. Observe his facial expression to ensure his comfort.

2. Slowly bend the patients hand toward her body, then away to comfortably reach end range of wrist inversion and eversion. Wrist supination and pronation 1. Grasp the patients wrist with one hand and his hand with the other to stabilize the hand and wrist. 2. Slowly turn the patients hand toward his feet, then toward his head to comfortably reach end range of supination and pronation. Finger exion and extension 1. Support the patients wrist with one hand. 2. Cover his ngers with the other hand and curl them over to make a st to comfortably reach full exion. 3. Uncurl the patients ngers and straighten themto comfortably reach full extension. Note the patients reaction and ask him if he is comfortable to identify the extent of comfortable extension and avoid moving the ngers past a comfortable ROM.

Be sure to stabilize the patients shoulder with your hand while rotating the shoulder joint. Observe his facial expression to ensure his comfort.

4. Move the patients hand gently back until it touches the bed next to his head. 5. Bring his hand back down until the palm of his hand touches the bed. Repeat as necessary. Elbow exion and extension 1. With the patients arm by his side and his palm up, ex and extend the elbow to comfortably reach end range of exion and extension. Repeat as necessary. Wrist extension and exion 1. Supporting the patients arm above the wrist, hold the palm of the hand and extend and ex the wrist to comfortably reach end range of wrist exion and extension. Wrist inversion and eversion 1. Grasp the patients wrist with one hand and grasp her hand with the other to stabilize the hand and wrist.

Extend the ngers, noting the patients reaction.

Documentation 1. Document the procedure, noting the patients reaction.

Date 10/18/08; 10:30 a.m. ROM exercises to upper body performed. Movements all within normal limits, patient does not report pain in any movement. ----------------------------------------- J. Morgan, CMA

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Clinical

Fitting a Patient with Crutches

Crutches can be used in pairs or one crutch can be used to assist gait. Most crutches are made of aluminum but some axillary crutches are wooden. There are three basic types of crutches:

Axillary crutches are tted to the patients armpit height. Because upper body strength and balance is needed for axillary crutch use, they are best utilized by stronger patients, children, and patients with minor injuries. (See Figure 35-11.) Forearm, or Lofstrand, crutches are xed with a plastic cuff around the forearm and a handlebar for each hand. The height of the crutch is shorter than the axillary crutch and

provides less stability. The forearm crutch height should accommodate the patients hand and forearm in a slightly bent position, with approximately 10 degrees of elbow exion. Platform crutches are preferred for patients who cannot bear weight in the upper arm or hand. The top of the platform crutch should reach the forearm with the elbow bent at 90 degrees. (See Procedure 35-8: Assisting a patient in ambulating with crutches, page 736.)

Casting
Casts are applied to immobilize a fracture and allow the bone to heal itself. The cast protects the body from reinjury

PROCEDURE 35-4

Performing ROM exercises, lower body

Task Use passive range-of-motion (ROM) exercises to maintain and increase joint mobility in the lower extremities to prevent contracture. Conditions None. Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform passive ROM exercises. Performance Standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. Explain to the patient that you will be gently moving his legs, within pain tolerance and exibility of the limb, to assure him that the ROM exercises will not hurt. Hip abduction and adduction 1. Support the patients knee and ankle to ensure proper movement of the hip. Keep your hand under the patients knee and hold the ankle to support the leg during abduction and adduction. 2. Keep the patients leg straight, while moving the entire leg away from his body to comfortably reach full abduction. 3. Move the patients leg back toward the midline of the body to comfortably reach full adduction. Hip and knee exion and extension 1. Support the patients knee and ankle to ensure proper knee and hip movement.

Keep your hand under the patients knee and hold the ankle to support the leg during abduction and adduction.

CHAP TER 35

Orthopedics

731

PROCEDURE 35-4contd

2. Bend the patients knee and raise it as far toward the patients chest as tolerated with comfort to comfortably reach full hip exion. 3. Lower and straighten the patients leg to comfortably reach full hip extension. Hip rotation 1. Support the patients leg at the knee and ankle to ensure proper hip movement. 2. Roll the patients leg in a circular motion, away from the body to comfortably reach full external rotation. 3. Roll the patients leg in a circular motion, toward the body to comfortably reach full internal rotation. Ankle and dorsiexion and plantar exion 1. Keeping the patients leg at on the bed. Grasp the ankle with one hand and the heel of the foot with the other to stabilize the ankle. 2. While holding the heel with the one hand, ex the patients foot and rest the bottom of the foot against your forearm. 3. Dorsiex the ankle by pushing the foot toward the patients head to comfortably reach full dorsiexion. 4. Keep your hand on the patients ankle and plantar ex the foot by pushing the foot down toward the foot of the bed to comfortably reach full plantar exion. Foot inversion and eversion 1. Grasp the patients ankle with one hand and the arch of his foot with the other. 2. Gently turn the patients foot inward. 3. Return the foot to midline, then gently turn it outward.

Stabilize the patients ankle while performing range-of-motion exercises.

Documentation 1. Document the procedure, noting the patients reaction.

Date 10/18/08; 11:10 a.m. ROM exercises to lower body performed. Patient reports some pain and stiffness upon extension of the left knee. All other movements within normal limits and pain free. ----------------------------------------------------------------- J. Morgan, CMA

PROCEDURE 35-5

Assisting with gait using a gait belt

Task Help the patient ambulate safely using a gait belt. Conditions Gait belt Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist with gait using a gait belt. Performance Standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. Explain to the patient that you will assist him in standing and walking. 3. Lock the brakes on the wheelchair; place the patients feet on the oor, and move the foot plates out of the way. 4. Place the gait belt around the patients waist. The belt should be snug but not tight for comfort and support. Any excess belt should be tucked in the back and out of the way.
Continued

732

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Clinical

PROCEDURE 35-5contd

5. Standing directly in front of the patient, grasp the gait belt from underneath on either side. Give the patient a signal to push up on the arm rests to a standing position so that you and the patient can work together. 6. Steady the patient in the standing position. Check the patient for signs of dizziness, pallor, and trouble balancing. If necessary, take the patients pulse to ensure that he is able to walk and to prevent injury from fainting. 7. If the patient looks steady and wants to walk, move to the patients side, keeping one hand on the gait belt at all times for support. 8. Place one hand on the patients arm for support. Make sure that your hand is on the gait belt with ngers underneath, palm upward, and elbow bent. 9. Starting with the same foot as the patient, keep in step with the patient. Allow the patient to control the pace and ask how he is feeling during walking for his safety.

10. Document the procedure, including the date, time, duration of ambulation, patients response, and instructions given in the patients medical record. Modication: Two-person assist with ambulation 1. Perform the preceding steps 1 thru 5. 2. Have an assistant stand on either side of the patient. Grasp the gait belt from underneath with one hand, and place the other hand on the patients back for support. 3. During ambulation, a person should be on either side of the patient. Both assistants should be slightly behind the patient to stabilize him and catch him if necessary. As in a one-person assist, allow the patient to set the pace.

Two-person assistance with a gait belt.

4. Document the procedure as above.

Date 10/18/08; 12:20 p.m. Proper positioning for holding a gait belt. Patient assisted from wheelchair to walking with use of gait belt. He walked across the room and reported no dizziness. --------------------------------------------- C. Smith, CMA

CHAP TER 35

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733

FIG 35-10 Standard canes and a walk cane.

FIG 35-9 Patient properly t for height to a walker.

and movement that would prevent the fractured bone from healing. Casting material can include plaster of Paris, berglass, or an air cast. Plaster of Paris is the oldest form of casting material and is seldom used. An air cast can be used if some mobility is allowed, because the patient can remove the air cast to bathe. If no mobility is desired, the patient will be tted with a berglass cast, the most common type of cast. The material is durable and easy to care for. (See Proper cast care, page 738.) Bone fractures must be reduced before casting. Reduction of a fracture is placing the fractured bone in a position conducive to healing in the proper position. Reduction of fractures is performed by the orthopedist in the ofce or in the operating room. A closed reduction is a reduction of a fracture that does not involve an incision and can be performed in the ofce by the orthopedist with or without the use

PROCEDURE 35-6

Assisting a patient in ambulating with a walker

Task Teach a patient how to ambulate with a walker independently and safely. Conditions Walker Gait belt Standard In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist a patient in ambulating with a walker. Performance Standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. Explain to the patient that you will assist him to standing and walking with the aid of a walker. 3. Lock the brakes on the wheelchair, place the patients feet on the oor, and move the foot plates out of the way. 4. Place the gait belt around the patients waist. The belt should be snug but not tight. Any excess belt should be tucked in the back and out of the way.
Continued

734

UNIT 3

Clinical

PROCEDURE 35-6contd

5. Check the walker to be sure that rubber tips are secure on all legs. Check the hand rests for damage or sharp edges that could injure the patient. Check the joints of the walker to make sure they are in the locked position. 6. Check the patients shoes to make sure that any ties are secure. Check to see if the shoes have rubber soles and are not slippery. 7. Check the height of the walker. It should be level with the tip of the patients femur, and the patients elbows should be exed at approximately 30 degrees for comfort and support to prevent the patient from falling and decrease the risk of fatigue. 8. Position the patient inside the walker. 9. Have the patient lift the walker and place all four legs of the walker in front of him so that the back legs of the walker are even with his toes to ensure that he does not move too far away from the walker and risk falling. 10. Instruct the patient to lean forward and transfer some of his weight to his arms while stepping with his stronger foot rst. Then follow with a step with the weaker leg.

11. Hold on to the back of the gait belt and check the patient for signs of fatigue. Be ready to catch the patient if he falls. 12. If the walker has rollers, the patient can simply roll the walker in front of him at a comfortable distance and pace. If the walker does not have rollers, instruct the patient to lift the walker slightly and place it in front of him. Allow the patient to nd a comfortable distance to move at each step. 13. Document the date, time, and duration of ambulation, the response of the patient, and instructions given to him. Initial the report.

Date 12/22/08; 1:05 p.m. Patient assisted in use of walker. He was assisted out of his wheelchair and he walked across the room with a walker. He reported feeling dizzy and was returned to his wheelchair. --------------------------- J. Morgan, CMA

PROCEDURE 35-7

Assisting a patient in ambulating with a cane

Task Teach a patient how to ambulate with a cane independently and safely. Conditions Cane Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist a patient in ambulating with a cane. Performance Standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. Explain to the patient that you will assist him in walking with a cane. 3. Check the cane to make sure that the bottom has a rubber tip, the handle is not broken, and no sharp edges are present that could injure the patient. 4. Apply the gait belt snugly (but not too tightly) around the patients waist. Tuck in any excess belt in the back of the belt so that the gait belt does not interfere with your contact and support of the patient. 5. Assist the patient to a standing position. Look for signs of dizziness to prevent the patient from falling. 6. Place the cane in the patients hand on the side of the strong leg. The cane should be adjusted so that the handle is at hip joint level. The cane on the strong side provides extra support to the weak side during gait. 7. During weight-bearing, the patients elbow should be exed at 20 to 30 degrees to promote the patients using the arm for balance. 8. Have the patient move the cane forward 10'' to 18'' ahead of him, depending on his ability and size. 9. Have the patient move his weak leg forward while transferring his weight to the cane. Transferring weight to the cane and not the weak leg will prevent pain to the affected leg and stabilize the gait. 10. Have the patient move his strong leg forward past the cane. Keep your hand on the gait belt and look for signs of fatigue or dizziness to ensure patient safety. 11. Follow along behind the patient on his weak side to be able to catch the patient in case he falls. Allow the patient to set the pace.

CHAP TER 35

Orthopedics

735

PROCEDURE 35-7contd

12. Document the date, time, duration of ambulation, patients response, and instructions given in the patients medical record.

Date 12/30/08; 1:05 p.m. Patient assisted in use of cane. He was helped out of his wheelchair using a gait belt and instructed on using the cane. He was able to take 5 steps but reported pain in the left knee. He was returned to the wheelchair. The left knee was inspected and found to be slightly swollen. An ice pack was applied to the knee. The patient was told to tell Dr. Rodriguez of the knee pain at his office visit tomorrow. --------------------------------- J. Morgan, CMA

Follow along behind the patient and allow him to set the pace.

of local anesthesia as necessary. If the bone fracture is more complicated, such as a compound, comminuted, or impacted fracture, reduction may be performed in asurgical setting. Surgical reduction of a fracture is referred to as open reduction with internal xation. After a reduction is carried out, a cast is generally applied. (See Procedure 35-9: Assisting with berglass cast application, page 739, and Procedure 35-10: Assisting with cast removal, page 739.) An arm sling provides support to an injured shoulder or arm. The sling helps the patient keep the arm in the appropriate position so that healing can occur properly. The arm sling also alerts people around the patient to his injury so they will avoid bumping into his arm. (See Procedure 35-11: Applying a triangular arm sling, page 740.)

Thermotherapy
The quantity of blood within the vessels of the muscle can be manipulated by thermotherapy, the therapeutic application of heat used to treat various muscle injuries. The application of heat to an injury promotes blood flow and comforts the injured patient. Heat should only be applied to an injury 24 hours after trauma to avoid excess swelling. When the time of injury is not certain, ice is applied.

Moist Heat
The application of moist heat to an injury will promote increased blood flow to the affected area and, therefore, promote healing. Most patients find moist heat to be soothing to an injury. To administer moist heat, a

736

UNIT 3

Clinical

hydrocollator is used. A hydrocollator is a thick, cloth sleeve filled with a porous clay that will retain water and heat. It is put in hot water to soak and placed in a terry cloth holder to place on the patient. For home use, patients can buy hydrocollators and covers at many pharmacies. (See Figure 35-12.) When placing the hydrocollator on a patient, observe the following safety precautions:

Place the unit on the patient. The patient should never lie on top of a heating unit because the weight of the patient will cause too much contact with the heat and could result in burns to the patient. After placing the unit on a patient, stay in the room for a few minutes. Ask the patient if the heat is too hot. Use extra towels wrapped around the hydrocollator cover when putting heat on an elderly patient. Decreased circulation in the elderly may cause them to fail to feel a burn forming.

Application of Warm, Moist Compresses

A warm, moist compress is applied by soaking and wringing gauze or a washcloth in warm water. Because warm (not hot) water is used, the compress can be placed directly on the skin. Patients can easily use warm compresses at home. Instruct patients to use warm compresses, not hot, to avoid burns.
FIG 35-11 Axillary, forearm, and platform crutches.

PROCEDURE 35-8

Assisting a patient in ambulating with crutches

Task Teach a patient how to ambulate with crutches independently and safely. Conditions Crutches Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist a patient in ambulating with crutches. Performance Standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. Explain to the patient that you will assist him in crutch walking. 3. Assemble and t the axillary crutches to the patient. Be sure that the joints of the crutches are secure; the rubber tips are on the ends, axillary pads, and hand rests; and the hand rests are in good shape (for example, no tears, missing pieces, or cracks in the wood). 4. Apply the gait belt and assist the patient to stand; place the crutches under his armpits. 5. Instruct the patient to carry his weight completely on his hands and not on his armpits to prevent injury to the shoulder joints. 6. Have the patient put all of his weight on the strong leg and bend his weak leg slightly so it will not drag on the oor to prevent stubbing his toe on the injured foot or scraping the cast or boot. 7. Assist the patient with the appropriate gait pattern. 8. Document the date, time, duration of ambulation, and instructions given in the patients medical record.

Date 10/20/08; 12:05 p.m. Crutches were fitted to the patient and he was instructed on their use. He was able to walk across the room with crutches. He was able to maintain balance and reports no pain. -------------------------------------------------- J. Morgan, CMA

CHAP TER 35

Orthopedics

737

PROCEDURE 35-8contd

Non-weight-bearing to injured leg (2 crutches) 1. Instruct the patient to transfer all his weight to his hands and step with the strong leg. 2. Tell him to bring the crutches forward and then swing his injured leg through without putting any weight on the injured leg to prevent transferring weight to the injured leg. Have him repeat these steps.
Non-weight-bearing, 2 crutches
1 Stand with feet together. 2 Bring strong leg forward.

Weight-bearing, 2 crutches
1 Stand with feet together. 2 Bring strong leg forward.

Crutch

Crutch

Left foot

Right foot (injured)

Crutch

Crutch

3 Bring crutches and weak leg forward, 4 Bring strong applying limited leg forward. pressure to weak leg.

Left foot

Right foot (injured)

F.P.O

3 Bring crutches forward and bring injured leg forward without 4 Bring strong bearing weight on it. leg forward. Weight-bearing, two crutches. (1) Stand with feet together. (2) Bring the strong leg forward. (3) Bring crutches and the weak leg forward, applying limited pressure to the weak leg. (4) Bring the strong leg forward.

Non-weight-bearing, two crutches. (1) Stand with feet together. (2) Bring the strong leg forward. (3) Bring crutches forward and swing the weak leg through. (4) Bring the strong leg forward.

Weight-bearing to injured leg with support of crutches (2 crutches) 1. Tell the patient to transfer all his weight to his hands and step with his strong leg. Instruct him to use the crutches and step with his injured leg at the same time. Explain that the patient can put some weight on his injured leg, but only when he transfers some of the weight to his hands for support and balance. Ask him to repeat the steps.

Weight-bearing to injured leg with support of one crutch 1. Explain to the patient that one crutch can be used on his strong side to assist his weak side. 2. Instruct the patient to step with his strong leg and then move the weak leg and the crutch forward at the same time for support to the injured leg. 3. Tell the patient to gauge the amount of weight to put on his weak leg according to his comfort level to prevent straining the injured leg and causing reinjury.

738

UNIT 3

Clinical

PROCEDURE 35-8contd Weight-bearing, 1 crutch

1 Stand with feet together. 2 Bring strong leg forward.

Crutch

Left foot

Right foot (injured)

3 Bring weak leg and crutch forward.

4 Bring strong leg forward.

Weight-bearing, one crutch. (1) Stand with feet together. (2) Bring the strong leg forward. (3) Bring the weak leg and crutch forward at the same time. (4) Bring the strong leg forward.

Patient Education

Proper Cast Care

After assisting with cast application, be sure to explain proper cast care to the patient, including: Showing the patient how to cover the cast while bathing. Keeping the cast dry and exposed to air as much as possible. A wet cast can remodel and cause tissue damage to the affected body part. Elevating the casted extremity as much as possible. This will help reduce swelling and pain. Observing ngers or toes for changes in color, temperature, or decreased sensation. This could indicate that the cast is too tight. The patient should call the ofce immediately. Calling the ofce if any bad odor, loss of sensation, numbness, tingling, bleeding about the cast is noted. Not sticking anything down the cast to itch the skin this could cause infection. Cleaning the cast with a damp cloth; decorating the cast with magic markers or paints, but not cutting or puncturing the cast for any reason.
FIG 35-12 Hydrocollator and cover.

Dry Heat
Application of dry heat affects supercial tissues, not deep tissues. It is used to improve circulation, relieve swelling, promote wound healing, and relax muscle spasm. Dry heat is most commonly applied using an electric heating pad. As with a hydrocollator, the heating pad should never be placed directly on the skin. Heating pads should be used for 15 to 20 minutes at a time, because prolonged heating could cause

CHAP TER 35

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739

PROCEDURE 35-9

Assisting with berglass cast application

Task Assist the physician in applying a berglass cast. Conditions Fiberglass casting material Basin of warm water Stockinette Webril padding rolls Bandage scissors Rubber gloves Sponge rubber (for padding) Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist with a berglass cast application. Performance Standards 1. Wash your hands. 2. Explain the procedure to the patient. Tell him that the fiberglass cast will feel wet and cool as it is applied and that it dries and hardens quickly. Explain that it will be completely hardened and protect the body part within 30 minutes so that he understands not to move the body part during the procedure. Answer any questions about the procedure or the 3. patients injury to promote patient understanding and cooperation. Prepare the stockinette by cutting to a length appropriate for the cast. Assist the physician in placing the stockinette directly on the skin under the cast to prevent the cast material from adhering to body hair or causing skin irritation. Assist the physician in wrapping the cast padding (Webril) around the stockinette to protect the patients skin when the cast is removed and to cushion bony areas under the cast. Assist the physician as required. Minimize patient discomfort by supporting the affected area. Provide cast care instructions to the patient and answer any questions he may have. Document the procedure in the patients chart.

4.

5. 6. 7. 8.

Date 11/10/08; 2:15 p.m. F iberglass cast applied to right forearm and wrist. Patient given instructions on cast care and told to report any discoloration of fingers or numbness to any part of the arm or hand. --------------------------------------------- J. Morgan, CMA

PROCEDURE 35-10

Assisting with cast removal

Task Assist the physician in the removal of a cast. Conditions Cast cutter Cast spreader Bandage scissors Bag or container for disposing of cast materials Basin, soap, and water Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist with cast removal. Performance Standards 1. Wash your hands. 2. Explain the procedure to the patient. Tell him that the cutter vibrates but does not spin. Explain to the patient that he may feel some pressure and warmth but his skin will not be cut by the cast cutter to allay the fears of the patient so that he will not move or jump during the procedure. Tell the patient that when he sees the limb without the cast, it will appear small and the color may be gray so that the patient is not afraid of the appearance of the limb. Reassure the patient that color and muscle tone will improve with therapy and exercise. After the procedure, give the patient written instructions and answer any questions. Gently wash the extremity with soap and water and apply skin lotion to remove any debris and prevent skin dryness. Clean the equipment to prevent contamination to the next patient. Wash your hands.
Continued

3.

4. 5.

6. 7.

740

UNIT 3

Clinical

PROCEDURE 35-10contd

8. Document the cast removal and the appearance of the body part. Record that written instructions were given to the patient.

Date 12/19/08; 3:25 p.m. Cast removed from patients right forearm and hand. Skin is intact. Skin was washed with soap and water and lotion applied. Patient is able to move the wrist slightly. He was instructed to begin physical therapy tomorrow and not to grip or lift with the right hand until evaluation tomorrow with the therapist. ------------------------------J. Morgan, CMA

PROCEDURE 35-11

Applying a triangular arm sling

Task Apply a triangular arm sling. Conditions Sling Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully assist with triangular arm sling application. Performance Standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. 3. Place the patients elbow in a 90-degree position against her chest. The patient can hold her injured arm with her opposite hand to avoid holding up the injured arm, which would cause pain. 4. Place one point of the triangle at the patients good shoulder and one point towards the affected elbow. 5. Slide the sling under the injured arm. Ask the patient to steady the injured arm with her other hand. Look for signs of pain and discomfort to ensure that the sling is comfortable. 6. Pull the bottom of the triangle up and around the injured arm next to the neck. 7. Tie the ends of the sling at the side of the neck because tying a knot at the back of the neck causes pain and interferes with mobility. 8. Make sure that the patient holds her injured arm at approximately 90 degrees so the arm is supported and blood ow is not compromised. 9. Use a safety pin to secure the elbow end of the sling. 10. Wash your hands and document the procedure.
Date 10/14/08; 10:30 a.m. Sling applied to left arm; patient instructed to remove the sling for bathing. ----------------------------------J. Morgan, CMA

burns. Place a towel, cloth, or blanket between the patient and the heating pad. Heating pads can also be purchased at most pharmacies.

Cryotherapy
Cryotherapy, the application of ice to an injury, is commonly used to reduce swelling and decrease pain. Ice is applied to injuries in the first 24 to 48 hours. Ice constricts blood vessels to decrease swelling, reduces bleeding, and numbs pain sensation by acting as a topical anesthetic. Ice can safely be applied for up to 20 minutes; if ice is left on

the skin too long, it could damage tissues. Chemical ice is commonly used in physician offices as well as at sporting events, in school nurses offices, and in other settings. The medical assistant can activate the bag of chemical ice by popping an internal bag that mixes two liquids within the bag. When these two chemicals mix, they cause an endothermic reaction, and the bag gets cold. The medical assistant should apply the ice directly to the skin or wrapped in a towel for comfort. Gel packs are also used to apply cold to the body. Gel packs are stored in a freezer and retain cold for approximately 30 to 45 minutes after

CHAP TER 35

Orthopedics

741

application. A gel pack should not contact the skin directly because it could adhere to the skin and cause discomfort. (See Figure 35-13.)

Ultrasound
Ultrasound can be used to administer heat to an injured body area. With ultrasound, high-frequency sound waves enter the musculature, creating friction in the tissues. This friction produces heat. The ultrasound can heat tissues more deeply than applying heat to the skins surface. (See Procedure 35-12: Administering ultrasound.)

Transcutaneous Electrical Nerve Stimulation

Pain management for chronic conditions can be aided by the use of a transcutaneous electric nerve stimulation (TENS) unit. The unit delivers an electrical current to the painful area and disrupts the pain signal from the body to the brain. The units are portable and inexpensive and can be self-administered after proper instruction. The medical assistant can provide instruction in the use and care of the unit. (See Procedure 35-13: Teaching a patient to use a TENS unit, page 742.)
FIG 35-13 Typical cold packs.

PROCEDURE 35-12

Administering ultrasound
Task To administer ultrasound to a body area of a patient. Conditions Ultrasound Aqueous-based gel Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully administer an ultrasound. Performance Standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. 3. Explain the procedure to the patient. 4. Ask the patient if she has any metal inside her body, such as surgical pins or screws. Ultrasound cannot be performed over metal because it will heat the metal inside the patients body, resulting in severe injury to the patients tissues. 5. Apply gel to the skin of the affected area. The gel should be kept at room temperature. 6. Touch the wand of the ultrasound to the gel on the skin. Move the wand around to the entire area to be examined to ensure that the entire area is treated. 7. Turn the timer on the machine to the appropriate time. Slowly turn up the intensity of the ultrasound from zero and ask the patient when she feels warmth or tingling to ensure that the patient is comfortable with the prescribed wattage. Turn the machine up to the prescribed wattage. 8. While turning up the machine, always keep the wand moving. Stopping the wand can cause burning inside the tissues. 9. When the time expires, remove the wand and clean it with a dry cloth or towel. Clean the patients skin with a separate dry cloth or towel. 10. Wash your hands and document the procedure.
Date 11/12/08; 10:30 a.m. Ultrasound applied for 10 minutes to lumbar paraspinals. Patient reports warming sensation. -------J. Morgan, CMA

742

UNIT 3

Clinical

PROCEDURE 35-13

Teaching a patient to use a TENS unit

Task Apply a transcutaneous electrical nerve stimulation (TENS) unit to a patient and teach him how to apply and regulate the TENS unit for home use. Conditions TENS unit Disposable sticky pads Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully teach a patient to use a TENS unit. Performance Standards 1. Wash your hands. 2. Introduce yourself and address the patient by name. 3. Wash the patients skin with alcohol to remove any lotion that may cause the pads to fail to adhere to the skin. 4. Make sure that the sticky pads are in good condition and that wires are safe (without exposed, frayed ends). Frayed ends may shock the patient, causing discomfort. 5. Apply the sticky pads to the patients skin on designated body areas, as directed by the physician, to ensure that the proper body area is stimulated. 6. Make sure that the wires that connect to the TENS unit are secure. Turn on the TENS unit slowly to avoid startling the patient with the sensation. 7. Ask the patient when he rst feels stimulation. Turn the machine up to a comfortable tolerance to promote stimulation without discomfort. 8. Explain to the patient that tolerance will increase and that he can turn the unit up or down as needed to promote therapeutic value along with comfort.

Explain to the patient that he can control the unit as needed.

9. Show the patient that he can wear the unit on his belt or clip it to his pocket and he can turn it on or off at any time. 10. Answer any questions, wash your hands, and document the procedure.
Date 10/18/08; 9:30 a.m. Apply the pads to the patients skin as directed by the physician. Applied TENS unit to lower thoracic and lumbar paraspinals. Patient instructed on use of TENS device. He was also advised to call the office if lower back pain increases. ------------------------------------------------------------- C. Smith, CMA

CHAP TER 35

Orthopedics

743

Chapter Summary

2. Practice gait training with the gait belt. Create a course through which fellow students must guide the patient using the gait belt. Make the course simulate the hazards that a patient may face.

The musculoskeletal system functions to provide movement and framework to the body. Musculoskeletal injuries are treated with therapy that restores physical function and educates patients to prevent reinjury. Modalities to treat musculoskeletal injuries range from application of ice packs to surgical correction. Because injury severity can vary greatly, rehabilitation can be very short for minor injuries or lengthy in the case of severe injuries that require surgery, immobilization, and casting. The medical assistants role in rehabilitation of musculoskeletal injuries is to help patients ambulate; provide care for wounds, sprains, and strains; and teach strategies for independent function. Using such modalities as ultrasound, TENS, and rangeof-motion exercises, the medical assistant can promote healing and pain control. The medical assistant is responsible for maintaining assistive devices, such as wheelchairs, crutches, canes, and walkers.

Case Studies
1. Mike Jones, a patient well known to the ofce, comes in appearing to be in a great deal of pain. His gait is very guarded and he doesnt put any weight on his right foot. He is unable to sit and prefers to stand leaning on the reception desk. What assistance should you offer to Mike? What assistance might he need during the physician examination? What questions should you ask Mike before the physician comes into the examination room? Why? 2. Hannah Morales is a 7-year-old with a broken forearm. She came to the ofce last week and was casted for the injury. Mrs. Morales calls the ofce and tells you that Hannah will not use her hand. She says that making a st or moving the hand causes shooting pain in the hand and up the arm. She notices that the hand is slightly discolored. What should you do?

Resources

Team Work Exercises

1. Split into groups of three to four students. Role-play various patient transfers with classmates, asking a classmate to play the part of a paraplegic patient. Use rooms on your campus, such as the cafeteria, classroom, and restroom. Discuss with the group the challenges that you encountered.

About Orthopedics: orthopedics.about.com HealthWeb Orthopedic Associations: www.healthweb.org/ orthopedics Musculoskeletal injuries: healthweb.org/browse.cfm? categoryid=2955 Rotator cuff tear: orthopedics.about.com/cs/rotatorcuff/a/ rotatorcuff_3.htm

CHAPTER

Ophthalmology and Otolaryngology

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary identify key structures of the eyes, ears, mouth, nose, and throat and their function describe some common pathologies of the eyes, ears, mouth, nose, and throat describe the physical examination techniques used to examine the eyes, ears, mouth, nose, and throat describe the role of the medical assistant in examination and treatment of disorders of the eyes, ears, mouth, nose, and throat. Instruction
Instruct patient with special needs Teach patients methods of health promotion and disease prevention

36
Conjunctivitis (pinkeye) Diabetic retinopathy Hypertensive retinopathy Exophthalmos Myopia Hyperopia Presbyopia Photophobia Cataracts Glaucoma Macular degeneration Ears Mnire disease Otitis externa Otitis media Labyrinthitis Tinnitus Vertigo Mouth Oral herpes Oral thrush Cleft lip Cleft palate Nose and Throat Rhinitis Tonsillitis

Procedures
Measuring distance and visual acuity using the Snellen chart Measuring near visual acuity Measuring visual acuity using the Ishihara color vision test Irrigating the eye Instilling eyedrops Testing hearing using an audiometer Irrigating the ear Instilling eardrops

Chapter Outline
Structures and Functions of the Eyes, Ears, Mouth, Nose, and Throat
Structures of the Eyes, Ears, Mouth, Nose, and Throat Eyes Ears Mouth Nose and throat Functions of the Eyes, Ears, Mouth, Nose, and Throat Eyes Ears Mouth Nose and throat

CAAHEP Competencies
Clinical Competencies Patient Care
Prepare patient for and assist with routine and specialty exams Apply pharmacological principles to prepare and administer parenteral medications

Ophthalmology and Otolaryngology Procedures

Assisting with Ophthalmic Examination Assisting with Ophthalmic Irrigation and Instillation Assisting with Otic Examination Tuning fork test Audiometric testing Assisting with Otic Irrigation and Instillation Assisting with Examination of the Mouth, Nose, and Throat

General Competencies Patient Instruction

Instruct individuals according to their needs

ABHES Competencies
Clinical Duties
Prepare patients for procedures Apply principles of aseptic technique and infection control Prepare and maintain examination and treatment area Prepare patient for and assist physician with routine and specialty examinations

Medical Terminology Related to the Eyes, Ears, Mouth, Nose, and Throat Common Diseases and Disorders of the Eyes, Ears, Mouth, Nose, and Throat
Eyes Astigmatism Blepharitis

Chapter Summary Team Work Exercises Case Studies Resources

745

Key Terms
accommodation

Ability of the eye to see objects in the distance and then adjust to a close object
astigmatism

Structures and Functions of the Eyes, Ears, Mouth, Nose, and Throat
The eyes, ears, mouth, nose, and throat are the structures that provide the special senses. These special senses include vision, hearing, balance, taste, and smell.

Abnormality of the eye in which the refraction of a ray of light is spread over a diffuse area rather than sharply focused on the retina
audiometer

Instrument used to measure hearing

cataract

Opacity (clouding) of the lens of the eye

cerumen

Structures of the Eyes, Ears, Mouth, Nose, and Throat

The eyes, ears, mouth, nose, and throat are made up of several structures, including the sclera, cornea, and retina of the eye; the auricle, tympanic membrane, and cochlea of the ear; the teeth, gums, tongue, and papillae of the mouth; the nares and olfactory neurons of the nose; and the nasopharynx, oropharynx, and laryngopharynx of the throat.

Yellow or brown waxy substance produced in the ceruminous glands of the ear
color deciency

Genetic or acquired abnormality in color perception

conjunctivitis

Inammation of the conjunctiva caused by bacteria or virus

corneal abrasion

Injury to the translucent anterior structure of the eye

equilibrium

Eyes
The eye is a globe-shaped organ that consists of three layers, or tunics:

State of balance, which is controlled by structures of the inner ear

glaucoma

Disorder that involves increased intraocular pressure, resulting in atrophy of the optic nerve and, possibly, blindness
gustation

sclera, the outer portion middle choroid, the middle portion retina, the inner portion. (See Figure 36-1.)

Sense of taste
hyperopia

Sclera and Cornea

The outermost layer of the eye includes the sclera and cornea. The sclera is opaque and has a distinctive white color. At the front of the eye, the sclera bulges forward to become the cornea, which is transparent. A thin mucous membrane called the conjunctiva covers the outer surface of the eye and lines the eyelids.

Error of refraction in which affected individuals can see distant objects clearly but cannot see near objects; also called farsightedness
Mnire disease

Syndrome characterized by recurring episodes of hearing loss, tinnitus, and vertigo that can progressively lead to deafness
myopia

Choroid
The middle layer of the eyeball is the choroid. The choroid is a dark blue vascular layer between the sclera and retina. The optic nerve, also called the second cranial nerve, is attached to the retina at one end and the diencephalon of the brain at the other. An opening in the choroid allows the optic nerve to enter the inside of the eyeball. Other structures in the choroid include the iris, ciliary body, lens, and suspensory ligaments. The iris is a colored structure that surrounds the pupil, which is a hole in the iris. The ciliary body is a circular muscle that lies posterior to the iris. The ciliary body is attached to a capsular bag that contains the lens (a clear, hard, transparent disk) and suspensory ligaments.

Error of refraction in which light rays are focused in front of the retina, enabling the person to see distinctly for only a short distance; also called nearsightedness
olfaction

Sense of smell
ophthalmoscope

Handheld instrument used to view the internal structures of the eye, including the retina, optic nerve, and blood vessels
otitis

Inammation of the ear

otoscope

Handheld instrument used to visualize the internal structures of the ear, ear canal, and ear drum
presbyopia

Permanent loss of accommodation of the crystalline lens that occurs in people over age 40
sinusitis

Retina
The innermost layer of the eye is the retina. (See Figure 36-2.) The retina is further divided into two layers. The thin outer layer is red due to blood ow from its main central artery. This outer layer lies next to the choroid. The thicker inner

Inammation of the sinuses, which can be caused by a virus, bacteria, or an allergy

tinnitus

Ringing in the ears

visual acuity

Ability to see at different distances

CHAP TER 36

Ophthalmology and Otolaryngology

747

Conjunctiva

Suspensory ligaments Retina Choroid Sclera

Zonules Anterior chamber

Cornea

Pupil Lens

Optic disc Iris Conjunctiva FIG 36-1 Structures of the eye. Ciliary body Suspensory ligaments

Optic nerve

layer is the visual portion and contains two types of visual receptors, called rods and cones. Rods and cones are elongated nerve cells that are lined up along the posterior portion of the retina. (See Figure 36-3.) They contain photopigments that undergo chemical changes when light strikes them.

membrane and tympanic cavity; and the innermost section, called the inner ear or labyrinth. (See Figure 36-4.)

External Ear
The external ear consists of the auricle, or pinna. It is made up of cartilage covered with skin and sits visibly outside of the head. The auricle cannot be moved by voluntary or involuntary muscles to focus sound from a given direction, and the shape of the auricle does not contribute to hearing. The auricle is connected to the external auditory canal, which is a slender tube that leads to the middle ear. The canal is lined with modied sweat glands called ceruminous glands.

Other structures
The eye contains two uids, or humors. Aqueous humor is found in the posterior and anterior chambers. Aqueous humor drains through a small opening called the Canal of Schlemm. The posterior chamber contains aqueous humor and vitreous humor. Vitreous humor is a jellylike substance that lls the posterior chamber. Lacrimal glands are located on the medial side of the eye and open through the lacrimal duct at the inner corner of the eye next to the nose. The lacrimal gland is connected to the nose through the nasolacrimal duct and drains into the nasal cavity.

Middle Ear
At the inner end of the external auditory canal is the tympanic membrane, which is a at, membranous structure. The tympanic membrane is connected to the rst of three tiny ossicles (bones) of the middle ear. These bones are, in order, the malleus (hammer), incus (anvil), and stapes (stirrups). These tiny articulating bones are located in the tympanic cavity.

Ears
The ear consists of three major sections: the outer, or external, ear; the middle ear, which consists of the tympanic

748

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Clinical

Pigment cells Choroid Sclera

Rod

Cone

Light waves

Pigmented cells

FIG 36-3 Rods and cones.

downward canal called the eustachian tube. The eustachian tube connects the middle ear to the pharynx.
Cone Rod Ganglion cell

Mouth
The mouth, or oral cavity, contains the teeth, gums, and the tongue. (See Figure 36-5.) The tongue is a muscular organ that lies partly in the oor of the mouth and partly in the pharynx. The surface of the tongue contains papillae, which contain the taste buds on their surface.

Outer layer

Inner layer

FIG 36-2 Microscopic structures of the retina.

Nose and Throat

Inner Ear
The rst structure of the inner ear is the cochlea, a snailshaped structure lled with a uid called perilymph. The inner surface of the cochlea is lined with a highly sensitive hearing structure called the organ of Corti. The organ of Corti contains nerve endings called hair cells, which are long, hairlike projections. The hair cells transmit impulses to the auditory nerve, located behind the ossicles. The last of the three ossicles, the stapes, ts into an opening on the cochlea called the oval window. The round window is an opening in the lower part of the temporal bone and is covered with a thin membrane. The semicircular canals, located behind the ossicles and two windows, contains perilymph and endolymph, a pale, transparent uid. Together with the cochlea, these structures make up the vestibular system. The tympanic cavity has a connecting

The nose is a triangular structure made up of bone and cartilage. (See Figure 36-6.) It is covered with skin and lined with a mucous membrane. It contains two openings, called nares (nostrils), which are separated by a cartilage portion called the nasal septum. The nasal cavity is two cavities, right and left, separated by the septum. Behind and above the nasal cavity are the sinuses, which are hollow, mucus-lined cavities. The sinuses are grouped by their location into the frontal sinuses (above the eyebrows in the frontal bone of the skull), maxillary sinuses (which are the largest sinuses and are located on either side of the nose), sphenoid sinuses (located in the sphenoid bone), and ethmoid sinuses (located between the nose and eyes in the ethmoid bone). Olfactory neurons are located among the epithelial cells of the nasal cavity. The receptors are located higher in the nasal cavity than air is normally inhaled.

CHAP TER 36

Ophthalmology and Otolaryngology

749

Incus Auricle Malleus Stapes

Semicircular canals Labyrinth Cochlear and vestibular branch

External auditory canal

Cochlea containing organ of Corti Tympanic membrane Eustachian tube

Round window

Oval window

FIG 36-4 Structures of the ear.

Soft palate Oropharynx

Uvula

Palatine tonsil Molar

called pharyngeal tonsils, which are lymphatic tissues. The nasopharynx continues inferiorly and becomes the oropharynx, which is softer than nasopharynx. It begins at the level of the soft palate and ends at the epiglottis. Located on either side of the oropharynx are the palatine tonsils, a collection of lymphatic tissue. Inferior to the oropharynx is the laryngopharynx, the lowest portion of the pharynx. It begins at the base of the tongue and is also made up of soft tissue. The inferior end of the laryngopharynx is connected to the larynx. The larynx further divides into the esophagus, which leads to the stomach, and trachea, which leads to the lungs.

Tongue Incisor

Functions of the Eyes, Ears, Mouth, Nose, and Throat

The eyes, ears, mouth, nose, and throat serve several important functions in the body, including providing the special senses of vision, hearing, taste, and smell as well as balance and protection against injury.

Gingiva FIG 36-5 Structures of the mouth.

Eyes
The nasal cavity is connected to a muscular tube called the pharynx, or throat, which is divided into three sections: the nasopharynx, oropharynx, and laryngopharynx. The nasopharynx, the rst portion of the pharynx, is a rigid muscular tube that is open to the eustachian tube on either side. The top and sides of the nasopharynx also contain the adenoids, also The eyes are the sensory organ responsible for sight. Each of the layers of the eye functions to protect the eye, provide vision, or communicate that vision to the brain.

Sclera and Cornea

On the outer layer of the eye, the sclera, or white of the eye, provides the strength, structure, and shape of the eye.

750

UNIT 3

Clinical

Sphenoid sinus

Frontal sinus

Superior nasal concha Middle nasal concha Nasopharynx Soft palate Palantine tonsil Oropharynx Laryngopharynx Inferior nasal concha Hard palate

Tongue

Esophagus

Epiglottis

Trachea

FIG 36-6 Structures of the nose and throat.

The transparency of the cornea allows light into the eye. The conjunctiva protects the cornea from dust and debris. Blinking, which normally occurs 12 to 20 times per minute, helps to protect the cornea against microscopic injury.

objects is called accommodation. The suspensory ligaments function to attach the ciliary body to the lens and keep the lens in place.

Retina
The innermost tunic of the eye, the retina, is responsible for the reception of visual impulses through the lens and transmission of these impulses to the brain. The retina has two layers with individual functions. The thin, outer layer contains pigment that protects the choroid and sclera from light at the back of the eye. The thick, inner layer of the retina contains rods and cones. Rods detect the presence of light. They function in dim light and produce images that are black and white only. Cones function in bright light and detect color. A deciency of cones results in color deciency, a genetic or acquired inability to distinguish colors. (See Color deciency.) As light waves from the anterior portion of the eye hit the retina, they stimulate the rods and cones. The visual information from the rods and cones is

Choroid
In the middle layer of the eyeball, the vascular choroid supplies blood to the entire eye. The colored iris surrounding the pupil expands and contracts to modify the quantity of light entering the pupil. When light is low, the pupil dilates (or the iris expands), appearing bigger to allow more light into the eye. If a bright light is then turned on, the iris expands causing the pupil to constrict, limiting the light entering the eye. The ciliary body produces aqueous humor and changes the shape of the lens to accommodate near and far sight. For near vision, the ciliary muscles contract, causing increased rounding of the lens; for far vision, the ciliary muscles expand, causing attening of the lens. This process of adjusting the thickness of the lens to see near and far

CHAP TER 36

Ophthalmology and Otolaryngology

751

directed to the optic nerve bers located on the inner surface of the thick inner layer of the retina. The optic nerve bers transmit visual information via ganglion neurons, which converge at the optic disc. The optic disc contains no rods or cones and is commonly called the blind spot. The optic nerve gathers visual stimuli from the ganglion neurons and then transmits the visual information to the brain for interpretation.

canal. Ceruminous glands that line the canal secrete cerumen, a yellow or brown waxy substance that traps tiny foreign particles and prevents them from entering the deeper structures.

Middle Ear
In the middle ear, the tympanic membrane vibrates when sound waves hit it. Vibration of the tympanic membrane causes movement of the ossicles. Sound, in the form of vibration, is transmitted from the tympanic membrane to the malleus, then incus, then stapes and then to the cochlea of the inner ear.

Other Structures
Aqueous humor in the anterior chamber provides nourishment for the lens and cornea. Vitreous humor in the posterior cavity gives shape to the eye. The aqueous humor, vitreous humor, and lens are all refractory structures; they bend light rays to focus them sharply onto the retina. Lacrimal glands keep the eye moist by producing tears that bathe and lubricate the eye. The anterior mucous membrane, the conjunctiva, produces a clear, watery mucus that allows the eyelid to slide over the eye without scraping when a person blinks. Corneal abrasion, a scrape to the anterior surface of the eye, can occur if the conjunctiva did not produce adequate amounts of mucus or if an object, such as a hairbrush, came in contact with the cornea.

Inner Ear
The cochlea receives vibration from the stapes through the oval window. Vibration from the stapes causes a disturbance of the perilymph, which disturbs the hair cells on the organ of Corti. The hair cells transmit impulses to the auditory nerve, where they are interpreted as sound. Because the eustachian tube connects the middle ear to the pharynx, it equalizes pressure on the outer and inner surfaces of the tympanic membrane. It allows air pressure in the middle ear to equalize with air pressure in the mouth and, therefore, outside of the body. (See Under pressure.) The inner ear also functions to provide equilibrium, which is the sense of balance. Static equilibrium is feeling a sense of balance when at rest; dynamic equilibrium refers to the sense of balance when in motion. The vestibular system controls both forms of equilibrium. Endolymph, the pale, transparent uid within the membranous labyrinth, responds to changes in body position based on gravity. The vestibulocochlear nerve transmits this information to the brain and the brain interprets the bodys position in space.

Ears
The structures in the three major sections of the ear function together to protect internal structures and provide hearing.

External Ear
The auricle of the external ear collects sound waves traveling through the air and channels them into the external auditory

Color deciency
Color deciency, formerly called color blindness, is the inability to distinguish colors. This disorder is a genetic or acquired abnormality. Complete color deciency, also called achromatopsia, is rare. Patients with achromatopsia may have no cones or malformed cones in the retina. The most common deciency, called Daltonism after chemist John Dalton, is the inability to distinguish red from green. Daltonism is caused by a recessive sex-linked genetic trait. Mothers pass the deciency on to daughters and sons; however, only sons will have the deciency. Approximately 8% of males have some degree of Daltonism. A patient may also acquire color deciency as a result of damage to the retina, optic nerve, or higher brain areas. This type of acquired color deciency can affect the perception of one or more colors. Deciencies in the ability to distinguish one color are: protanopiathe inability to see red deuteranopiathe inability to see green tritanopiathe inability to see blue.

Mouth
The mouth contains the teeth, gums, and tongue. The teeth are used for chewing food, or mastication. The anterior teeth, the incisors, tear food, and the posterior teeth, the molars, grind food. The gums anchor the teeth in place. Gustation,

Under pressure
When pressure changes suddenly, such as in an airplane, pressure can be equalized by deliberate swallowing. Many people chew gum because it causes jaw movement and simulates swallowing. The medical assistant can advise patients who are planning to travel by airplane to bring chewing gum, especially for children, because the anatomy of the head and eustachian tubes can cause pain when external pressure changes. Babies can be bottle or breastfed on an airplane to equalize pressure and prevent pain in the ears.

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Clinical

the sense of taste, is a function of the tongue. The tongue contains papillae, or taste buds, which detect the avors of sweet, salty, sour, and bitter. The muscular nature of the tongue also aids in swallowing food after chewing. (For more information on the digestive processes associated with the teeth, gums, and tongue, see Chapter 30, Gastroenterology, page 537.)

will grow in size if the throat is infected. The lower sections of the pharynx, the oropharynx and the laryngopharynx, are muscular and push food down into the esophagus when a food bolus is pushed backward by the tongue during swallowing. The palatine tonsils protect the opening to the respiratory tract from microscopic organisms that may cause infection.

Nose and Throat

Hairs just inside of the nostrils of the nose block the entrance of dust and small insects into the nasal cavity. The nasal cavity lters, moistens, and warms inspired air to prepare the air for entrance to the lungs. Olfactory neurons function as receptors for the sense of smell, or olfaction. Because the receptors are located higher in the nasal passage than air is normally inhaled, weak scents must be inhaled deeply for identication. The sinuses, located behind and around the nose, drain secretions from the nasal cavity and equalize pressure inside the head to match the surrounding air pressure. Sinusitis, inamed and infected sinuses, can occur from allergies, u viruses, or the common cold. After air is inspired, ltered, moistened, and warmed, it enters the pharynx. The pharynx serves as a passageway for air, food, and liquids. The adenoids in the nasopharynx produce white blood cells to ght infection in the throat and

Medical Terminology Related to the Eyes, Ears, Mouth, Nose, and Throat
Disorders of the eyes, ears, mouth, nose, and throat are among the most common problems that lead people to seek medical care. Whether they work in family practice ofces, in pediatrics, in urgent care centers, in ophthalmology ofces, with audiologists, or in plastic surgery centers, medical assistants play an important role in the provision of health care to these patients. To be effective in their role, medical assistants must become well versed in the language and vocabulary that pertain to the eyes, ears, nose, and throat. The following tables list common medical terminology related to the eyes, ears, nose, and throat.

Table 36.1 |

Word Elements

This table contains combining forms, prexes, and sufxes related to the eyes, ears, mouth, nose, and throat, along with examples of terms that use the word element, a pronunciation guide, and a denition for each. Word Element
Combining Forms acous/o audi/o blephar/o corne/o dipl/o irid/o hearing hearing eyelid cornea double iris acoustic (a-KOOS-tk) audiometry (aw-de-OM- e) e-tr blepharitis (blef- I-ts) a-R corneous (KOR-ne- us) a) diplopia (dp-LO-pe- iridesis (-RID- s) e-s Pertaining to hearing Measurement of hearing Infection and inammation of the eyelid Pertaining to the cornea Two images of an object seen at the same time Surgical repositioning of the pupil by bringing a portion of the iris through an incision in the cornea kerat/o cornea (or hard substance) myring/o nas/o ocul/o tympanic membrane nose eye myringoplasty (mr-IN-g as-te) o-pl nasopharyngeal (n o-far-IN-j al) a-z e- oculomycosis (ok- o-m-KO-ss) u-l Surgical repair of the tympanic membrane Pertaining to the nose and pharynx Any disease of the eye caused by fungus keratocele (ker-AT-o-sel) Herniation of the cornea

Meaning

Example

Meaning

CHAP TER 36

Ophthalmology and Otolaryngology

753

Table 36.1 |

Word Elementscontd
Meaning
eye mouth ear lens

Word Element
ophthalm/o or/o ot/o phac/o

Example
ophthalmalgia (of-thal-MAL-j a) e- orofacial (or- -sh al) o-FA e- otorrhea (o-to-RE- a) phacomalacia (fak- a-LA-sh a) o-m e-

Meaning
Pain in the eye Concerning the mouth and face Flow or discharge from the ear Softening of the lens, usually as a result of a cataract

pharyng/o presby/o retin/o rhin/o scler/o stomat/o tympan/o Prexes diploexhyperSufxes -opia -plegia -ptosis -scope

pharynx old age retina nose sclera, hardening mouth tympanic membrane

pharyngoparalysis (far-n-g ar-AL--ss) o-p presbyopia (pr e-O-pe- ez-b a) retinopathy (r -NOP- e) et- a-th rhinoplasty (RI-n as-te) o-pl a) sclerectasia (skle-r ek-TA-ze- stomatosis (sto-m -ss) a-TO tympanosclerosis (tm-p o-skle-RO-ss) an-

Paralysis of the muscles of the pharynx Age-related loss of lens accommodation Any disorder of the retina Plastic surgery of the nose Protrusion of the sclera Any disease of the mouth Hardening of the tympanic membrane

double, twin out, away from excessive

a) diplopia (dp-LO-pe- exophthalmia (eks- of-THAL-m a) e- hyperacusis (h-p a-KU-ss) er-

Double vision Abnormal protrusion of the eyeball Abnormal sensitivity to sound

vision paralysis, stroke prolapse downward instrument for viewing

myopia (m-O-pe- a) e- ophthalmoplegia (of-thal-m o-PLE-j a) blepharoptosis (blef- o-TO-ss) a-r ophthalmoscope (of-THAL-m op) o-sk

Nearsightedness Paralysis of ocular muscles Drooping or prolapse of the eyelid Instrument used for the examination of the interior of the eye

-tropia

turning

a) exotropia (eks- o-TRO-pe-

Abnormal outward turning of one or both eyes

Table 36.2 |

Pathologic Terms

This table lists some of the most common pathologic terms related to the eyes, ears, mouth, nose, and throat with a brief denition for each. Term
anacusis an- U-ss a-K Chalazion k a-LA-z e- on retinal detachment a RET--n l

Denition
Total deafness

Benign hard tumor of the eyelid

Separation of the inner visual layer of the retina from the outer pigment layer

Continued

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Clinical

Table 36.2 | Term

epistaxis ep--STAK-ss gingivitis jn-j-V-ts I glossoplegia e- gl o-PLE-j a os- hordeolum o-l hor-DE- um nyctalopia nk-t -LO-pe- a a nystagmus ns-TAG-m us

Pathologic Termscontd
Denition
Nosebleed

Inammation, swelling, and redness of the gums

Paralysis of the tongue due to injury of 12th cranial nerve (commonly from a stroke)

Localized swelling of one or more glands of the eyelid; also called stye

Inability to see in low light or at night

Involuntary eye movement that may be back and forth or circular

otosclerosis o-to-skl -ss e-RO pharyngitis f ar-n-J-ts I

Hardening of the oval window causing progressive deafness

Inammation of the mucous membranes and lymphoid tissues of the pharynx

Table 36.3 |

Abbreviations

In ophthalmology and otolaryngology, as with other areas of health care, abbreviations are commonly used. Abbreviations such as the ones listed below save time and effort in documentation and written communications. Abbreviation
Ophthalmology ARMD CK EOM IOL IOP LASIK LTK *OD *OS *OU PERRLA RK ROP RP VA VF age-related macular degeneration conductive keratoplasty extraocular movement intraocular lens intraocular pressure laser-assisted keratomileusis (surgical correction to the lens) laser thermal keratoplasty right eye left eye both eyes together pupils equal, round, and reactive to light and accommodation radial keratotomy retinopathy of prematurity retinitis pigmentosa visual acuity visual eld SOM T&A TM TMJ

Term

Abbreviation
Otolaryngology AC *AD *AS *AU BC BOM EAC ENT HEENT NIHL PND PE tube

Term
air conduction right ear left ear both ears bone conduction bilateral otitis media external auditory canal ears, nose, and throat head, eyes, ears, nose, and throat noise-induced hearing loss post nasal drip (or drainage) pressure-equalizing tube (placed in the eardrum) serous otitis media tonsillectomy and adenoidectomy tympanic membrane temporomandibular joint

* The Joint Commission has determined that these abbreviations create confusion and error in charting and providing care. Although the medical assistant should refrain from using these abbreviations, she must know their meanings in order to correctly interpret medical records.

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Common Diseases and Disorders of the Eyes, Ears, Mouth, Nose, and Throat
There are many diseases and disorders that involve the eyes, ears, mouth, nose, and throat. Some of the most common include errors of refraction, bacterial infection, hearing decits, and structural abnormalities of the nose and throat that cause snoring or obstructed breathing.

the eyes, pain, swelling, and, sometimes, a yellow discharge from the eyes. Diagnosis is determined by visual inspection. Treatment includes antibiotic eyedrops and proper hand washing. (See Hands off the eye!)

Diabetic Retinopathy
ICD-9-CM code: 362.01 Diabetes, when poorly controlled, can cause progressive damage to the retina by prolonged dilation of blood vessels. The chronic dilation of the retinal blood vessels can cause hemorrhage and macular edema. As the dilated blood vessels leak, they form exudates of dried uid deposits that oat on the retina and can cause blindness. Nearly all patients who have had diabetes for 15 years or longer have some retinal damage. Damage to the retina is irreversible, but strict control of diabetes prevents further damage and preserves vision. Regular ophthalmological screening is recommended for patients with diabetes to detect retinopathy before irreversible damage occurs. (See Figure 36-7.)

Eyes
Common disorders of the eyes include astigmatism, blepharitis, conjunctivitis, exophthalmos, myopia, hyperopia, presbyopia, photophobia, cataracts, glaucoma, and macular degeneration.

Astigmatism
ICD-9-CM code: 367.20 In astigmatism, the cornea or lens has a defective curvature so that light rays diffuse over a large area on the retina. This diffusion causes the light coming into the eye to be focused on more than one point on the retina. The patient will not see a sharply focused image and may see more than one image. The exact cause of astigmatism is unknown and may be hereditary. Diagnosis is determined using an astigmatometer, a device that measures the degree of astigmatism. Treatment involves corrective lens surgery if the degree of astigmatism is limited. Severe defects to the cornea or lens can be treated with corrective lenses only, either glasses or contacts.

Hypertensive Retinopathy
ICD-9-CM code: 362.11 The retina can be damaged by chronic hypertension in which increased blood pressure pushes more blood into the vessels of the retina. The chronic dilation of the retinal blood vessels causes the same damage as seen in diabetic retinopathy. Increased blood volume and pressure cause leakage of uid and cellular debris from blood vessels into the retina, which then dries, forming deposits on the retina. Conditions that lead to hypertension include toxemia of pregnancy, glomerulonephritis, and coronary artery disease. Treatment for hypertension will prevent further damage to the retina but, as with diabetic retinopathy, the damage is irreversible. Regular ophthalmological screening is recommended to detect damage; monitoring of blood pressure and adjusting antihypertensive medication to maintain healthy blood pressure will prevent further damage. (See Figure 36-8.)

Blepharitis
ICD-9-CM code: 373.0 Blepharitis is an inammation of the hair follicles and glands along the edges of the eyelids. This inammation may develop from bacteria and excess secretions on the eyelid hair follicles. Blepharitis may also develop from pediculosis (infestation with lice) of the eyebrows and lashes. Symptoms include itching and burning sensations, constant rubbing and itching of the eyes, red-rimmed eyelid margins, greasy scales, and sticky, crusted eyelids. Ulcerated lid margins, loss of lashes, and presence of lice eggs with pediculosis may be seen. Diagnosis is determined by visual inspection. Treatment includes warm saline compresses and antibiotic ointments applied to the lid margins.

Patient Education

Hands Off the Eye!

Conjunctivitis is commonly spread from one eye to the other when the patient rubs the affected eye to try to ease itching. The medical assistant should instruct the patient with conjunctivitis to avoid touching the affected eye and, if he does, to wash his hands immediately to prevent the spread of infection to the unaffected eye. The medical assistant should also explain that conjunctivitis is extremely contagious. To prevent the spread of conjunctivitis to others, the patient should not share bath towels, face cloths, pillowcases, or sunglasses with others.

Conjunctivitis
ICD-9-CM code: Acute 372.0; Chronic 372.1 Conjunctivitis, also called pinkeye, is a viral or bacterial inammation of the conjunctiva, the mucous membrane of the anterior eye. Conjunctivitis is usually caused by bacteria (Streptococcus or Staphylococcus) or a virus (herpes simplex). Symptoms include redness and a bloodshot appearance in

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"Cotton-wool" spots Hemorrhages

Neovascularization

Background diabetic retinopathy

Proliferative diabetic retinopathy FIG 36-7 Diabetic retinopathy.

Exophthalmos
ICD-9-CM code: 376.30 Exophthalmos is a protrusion of one or both eyeballs. Possible causes include a hyperactive thyroid, a tumor, orbital cellulites, leukemia, an aneurysm, or trauma. Symptoms include protrusion of the eyeball and other symptoms, depending on the cause, such as tachycardia and increased systolic blood pressure (hyperthyroidism); weight loss, fatigue, and, possibly, facial deformity (tumor); inammation and erythema (orbital cellulites); decreased white blood cell count (leukemia); and intracranial bleeding (aneurysm and trauma). Diagnosis is determined by visual inspection. Treatment is directed at the cause of exophthalmia, such as thyroid hormone rebalancing, tumor resection, antibiotics for orbital cellulites, chemotherapy for leukemia, surgical repair for aneurysm, and reconstruction in the case of trauma.

Flame-shaped hemorrhages

"Cotton-wool" spots Dilated vessels

Edema of the optic disc

Myopia
ICD-9-CM code: 367.1 Myopia, also called nearsightedness, is an error of refraction that causes light rays to focus in front of the retina. This refraction error limits clear vision to only a short distance. The main cause of myopia is a misshapen eyeball. Symptoms are blurred vision when the patient is looking at objects beyond immediate surroundings. Errors of refraction that are related to the shape of the eyeball are generally hereditary.

Macular star-shaped (exudates)

Retina

FIG 36-8 Retinal changes due to hypertension.

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Diagnosis is established using a vision test. Treatment includes a negative, or concave, lens of the proper strength to counter the effect of the defect and cause sharp focus at far distances. Radial keratotomy, a surgical procedure to correct the shape of the lens, will correct the problem.

Presbyopia
ICD-9-CM code: 367.4 Presbyopia is permanent loss of accommodation of the crystalline lens of the eye and usually occurs in people in their mid-40s. This disorder causes an inability to maintain focus on objects held near to the eye. Symptoms include an inability to read small print without straining and the use of bright light. As the illness advances, all normal-sized print is out of focus at a normal reading distance. Diagnosis is established using a vision test and considering age. Treatment is usually glasses or contact lens for reading.

Hyperopia
ICD-9-CM code: 367.0 Hyperopia, also called farsightedness, is a defect in vision in which parallel light rays come into focus behind the retina. This refraction error limits clear vision to objects at a long distance. Symptoms include ocular fatigue and poor vision. Errors of refraction that are related to the shape of the eyeball are generally hereditary. Diagnosis is established using a vision test. Treatment includes a positive, or convex, lens of the proper strength to counter the effect of the defect or radial keratotomy to correct the shape of the lens. (See Figure 36-9.)

Photophobia
ICD-9-CM code: 368.13 Photophobia is an unusual intolerance to light that occurs in patients suffering from measles, mumps, rubella, meningitis,

Normal eye

Myopia

Hyperopia

Astigmatism

Concave lens correction

Convex lens correction

FIG 36-9 Eyeball shape affects where the image is projected. (A) Normalon the retina. (B) Myopiain front of the retina. (C) Hyperopiabehind the retina. (D) Astigmatismmultiple images on the retina. (E) Concave lens correction for myopia. (F) Convex lens correction for hyperopia.

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or eye inammation. The major symptom is sensitivity to light. Diagnosis is determined by visual inspection and patient history. Treatment is directed at the cause of photophobia (specic infectious agent).

Cataracts
ICD-9-CM code: 366- (use 4th and 5th digit) Cataracts are opacities of the lens of the eye and usually occur with age, trauma, endocrine or metabolic disease, or intraocular disease. Cataracts are the leading cause of blindness in adults worldwide. After the age of 65, 90% of adults have some cataract formation. Symptoms include gradual blurring, loss of visual acuity (sharpness of vision at varying distances), and a milky-white pupil. People with cataracts complain of seeing halos around lights and being blinded at night by oncoming automobile headlights. Diagnosis is determined by visual examination (in advanced cases) and a vision test. Treatment is surgical removal of the lens. Wearing sunglasses, contact lenses, or glasses can improve vision; however, these are not curative measures.

Glaucoma
ICD-9-CM code: 365- (use 4th and 5th digit) Glaucoma is an increased intraocular pressure resulting in atrophy of the optic nerve, which can lead to blindness. Glaucoma may be caused by the aqueous humor draining from the eye too slowly to keep up with its production in the anterior chamber. There are two types of glaucoma: acute (narrow-angle) and chronic (open-angle). Because the progression of narrowangle glaucoma is rapid, diagnosis can be determined quickly; the disease will cause extreme ocular pain, blurred vision, redness of the eye, and dilation of the pupil. Nausea and vomiting can accompany eye symptoms and blindness can occur in 2 to 5 days. Open-angle glaucoma may produce no symptoms except the gradual loss of peripheral vision over a period of several years. Diagnosis is determined using a tonometer, which takes measurements of intraocular pressure (IOP). The normal IOP range for adults and children is 14 to 16 mm Hg. An IOP of 22 mm Hg or higher conrms the diagnosis of glaucoma. Treatment includes medication with miotics (eserine and pilocarpine), timolol maleate, intravenous mannitol, and parenteral acetazolamide.

vision. Macular degeneration is incurable and one of the leading causes of blindness in people over 55 years of age. Risk factors, besides age, include cigarette smoking, family history, cardiovascular disease, elevated blood cholesterol levels, light eye color, and excessive sun exposure. Macular degeneration can occur from inammation and infection or injury. However, most macular degeneration is related to age, referred to as age-related macular degeneration (ARMD). There are two types of ARMD: wet and dry. Dry ARMD is the more common type and accounts for 90% of cases of ARMD. Symptoms include small yellow deposits (drusen) that form under the macula and interfere with central vision. The drusen are dried retinal pigment cells, which is why this type is called dry ARMD. Dry ARMD causes some loss of vision but rarely leads to total blindness. Wet ARMD affects 10% of patients and is much more severe. In this type, new blood vessels form under the macula, which is why the alternative name for this type is neovascular ARMD. Blood and vitreous uids can leak from these cells, destroying central vision cells and leading to permanent blindness. Diagnosis of all forms of macular degeneration is established by inspecting the maculae with an ophthalmoscope (an instrument used to examine the interior of the eye). Treatment includes laser therapy to delay or prevent blindness.

Ears
Common diseases and disorders of the ears include Mnire disease, otitis (inammation of the ear) externa, otitis media, labyrinthitis, tinnitus, and vertigo.

Mnire Disease
ICD-9-CM code: 386.0 Mnire disease involves recurring episodes of hearing loss, tinnitus, vertigo, and aural fullness, which commonly result in progressive deafness. The cause of Mnire disease is unknown. Symptoms include severe dizziness (vertigo), ringing in the ears (tinnitus), nausea, vomiting, perspiration, and periodic loss of balance. Diagnosis is established by physical examination, which may reveal nystagmus and hearing loss, and patient history, which may reveal a feeling of fullness and pain in the ear. Treatment includes bed rest for acute attacks, antihistamines, sedatives, smoking cessation, low-salt diet, and, possibly, diuretics.

Macular Degeneration
ICD-9-CM code: 362.50 Macular degeneration is a disorder in which changes in the pigmented cells of the retina and macula lead to progressive loss of fine vision. The maculae are the most sensitive cells of the retina and are responsible for central

Otitis Externa
ICD-9-CM code: 380.10 Otitis externa, also called swimmers ear, is an infection or inammation of the external auditory canal. Contact allergy,

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acute bacterial infection, or fungi can cause otitis externa. Children are most commonly affected. Symptoms include pain and temporary hearing loss. Diagnosis is established using physical examination, which reveals a red, inamed, tender outer ear as well as narrowing of tissues in the ear canal due to swelling. Treatment includes antibiotic ear drops, pain medication, and thorough ear cleaning. (See Handling swimmers ear.)

Otitis Media
ICD-9-CM code: Acute nonsuppurative 381.0; Acute suppurative 382.0 Otitis media is the presence of uid in the middle ear and is commonly associated with respiratory infections. Otitis media usually occurs from an organism that has caused a sore throat or cold. Small children are most commonly affected because the eustachian tubes are positioned horizontally during growth and development of the head. In addition, small children may not yet have the ability to clear their noses properly. Symptoms include severe pain, fever, and temporary hearing loss. The tympanic membrane may be red and inamed and can rupture. (See Tympanic membrane in otitis media.) Diagnosis is established from visual examination of the tympanic membrane and patient history. Treatment includes nasal decongestants or antibiotics for the inammation or infection and acetaminophen or ibuprofen for pain.

Patient Education

Handling Swimmers Ear

Because otitis externa (swimmers ear) is common in children, the medical assistant can teach patients and parents how to deal with the symptoms as well as prevent the occurrence or recurrence of the condition. The medical assistant should advise patients to: use a clean towel to dry the ear canals after swimming while refraining from pushing anything into the ear canal (because doing so can cause irritation or injury) place a warm heating pad (not hot) on top of the ear or warm the ear gently with a hair dryer to reduce the pain of an existing infection use earplugs while swimming, diving, or waterskiing to prevent recurrence (then remove the earplugs after swimming and dry the ear canals properly).

Labyrinthitis
ICD-9-CM code: 386.30 Labyrinthitis, also called otitis interna, is an inammation of the labyrinth. It is caused by a viral or bacterial infection or head trauma. Symptoms include vertigo, vomiting, and nystagmus. Diagnosis is determined using the patient history of symptoms. Treatment is directed at the cause: antibiotics for infection or treatment of the head trauma.

Tinnitus
ICD-9-CM code: 388.3 Tinnitus is a subjective ringing, buzzing, tinkling, or hissing sound in the ear. Tinnitus may be caused by impacted cerumen,

Tympanic membrane in otitis media

Inspection of the tympanic membrane is used to diagnose otitis media, commonly seen in children. The healthy tympanic membrane is gray and shiny. The infected tympanic membrane is red or pink, possibly with a visible discharge. Children get otitis media or middle ear infections more commonly than adults because the eustachian tube in a child is parallel to the pharynx. The infection may be caused by a virus but is most commonly caused by Streptococcus pneumoniae. Around 12,000,000 cases of otitis media occur every year in the United States.

Healthy tympanic membrane Infected tympanic membrane

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myringitis, otitis media, otosclerosis, or drug toxicities (salicylates and quinine). Symptoms include difculty hearing conversational speech and difculty sleeping due to the continuous sensation of ringing in the ears. Diagnosis is established taking a detailed patient history. Treatment is directed at the cause of tinnitus, including irrigating impacted cerumen, antibiotics for infection, or cessation of ototoxic medication.

infected saliva. The major symptom is lesions inside the mouth. Diagnosis is established by visual inspection and confirmed by wound culture. Treatment includes oral acyclovir to treat the outbreak and recurrences. The medical assistant should instruct the patient to avoid touching lesions, because the virus can spread via contact. The medical assistant can discuss hygiene habits with the patient to prevent spread to family members.

Vertigo
ICD-9-CM code: 386.2 Vertigo is the sensation of moving around in space or having objects move around the person. Vertigo may be caused by middle ear disease, salicylate toxicity, alcohol, streptomycin administration, sunstroke, postural hypotension, or toxemia due to food poisoning. Symptoms include dizziness, sensation of faintness, or inability to maintain normal balance. Diagnosis is established by taking a detailed patient history. Treatment is directed at removing the cause of vertigo and may include medication, cessation of medication, reducing body temperature and administering IV uids, or eliminating alcohol from the diet. (See Preventing injury from an inner ear disturbance.)

Oral Thrush
ICD-9-CM code: 112.0 (newborn 771.7) Oral thrush, also called candidiasis, is an infection of the skin or mucous membrane with any species of Candida, but mainly Candida albicans. Oral thrush is caused by a disruption in the composition of normal ora or a change in host defenses. Patients with suppressed immune systems, such as those with human immunodeciency virus (HIV) or patients being treated with chemotherapy or immunosuppressive drugs, are at higher risk. Neonates are sometimes born with oral thrush because normal ora in the mouth has not yet been established. Symptoms include oral lesions; white patches on the mucosa and tongue; a red, irritated surface of the tongue; and lesions on other parts of the body, including the groin and abdomen, and under pendulous breasts. Diagnosis is established using visual inspection. Treatment includes uconazole, clotrimazole lozenges, or nystatin oral solution.

Mouth
Common diseases and disorders of the mouth include oral herpes, oral thrush, cleft lip, and cleft palate.

Oral Herpes
ICD-9-CM code: 054.9 Oral herpes, also called a cold sore, is a vesicular eruption caused by herpes virus. It is transmitted by contact with

Cleft Lip
ICD-9-CM code: 749.10 Cleft lip is a common developmental abnormality that occurs between 4 to 8 weeks of fetal development. Incidence

Patient Education

Preventing Injury from an Inner Ear Disturbance

Various inner ear disturbances can cause dizziness and loss of balance. The medical assistant can advise patients and caregivers on certain measures to prevent injury from dizziness. rushing to walk or change positions. Sudden movement can exacerbate vertigo. Also, alcohol consumption disturbs the vestibulocochlear nerve and its ability to transmit information about balance and body position to the brain. It can cause uncoordinated movements and delayed reactions. The medical assistant should advise patients to refrain from drinking alcohol if they experience dizziness or nausea, as in Mnire disease, labyrinthitis, and vertigo, because alcohol will exacerbate the symptoms.

Ride the rails

The medical assistant should urge patients and caregivers to use side rails on beds and railings on stairs for added stability. Bathtubs can be equipped with seats, railings, and handheld shower heads for safer bathing. Patients who suffer from severe symptoms of vertigo should not bathe independently if safety is compromised.

Other measures
In addition to using railings, the medical assistant should encourage patients to rise slowly from sitting and avoid

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of cleft lip is approximately 1 in 700 births. The cleft, or opening, results from a failure of the maxillary processes to fuse and can be unilateral or bilateral. The length of the opening can range from a small notch to a cleft that extends into the base of the nostril. The infant will have feeding problems because the lips cannot completely close around a nipple to create suction. Treatment with plastic surgery is effective in correcting the defect and appearance.

cause tonsillitis; however, the most common is Streptococcus. Symptoms include intense pain in the throat for a short period of time, fever, and general malaise. Diagnosis is established by patient history and visual inspection, which reveals a red, inamed throat and, commonly, white pustules. The causative organism is determined by throat culture. Treatment may include a tonsillectomy for chronic infection, antibiotic treatment, bed rest, liquid-to-soft diet, and analgesic throat spray.

Cleft Palate
ICD-9-CM code: 749.00 Cleft palate is the failure of the soft and hard palates to fuse in the 7th to 12th week of fetal development. The opening between the oral and nasal cavities greatly increases the risk of aspirating fluid into the lungs. Incidence of cleft palate, as with cleft lip, are 1 in 700. An infant may be born with either disorder or a combination of both. The infant with cleft palate will have feeding difficulty due to a lack of pressure created in the mouth for swallowing. Prior to surgical correction, a special nipple may be used to close the opening to the nasal cavity while feeding the infant. Plastic surgery corrects the defect and appearance. Speech therapy is commonly needed later in life, as is orthodontic care. The risk of a baby being born with either cleft lip or palate increases with the number of affected relatives and the severity of the clefts. Environmental factors that increase risk for both disorders include cigarette smoking, alcohol, phenytoin, and methotrexate.

Ophthalmology and Otolaryngology Procedures

Ophthalmology is a medical specialty that focuses on the study and treatment of disorders of the eye. Otolaryngology is a medical specialty that focuses on the study and treatment of disorders of the ear, mouth, nose, and throat. Physicians that specialize in these areas of the body include:

Nose and Throat

Common diseases and disorders of the nose and throat include rhinitis and tonsillitis.

Rhinitis
ICD-9-CM code: 477 (use 4th digit) Rhinitis is inflammation of the nasal mucosa. This inflammation can occur seasonally or year-round. Allergic rhinitis is a reaction to airborne allergens. Symptoms include sneezing, profuse watery discharge, itching of the eyes and nose, conjunctivitis, and tearing. Diagnosis is established using visual inspection and patient history. Treatment includes rest, adequate fluids, and a wellbalanced diet. Avoidance of allergens is also recommended if possible. Analgesics and antipyretics may be administered for comfort.

ophthalmologistmedical doctor who diagnoses and treats disorders and diseases of the eye and can perform eye surgery optometristdoctor of optometry who prescribes corrective eyewear and diagnoses and treats disorders and diseases of the eye opticianspecialist who lls prescriptions for corrective lenses for eyeglasses and contact lenses (not a medical doctor) otorhinolaryngologistsmedical doctor who diagnoses and treats diseases and disorders of the ear, nose, and throat as well as the mouth as it pertains to the structural needs of eating and breathing (also called an ENT).

Family physicians, pediatricians, internists, and school nurses may also evaluate the function of eyes and ears in annual screenings or school examinations. They will refer patients with vision or hearing deficits to a specialist for treatment. The medical assistant working for a specialist or a general practice may be required to assist in the evaluation or treatment of the eyes, ears, mouth, nose, and throat.

Assisting with Ophthalmic Examination

The physician examines the interior of the eye with an ophthalmoscope. The ophthalmoscope is a handheld instrument that shows the condition of the retina, optic nerve, and the blood vessels of the eye. The physician may administer mydriatic drops to dilate the pupil and view it

Tonsillitis
ICD-9-CM code: 463 Tonsillitis is inammation and infection of the tonsils. It causes pain upon swallowing. Many infectious agents can

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with the ophthalmoscope. (See Mydriatics and patient safety and comfort.) The medical assistant must keep the ophthalmoscopes bulbs and batteries in working order and the instrument must be sanitized with an alcohol wipe. Assessing the patients visual acuity and ability to see color begins with manual vision testing. The medical assistant or physician may ask a patient to read a chart to

Front ofceBack ofce connection

Mydriatics and Patient Safety and Comfort

In the ophthalmologists ofce, the physician may dilate the pupils for examination or treatment with a medication called a mydriatic. Mydriatics dilate the pupil and prevent constriction of the pupil when light enters the eye. Because dilating the pupils causes an increased amount of light to enter the eye, the patients eyes will be sensitive to this added light. The administrative medical assistant who is making an appointment for an ophthalmic examination or treatment that requires mydriatics should advise the patient to bring sunglasses and explain why. The clinical medical assistant can turn off the lights in the examination room for the patients comfort. The patient may not be able to drive himself after administration of the mydriatic. The effects of the mydriatic wear off in a few hours, so the medical assistant should tell the patient not to read or watch TV until the effects have worn off.

assess the patients vision. The most common chart used in this type of examination is the Snellen chart. (See Procedure 36-1: Measuring distance and visual acuity using the Snellen chart.) She may also measure near visual acuity using a near-vision acuity card, such as the Jaeger card. (See Procedure 36-2: Measuring near visual acuity, page 764.) The medical assistant may also test a patients ability to distinguish color using the Ishihara color vision test. (See Procedure 36-3: Measuring visual acuity using the Ishihara color vision test, page 765.) Under the direction of a physician, the medical assistant can perform these screenings independently. If visual deficiencies associated with errors of refraction are noted, the physician will then conduct further testing to prescribe corrective lenses if necessary.

Assisting with Ophthalmic Irrigation and Instillation

The eye can become irritated and inamed by irritants that get into the conjunctiva or by infection, most commonly caused by bacteria. The medical assistant can irrigate the patients eye to remove irritants and cleanse the eye of pus formed by the infection process. (See Procedure 36-4: Irrigating the eye, page 766.) The medical assistant can also instill medications into the eye that soothe the eye or kill pathogenic bacteria. (See Procedure 36-5: Instilling eyedrops, page 768.) While instilling eyedrops, the medical assistant should teach her patient or caregiver the proper techniques for medication instillation into the eye. (See Instilling eyedrops, page 769.)

Assisting with Otic Examination

The physician examines the ears with an otoscope, which is a handheld instrument with a light used to examine
(Text continues on page 770)

PROCEDURE 36-1

Measuring distance and visual acuity using the Snellen chart

Task Accurately measure visual acuity using a Snellen eye chart. Document the procedure in the patients medical record. Conditions Snellen eye chart Eye occluder Floor mark at 20 feet from the eye chart Patients medical record Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will accurately measure visual acuity using a Snellen eye chart. Performance Standards 1. Wash hands. 2. Ensure that the examination room is well lit. 3. Assemble equipment and supplies, including sanitizing the occluder and allowing it to dry completely to ensure that it is not contaminated.

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PROCEDURE 36-1contd

4. Introduce yourself and address the patient by name. 5. Explain the procedure to the patient and answer any questions she may have. Tell the patient that she will be asked to read lines of letters, objects, or a rotating E. Explain to the patient that she should not squint during the examination, because squinting changes the results of the test. Make sure that the patient does not have an opportunity to memorize the chart to ensure that her vision, not her memory, is assessed. 6. Ask the patient if she is wearing contact lenses and observe for eyeglasses. Because the test is a screening test, conrm with the physician if the patient should keep corrective eyewear on during the examination to ensure that the procedure is correctly charted with or without corrective lenses. 7. Ask the patient to stand (or sit if standing is difcult) on the oor mark, 20 feet from the Snellen chart to ensure accurate results. 8. Select the appropriate Snellen chart for the patient. Use an object chart for preschoolers who may not know the letters of the alphabet. Use a rotating E chart for adult patients who speak a foreign language, because they may

not know the correct English names for the letters. Be sure to explain the procedure through an interpreter or through hand motions, if necessary. Conrm that the patient understands the procedure. (See step 5.) 9. Position the center of the Snellen eye chart at the patients eye level so that the patient doesnt need to look up or down to see the chart. Stand to the side of the chart during the procedure so you do not obstruct the patients view of the chart. 10. Ask the patient to cover her left eye with the occluder and to keep her left eye open. Keeping the left eye open makes it harder to squint with the right eye, which would increase visual acuity and change test results. Preschoolers may not know their right and left, so assist them as necessary.

20 20

20 FT 6.1 M

20/200
20 200 200 FT 61 M

2 3 4 5 6 7 8 9 10 11
Snellen chart with Letters

20/100
20 100 100 FT 30.5 M

20/70
20 70 70 FT 21.7 M

20/50 20/40 20/30 20/25 20/20

20 60

50 FT 15.2 M

20 30

30 FT 9.1 M

20 20

15 FT 4.6 M

20 10

10 FT 3.0 M

Object Snellen chart Continued

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PROCEDURE 36-1contd

20 20

50

60

80 90 100 11 0 1 70

20

30

20 FT 6.1 M

20 200

200 FT 61 M

1 2 3 4 5 6 7 8

20 100

100 FT 30.5 M

20 70

70 FT 21.7 M

20 60

50 FT 15.2 M

20 30 20 20

30 FT 9.1 M 20 FT 6.1 M

11. Measure the visual acuity of the right eye. Always starting with the right eye creates a routine and makes charting consistent, which can reduce errors. 12. Ask the patient to identify each letter, object, or direction of the E verbally or with a hand motion (whichever is preferred by the patient) as you point to it. Start at the 20/70 line. Starting at a line that is above the 20/20 line gives the patient an opportunity to become familiar with the test and gain condence in the procedure. 13. Proceed up or down the chart as necessary. 14. If the patient is able to read the 20/70 line, proceed down the chart asking her to read the 20/50 line, 20/40, 20/30, 20/20, and further if possible. 15. If the patient is unable to read the 20/70 line, proceed up the chart to the 20/100 line. If the patient is unable to read this line, ask them to read the 20/200 line. 16. Chart the results of the right eye. Record the smallest line that the patient can read with one or no errors. If the patient makes two or more errors on a line, the patient may be guessing, which is not a true assessment of vision. (Note: Observe the patient for squinting, leaning, tilting the head, or eyes watering. These signs indicate that the patient is having difculty reading the chart.) 17. Repeat the procedure for the left eye. Ask the patient to place the occluder in front of her right eye. Remind the patient to keep her right eye open.

14

40

16 0 15

10 2 0

30

0 180 0 17

20 15 20 10

15 FT 4.6 M 10 FT 3.0 M

Date 02/18/08; 10:00 a.m. Snellen test: Right eye 20/30 -1, left eye 20/20 ----------------------------------------------------------------------------- C. Smith, CMA

Rotating E Snellen chart

PROCEDURE 36-2

Measuring near visual acuity

Task Accurately measure near visual acuity using the Jaeger near-vision acuity card. Document the procedure in the patients medical record. Conditions Jaeger card Eye occluder 18-inch ruler or tape Patients medical record Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will accurately measure near visual acuity. Performance Standards 1. Make sure the examination room is well lit and wash your hands. 2. Assemble the equipment and supplies. Sanitize the occluder and allow it to dry completely to prevent contamination.

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PROCEDURE 36-2contd

3. Introduce yourself and address the patient by name. 4. Explain the procedure to the patient; answer any questions he may have to promote cooperation and understanding. 5. Have the patient sit in a comfortable position. 6. Hand the patient the Jaeger card. Ask him to hold the card 14" to 16" away from his eyes and measure the distance to promote accurate results.

7. Ask the patient to cover his left eye with the occluder. Instruct him not to close his left eye to prevent squinting. 8. Ask the patient to read the paragraphs on the card out loud. The patient should start reading at the top of the card (largest print) and continue reading until he cannot read the smaller print. Starting with the large print ensures that the patient understands the procedure and will continue to read until he is unable to distinguish the letters. 9. Record the results of the right eye in the medical record. 10. Ask the patient to cover his right eye with the occluder and repeat the test for the left eye. 11. Record the results of the left eye in the medical record. 12. Ask the patient to read the card without the occluder, testing vision in both eyes. 13. Record the results of both eyes in the medical record.
Date 02/18/08; 10:30 a.m. Jaeger card: Right eye - successfully read no. 6 (1.25M) without glasses; left eye - successfully read no. 7 (1.50M) without glasses. Both eyes successfully read no. 6 (1.25M) without glasses. ------------------------------------- C. Smith, CMA

Ask the patient to hold the Jaeger card 14" to 16" away from his eyes.

PROCEDURE 36-3

Measuring visual acuity using the Ishihara color vision test

Task Accurately measure color visual acuity using the Ishihara color vision test. Document the procedure in the patients medical record. Conditions Ishihara color plate book Cotton swab Watch with second hand Patients medical record Pen Standards In the time specified and within the scoring parameters determined by the instructor, the student will accurately measure visual acuity using the Ishihara color vision test. Performance Standards 1. Wash your hands and ensure that the examination room is well lit with natural light if possible. Natural daylight is most accurate; articial light may change the appearance of the test plates. 2. Assemble the equipment and supplies. 3. Introduce yourself and address the patient by name. 4. Explain the procedure to the patient to promote accurate results. 5. Use the rst plate in the book to explain the procedure to the patient. Tell the patient that he will have 3 seconds to identify numbers verbally or trace a winding path formed by the colored dots on the card. The patient should keep both eyes open during the procedure. The rst plate is highly contrasted and is designed so that it can be read correctly by everyone. The medical assistant can ensure that the patient understands the procedure.
Continued

766

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Clinical

PROCEDURE 36-3contd

7. Ask the patient to identify the number on the plate or, using a cotton-tipped swab, trace the winding path. Sometimes require the patient to trace the number. Tracing ensures that the number was not memorized and that the patient can truly distinguish the colors. 8. Record the results of each plate on a piece of paper. After all 11 plates have been tested, record the results in the patients medical record. Writing in the medical record and performing the test simultaneously may cause you to rush and write sloppily. Take your time and record results at the end of the procedure. Indicate the plates that the patient read incorrectly by recording the number of the plate with an X next to it. Alternatively, simply list the numbers of the plates read incorrectly.

Date 02/19/08; 10:30 a.m. Ishihara test: Plates 8X, 9X. ----------------- C. Smith, CMA

Date 02/19/08; 10:30 a.m. Ishihara test: Pt. unable to identify plates 8 & 9. ------------------------------------------------------------------------ C. Smith, CMA

Date 02/19/08; 10:30 a.m. Ishihara test: vision on all plates normal. - C. Smith, CMA

Ishihara color vision test plates

6. Hold the color plate 30" from the patient at a right angle to the patients line of sight to ensure that the patient can see the plate.

PROCEDURE 36-4

Irrigating the eye

Task Irrigate the patients affected eye to cleanse it of a foreign object, cleanse a discharge, cleanse chemicals, apply antiseptic, or apply heat. Conditions Sterile irrigation solution Sterile bulb syringe (rubber)

Kidney-shaped basin to catch irrigation solution Sterile cotton balls Sterile gloves Biohazard waste container Patients medical record Pen

CHAP TER 36

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PROCEDURE 36-4contd

Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully irrigate the patients eye. Performance Standards 1. Wash hands. 2. Assemble equipment and supplies. Use separate equipment if both eyes are to be irrigated to prevent cross-contamination. 3. Introduce yourself and address the patient by name. 4. Explain the procedure to the patient and answer any questions she may have to promote patient understanding and cooperation. 5. Position the patient in the supine position to aid the entrance of the solution into the eye. 6. Check the expiration date on the solution bottle. Expired solution may be harmful to the eye. 7. Check the label for the right medication three times to be sure to use the correct solution for irrigation. 8. Warm the solution to body temperature to ensure patient comfort. 9. Tilt the patients head toward the affected eye and place a towel on the patients shoulder to avoid crosscontamination of the affected eye by allowing the solution to ow laterally away from the unaffected eye. 10. Place the basin next to the affected eye as shown.

11. Put on sterile gloves to prevent contamination. 12. Moisten two or three cotton balls with the irrigation solution and clean the eyelids and eyelashes of the affected eye from the inner to the outer canthus to protect the unaffected eye from cross-contamination. Discard the cotton ball after each wipe.

Direct the ow of solution from the inner canthus to the outer canthus to prevent the solution from entering the other eye.

Ask the patient to hold the basin next to her eye and to remain still. Continued

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Clinical

PROCEDURE 36-4contd

13. Expose the lower conjunctiva by separating the eyelid with your index nger and thumb, as shown, making sure that the ow of irrigation solution is away from the unaffected eye.

14. Ask the patient to stare at a xed spot to decrease the reex to close the eye. Note: You will still need to keep the eye open with your ngers during irrigation. The patients reex is to shut the eye. 15. Irrigate the affected eye with sterile solution by resting the bulb on the bridge of the patients nose. Be careful not to touch the tip of the bulb syringe to any part of the patients face to avoid contaminating the sterile bulb syringe and solution. 16. Allow the stream to ow from the inner canthus to the outer canthus, as seen below. 17. After irrigation, dry the eyelid and eyelashes with sterile cotton balls to prevent contamination of the eye. 18. Discard supplies in a biohazard container if discharge or exudate is present because bodily uids are considered biohazard waste. 19. Remove your gloves. 20. Wash your hands and document the procedure.
Date 02/20/08; 11:15 a.m. Left eye irrigation, small amount of particle irritants removed. ---------------------------------------------- C. Smith, CMA

21. Repeat the procedure on the other eye if a bilateral procedure is indicated.

Separate the eyelid with your index nger and thumb.

PROCEDURE 36-5

Instilling eyedrops
Task Instill eyedrops to treat eye infections, soothe irritation, anesthetize the eye, or dilate pupils. Conditions Sterile eye dropper Sterile ophthalmic medication as ordered by the physician Sterile cotton balls

Sterile gloves Biohazard waste container Patients medical record Pen

Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully instill eyedrops.

CHAP TER 36

Ophthalmology and Otolaryngology

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PROCEDURE 36-5contd

Performance Standards 1. Wash your hands. 2. Assemble the necessary equipment and supplies. 3. Introduce yourself and address the patient by name. 4. Explain the procedure to the patient and answer any questions that she may have to promote patient cooperation. Tell the patient that the instillation may temporarily blur her vision. If the medication is to dilate the pupil for examination, explain to the patient that the eye will be very sensitive to light. 5. Check the medication label carefully against the physicians orders. Note the name of the medication and the expiration date. Check the label three times to avoid instilling the wrong medication or expired medication that may harm the eye. 6. Position the patient in a sitting or supine position to ensure that all of the medication enters the eye. 7. Ask the patient to stare at a xed spot up on the ceiling to decrease the reex to close the eye. 8. Hold the eye open by placing a tissue under the eye and gently pulling down on the skin below the eye to ensure all of the medication enters the eye. Use the patients forehead as a rest for your hand, as shown. 9. Place the number of drops ordered in the lower conjunctival sac or a thin line of ointment in the lower surface of the eyelid. Be careful not to touch the tip of the eye dropper to any portion of the patients eye to avoid contaminating the dropper and medication. 10. Ask the patient to close her eye and roll her eyeball to distribute the medication evenly. 11. Document the procedure in the patients chart.

Use the patients forehead as a rest for your hand. Date 02/20/08; 11:30 a.m. 3 drops Alphagan P in left eye. ------------ C. Smith, CMA

Patient Education

Instilling Eyedrops
When the medical assistant instills eyedrops in the medical ofce she can teach the patient or caregiver how to instill them at home. While administering the drops, the medical assistant should mention these points: Wash your hands before and after administering drops. Do not touch the tip of the dropper to the eye or any object because it is sterile. Avoid contaminating the eyedrops to prevent reinfection. Store eyedrops as directed on the label, usually at room temperature in the sealed container. Remember that prescription eyedrops are a medication and should be used only by the patient for whom it was prescribed. Never share eyedrops because they may be contraindicated for some patients.

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UNIT 3

Clinical

the ear. The physician is able to check the appearance of the ear canal and the tympanic membrane, or eardrum. To straighten the canal, the physician will pull the adults auricle upward and backward and a childs auricle downward and backward (up to age 3). The otoscope uses a speculum that fits into the external ear canal and must be disposable or sanitized for reuse. The medical assistant is responsible for maintaining the otoscope and charging and changing the batteries as necessary. She should follow the manufacturers guidelines for cleaning and maintenance. (See Figure 36-10.)

Tuning Fork Test

Testing hearing acuity with a tuning fork can detect both conduction defects and nerve impairment. There are two basic tests: the Weber and Rinne tests. The physician may perform these tests or train the medical assistant to do so.

Weber Test
In the Weber test, the medical assistant should hold the tuning fork at the base and strike it against her palm to cause the tuning fork to vibrate. She should then hold the fork on the center of the patients head. If the patient hears the sound equally in both ears, the test result is normal. If the patient has a conductive hearing loss, the sound will be stronger in the problem ear. A sensorineural hearing loss will cause the sound to be heard faintly or not at all in the affected ear. (See Figure 36-11.)

Rinne test
In the Rinne test, the medical assistant should place the base of the vibrating tuning fork on the patients mastoid bone. She should then ask the patient to report when he can no longer hear the sound. The medical assistant should then

FIG 36-11 Weber test for sensorineural hearing loss.

hold the tuning fork beside the patients ear (without touching the patients head) and ask the patient if he can hear it. If the patient hears the tuning fork, the test result is normal, because air conduction hearing should be greater than bone conduction hearing. Conductive hearing loss will cause the patient to hear the sound longer through bone conduction, so when the tuning fork is then placed next to the ear, no sound is heard. If the patient has a sensorineural hearing loss, the sound will be reduced. The patient will hear the sound longer through air conduction than bone conduction but not twice as long. (See Figure 36-12.)

Audiometric Testing
Hearing tests can be administered through the use of an audiometer, an instrument used to test a patients hearing by determining hearing thresholds of pure tones at varying frequencies. The manufacturers specic guidelines should be followed when administering the test. If hearing decits are recognized, the patient can be referred to an audiologist for hearing aids or other assistive therapies. (See Procedure 36-6: Testing hearing using an audiometer.)

FIG 36-10 Otoscope.

CHAP TER 36

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FIG 36-12 Rinne test. (A) On the mastoid bone. (B) Beside the patients ear.

PROCEDURE 36-6

Testing hearing using an audiometer

Task Use an audiometer to test a patients hearing. Conditions Audiometer Headphones Enclosed area (such as a small room or cubicle) Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully test hearing using an audiometer. Performance Standards 1. Wash your hands. 2. Assemble the equipment and supplies. 3. Introduce yourself and address the patient by name. 4. Explain the procedure to the patient and establish a signal for the patient to give when she hears the tone (such as holding up a hand or nger on the same side as she hears the tone) to ensure that the patient gives the signal corresponding to each ear. 5. Make sure that the patient is comfortably seated and place headphones over one of her ears.
Continued

772

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Clinical

PROCEDURE 36-6contd

6. Begin with a low frequency and watch the patient for an indication that she hears the sound. Push the button to record the results. Beginning the test with sounds that are more commonly heard ensures that the patient is performing the test correctly. 7. Gradually increase frequency until you complete the test for the rst ear. 8. Repeat the procedure for the other ear.

9. Document results in the patients medical record. 10. Clean the equipment as directed by manufacturers instructions to prevent contaminating the next patient.

Date 02/21/08; 10:30 a.m. Audiometry test administered in both ears. No hearing deficits observed. ----------------------------------- C. Smith, CMA

Assisting with Otic Irrigation and Instillation

The ear may require a cleaning procedure known as irrigation. The medical assistant can perform an ear irrigation to dislodge a foreign object or clear the ear of impacted cerumen. (See Procedure 36-7: Irrigating the ear.) The medical assistant may also be required to instill medication into the ear to combat infection or soften dried cerumen. (See Procedure 36-8: Instilling eardrops, page 774.) In each procedure,
PROCEDURE 36-7

the medical assistant must take care to observe the patient. Many patients with inner ear disturbances may need assistance because of feelings of dizziness, nausea, or pain.

Assisting with Examination of the Mouth, Nose, and Throat

The physician will examine the mouth, nose, and throat during routine examinations or if the patient complains of pain or an inability to breathe, swallow, or speak easily. The

Irrigating the ear

Task Irrigate the patients affected ear to relieve inammation or cleanse it of cerumen, a foreign object, or discharge. Conditions Irrigation solution, as ordered by the physician, warmed to body temperature (98.6F) Ear syringe Kidney-shaped basin to catch irrigation solution Basin for warmed solution Towel Cotton balls Gloves Patients medical record Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully irrigate the ear. Performance Standards 1. Wash your hands. 2. Assemble the equipment and supplies. 3. Introduce yourself and address the patient by name. 4. Explain the procedure to the patient and inform her that she may experience minimal dizziness or discomfort during the procedure when the solution comes into 5. contact with the tympanic membrane. Answer any questions that the patient may have to promote patient understanding and cooperation. Check the label of the solution three times and check the expiration date to ensure that you are not instilling the wrong or expired medication, which may harm the ear. Warm the bottle of solution under running water. The solution should be close to body temperature (98.6F) for the comfort of the patient. Pour the solution into a basin and ll the syringe with the warmed irrigation solution as prescribed by the physician. Use approximately 30 to 50 ml of solution at a time to promote patient comfort. Position the patient in the sitting position, with her head tilted toward the affected ear so that the solution will enter the ear and then wash out of it. Place a towel on the patients shoulder and the ear basin under the affected ear. Ask the patient to hold the basin in place to retain the uid washed from the ear. Clean the outer ear with a wet cotton ball moistened with irrigation solution to ensure that the material collected in the basin is only from inside the ear. Gently pull the auricle upward and backward to straighten the ear canal (downward and backward if the patient is 3 years old or younger) to straighten the ear canal and allow the uid to enter it.

6.

7.

8.

9.

10.

11.

CHAP TER 36

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PROCEDURE 36-7contd

Ask the patient to hold the basin.

12. Expel air from the syringe and gently insert the syringe tip into the affected ear. Be careful not to insert the syringe too deeply. Direct the solution upward toward the roof of the canal to allow the solution to ow downward, cleansing the entire canal. Be careful to avoid occluding the external auditory canal because complete occlusion of the canal can cause increased pressure and, possibly, a ruptured tympanic membrane. 13. Note in the medical record any material that is irrigated, such as impacted cerumen, objects, dirt, and small particles of metal. 14. Rell the syringe with more clean, warmed solution from the other basin. 15. Repeat the irrigation, allowing the solution to drain from the ear. Ask the patient how she feels. Stop the procedure if the patient is too uncomfortable to prevent dizziness and possible fainting. 16. Dry the outer ear and inspect the canal with the otoscope to verify the procedure has removed the foreign body. If the foreign material is still in the canal, repeat the procedure. 17. After you complete the procedure, dry the patients ear and face and remove the towel and basin. Have the

18. 19. 20. 21. 22.

patient lie on her affected side on the examination table so that the ear can continue to drain. If you are performing a bilateral procedure, allow the patient to rest before performing the second irrigation to prevent dizziness or fainting. Give cotton balls to the patient to wipe any further drainage. Ask the patient how she feels. Dispose of supplies. Wash your hands. Document the procedure, noting the return and amount. Provide postcare instructions to the patient. Be sure to tell the patient to call the ofce and speak to the physician if she feels pain or continued dizziness. Also emphasize to the patient that she should not insert a cotton applicator or any other object into the ear canal.

Date 02/21/08; 10:30 a.m. Right ear irrigation, impacted cerumen dislodged. Patient reports tinnitus has stopped, hearing seems louder. ---------------------------------------------------------------- C. Smith, CMA

medical assistant can provide tongue depressors and the otoscope light to the physician to use to inspect the inside of the nose and view the back of the throat. If the throat appears inamed, the physician may direct the medical assistant to perform a throat culture. Many patients get sore throats from a bacterial infection. Streptococcus is one bacteria that causes a sore throat, commonly

called Strep throat, which can be treated with antibiotics. However, many patients have a sore throat that is caused by a virus, an allergic reaction, or overuse (for example, singing or yelling). The medical assistant can provide patient education on the use of antibiotics to help patients choose the appropriate treatment for their sore throat. (See Antibiotic overuse, page 775.)

774

UNIT 3

Clinical

PROCEDURE 36-8

Instilling eardrops
Task Instill eardrops to soften impacted cerumen, ght infection locally with antibiotic drops, or administer analgesics to relieve pain. Conditions Otic medication as prescribed by the physician Sterile eardropper Cotton balls Gloves Drape or paper towel Patients medical record Pen Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully instill eardrops. Performance Standards 1. Wash your hands. 2. Assemble equipment and supplies. 3. Introduce yourself and address the patient by name. 4. Explain the procedure to the patient to promote patient cooperation. 5. Check the label of the medication three times for correct medication and expiration date because expired medication or the wrong drug can cause harm to the patient. 6. Warm the ear drops under running warm water for patient comfort. 7. Position the patient to lie on her unaffected side or in a sitting position with her head tilted toward her unaffected ear so that the medication will ow into her ear and will not run down her neck. 8. Provide the patient with a paper towel or nonsterile drape for her shoulder to protect her clothing from staining by the medication. 9. Draw up the prescribed amount of medication into the sterile eardropper. 10. Gently pull the top of the auricle up and back (for adults) or pull the earlobe down and back (for children ages 3 and under) so that the medication will ow into the ear and will not run out. 11. Squeeze the rubber bulb to instill the prescribed dose of medication into the affected ear. 12. Ask the patient to maintain the position for about 5 minutes after instillation so that the ear will retain the medication.

Squeeze the rubber bulb to instill the prescribed dose into the affected ear.

13. If instructed by the physician, insert a moistened cotton ball into the external ear canal for 15 minutes because moistened cotton will not absorb the medication and will help retain the medication in the ear. 14. Wash your hands. 15. Document the procedure in the patients medical record.
Date 02/21/08; 10:35 a.m. 4 drops Ciprodex administered to right ear. ------------------------------------------------------------------------------- C. Smith, CMA

16. Repeat the procedure with the other ear if a bilateral procedure is ordered. 17. Teach the patient or caregiver how to instill the drops, stressing the importance of handwashing before and after instillation. As with eyedrops, make sure the patient understands that she should avoid touching the tip of the dropper to her ear or any object.

CHAP TER 36

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Patient Education

Antibiotic Overuse
Before or after taking a throat culture is a great time for the medical assistant to educate her patient about the difference between a viral infection and a bacterial infection. A patient may view antibiotics as a magic pill or cure-all. Some patients may be quite insistent that they need an antibiotic even though no bacterial infection is found. The physician or the medical assistant can explain that viruses and bacteria are different organisms and that antibiotics are unable to kill a virus. The medical assistant should make sure the patient knows that, in fact, overuse of antibiotics will actually strengthen the bacterias defenses and make them harder to kill when bacterial infection is present. The medical assistant should emphasize proper handwashing techniques as a means of preventing future infection.

2. Discuss what signs and symptoms parents should be aware of that may indicate a vision or hearing impairment in their child. Create a brochure to give to parents of infants, toddlers, and preschoolers that includes anatomical diagrams of the eye, ear, mouth, nose, and throat and warning signs of problems.

Case Studies
1. Wendy Howard brings her 7-year-old son Devin to the ofce because he has an earache. Devin has had several colds this winter and has missed several days of school. He appears tired and lethargic. Upon examination, the physician diagnoses Devin with otitis media and prescribes oral antibiotics and eardrops. In addition to treating the present infection, what can you tell Wendy and Devin to do to prevent future infections? 2. Mr. McDaniels is a 67-year-old patient who has been coming to the ofce for several years. He exercises often, eats right, and is very t. You notice lately that he asks you to repeat questions and you and the other staff members need to speak more loudly for him to hear you. Mr. McDaniels doesnt acknowledge that his hearing is gradually diminishing. Discuss with the group how to approach the patient without insulting him.

Chapter Summary

The medical assistant assisting with examination and treatment of the eyes, ears, mouth, nose, and throat must have an understanding of the anatomy and physiology of these areas. Proper patient education during vision and hearing assessment will ensure that accurate test results are obtained. When performing irrigation or instillation of medication to the eye or ear, the medical assistant must answer patient questions and inform the patient of the procedure as it occurs. Because the patient or caregiver will probably need to administer the medication at home, the medical assistant should teach the proper sterile technique during the procedure and answer any questions as they arise. Educating patients on the benets of frequent handwashing will prevent infection of the eye, ear, mouth, nose, and throat.

Resources

Anatomy of the ear: ctl.augie.edu/perry/ear/hearmech.htm Anatomy of the eye: www.emedicinehealth.com/anatomy _of_the_eye/article_em.htm and www.discoveryfund.org /anatomyoftheeye.html Diabetic retinopathy: www.allaboutvision.com/faq/diabetic.htm Digital Journal of Ophthalmology: www.djo.harvard.edu Information on diagnosis and treatment of streptococcal throat infection:www.emedicinehealth.com/strep_throat /article_em.htm Macular degeneration: www.blindness.org/Macular Degeneration/ Otitis media in children: www.kidsource.com/ASHA/otitis.html Scanlon, V.C., and Sanders, T.: Essentials of Anatomy and Physiology, 5th ed. Philadelphia: F.A. Davis Co., 2007. Swimmers ear self-care: www.mayoclinic.com/health /swimmers-ear/DS00473/DSECTION=10

Team Work Exercises

1. Ask a local school nurse if you can assist or observe Snellen, Jaeger, or Ishihara eye testing of students. Ask the nurse what follow-up procedures are in place for children with visual impairments, referrals to specialists, and so forth. What resources are available for eyewear for students who cannot afford glasses or contact lenses?

CHAPTER

Nutrition
Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms presented in the glossary dene energy and nonenergy nutrients discuss how a balanced diet promotes good health discuss the dangers of overnutrition and obesity dene nutrient density name and give a food source for water-soluble and fat-soluble vitamins name and give a food source for the major minerals name a deciency symptom of two vitamins and two minerals discuss syndrome X and its health implications dene anorexia and bulimia and some of their signs and symptoms.

37
ABHES Competencies
Instruction
Instruct patients with special needs Teach patients methods of health promotion and disease prevention

Chapter Outline
Understanding Nutrition Macronutrients
Carbohydrate Simple carbohydrates Complex carbohydrates Carbohydrate digestion Regulation of blood glucose Proteins Essential and nonessential Protein digestion Body protein manufacturing Fats Fatty acids Triglycerides Phospholipids Sterols Digestion of fat

Older Adults Medical Conditions HIV and AIDS Cancer Diabetes Soft diet Bland diet Sodium-restricted diet Weight-loss diets

Common Nutritional Diseases and Disorders

Macronutrient Disorders Kwashiorkor Marasmus Morbid obesity Syndrome X Micronutrient Disorders Rickets Scurvy Pellagra Beriberi

Micronutrients
Vitamins Minerals Water

Chapter Summary Team Work Exercises Case Studies Resources

CAAHEP Competencies
General Competencies Patient Instruction
Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention Identify community resources

Planning for Good Nutrition Nutrition for Special Populations

Pregnancy Children Infancy to age 2 Ages 2 to 12 Adolescence

777

Key Terms
adenosine triphosphate

Understanding Nutrition
Finding a diet that is nutritionally balanced, satises taste, and ts a busy lifestyle is an ongoing struggle for many Americans. Because food choices and quantity of food eaten impact all aspects of health, the medical assistant can play an important role in educating patients to make good food choices and control portions. In addition, the successful health care educator leads by example and benets from practicing healthy eating and exercise habits. A nutrient is a chemical substance obtained from food and used in the body to provide energy, build structural materials, support growth and maintenance, or repair body tissues. Nutrients also reduce the risk of disease by promoting proper function of organs and tissues. Nutrients can be divided into two main categories: macronutrients and micronutrients.

Usable energy of cells

calorie

Unit by which food energy is measured

carbohydrate

Compound containing carbon, hydrogen, and oxygen atoms

catabolism

Body process that converts large structures into smaller ones

cholesterol

Multiringed, waxy lipid found in all body cells

dehydration

Condition in which body water output exceeds water input

disaccharide

A sugar composed of 2 monosaccharides

emulsication

Process of making an emulsion, allowing fat and water to mix

fatty acid

Long, unbranched fat used by the body to manufacture various lipoproteins

glucose

Monosaccharide used by the brain and tissues for fuel

glycemic index

Macronutrients
Energy in the body is dened as the capacity to do work. The human body needs energy to do physical and chemical work. The sum of these physical and chemical processes that enable the body to meet the demands of living is called metabolism. The body uses the energy in foods to create body heat, move muscles, conduct nervous signals, produce hormones, regulate functions such as heart rate, and repair damaged tissues. Energy taken into the body is measured in calories. A calorie is a unit of measure that represents the amount of heat energy needed to raise 1 g of water 1 Celsius. Because a calorie is such a tiny measure of energy, food energy is expressed in Kilocalories, which is equal to 1000 calories. Kilocalories are more commonly known as Calories (with a capital C). Thus, calorie values on food labels are always capitalized to denote the kilocalorie. Nutrients that are measured in Calories (kcal) and, thus, contain energy include:

Scale that lists the amount of time it takes for a food to raise blood glucose levels
insoluble ber

Indigestible food components that do not dissolve in water

lipid

Family of compounds that are insoluble in water, including fatty acids, triglycerides, phospholipids, and sterols; also called fat
malnutrition

Condition caused by insufcient intake of nutrients

metabolism

All physical and chemical changes within the body that build and break down substances
micronutrient

Elements and compounds needed in the diet that do not contribute energy to the body
mineral

Inorganic element
monosaccharide

Single unit of sugar

nutrient

Chemical substance obtained from food and used in the body to provide energy, build structural materials, support growth and maintenance, or repair body tissues
overnutrition

carbohydrates fats proteins.

Carbohydrate
Carbohydrates are the main source of fuel for humans and should comprise 45% to 55% of total calorie intake. (See Economics of proper nutrition.) They are molecules made up of carbon, hydrogen, and oxygen. Carbohydrates are categorized as simple or complex, depending on the amount of energy needed to digest them.

Condition caused by excess intake of nutrients

protein

Dietary source of amino acids used to build various body tissues, hormones, and antibodies
soluble ber

Indigestible food component that dissolves in water to form a gel

undernutrition

Condition caused by insufcient intake of calories and, sometimes, nutrients

vitamin

Organic molecule that contains carbon and several different elements needed by the body to support chemical reactions

CHAP TER 37

Nutrition

779

Economics of proper nutrition

Carbohydrates are the most abundant and cheapest food source and represent the bulk of caloric consumption worldwide. Because most sources of protein and fat come from animals in the form of meats, milk, and cheese, these foods are more expensive to produce. Thus, people in developing countries may only have carbohydrate sources of foods. This lack of adequate dietary protein can cause nutritional disorders, especially in children. Although sources of protein in the United States and other developed countries are abundant, they are expensive. Patients with a limited income are, thus, restricted in the variety of food in their diet due to cost. If a patient is unable to buy enough food, the medical assistant can help identify local social service agencies, such as food banks, food stamps, and meal services.
H

CH2OH C C HO H C C O C OH OH CH2OH OH C H C H

CH2OH C

CH2OH C OH

H C OH C H

O C OH H

C
H

C H

C OH

OH

FIG 37-1 Chemical structures of monosaccharides. (A) Glucose. (B) Fructose. (C) Galactose.

Simple Carbohydrates
Simple carbohydrates are commonly referred to as simple sugars. Because of their uncomplicated chemical structure, they require little time for digestion by the body. There are two types of simple carbohydrate:

monosaccharides disaccharides.

Monosaccharides
All carbohydrates are made up of monosaccharides, which are single units of sugar. Although there are many monosaccharides, including xylose, mannose, and sorbose, three are more common in the human diet:

glucose fructose galactose. (See Figure 37-1.)

When a person ingests disaccharides, his body must break them down into usable forms of energy. First, it breaks disaccharides down into their separate monosaccharide units. Thus, sucrose breaks down into glucose and fructose, lactose into glucose and galactose, and maltose into the two glucose molecules. Then the body rearranges fructose and galactose into glucose in the liver for energy needs. The body uses glucose as its main source of fuel. Glucose circulates in the bloodstream, which delivers it to all of the organs and tissues of the body. An anaerobic reaction in tissues converts glucose to lactic acid. In the conversion process, each glucose molecule yields two molecules of adenosine triphosphate (ATP). ATP is the fuel that cells use to perform their necessary functions. A similar reaction in the presence of oxygen (aerobic) changes glucose to pyruvate and then, in a multistep reaction called the Kreb cycle, also yields two ATP molecules.

Other than fructose, which is present naturally in fruit and added to processed foods as crystalline fructose or high fructose corn sweetener, monosaccharides are not present in foods. More commonly, they are chemically bonded together in various combinations of two monosaccharides to form a disaccharide.

Complex Carbohydrates
Complex carbohydrates, also known as polysaccharides, are made up of many units of monosaccharides, the simple sugars. There are three types of complex carbohydrates:

Disaccharides
Three disaccharides constitute the main dietary sources of sugar for humans:

starch glycogen ber.

sucrose, a combination of glucose and fructose and found in such foods as granulated sugar, sugar beets, honey, and maple syrup lactose, made up of glucose and galactose and found in milk and dairy products maltose, made up of two molecules of glucose and found in beer. (See Figure 37-2.)

Unlike simple sugars, complex carbohydrates have more complicated chemical structures. Thus, they require more time in digestion to break the chemical bonds between the sugar units to make them usable by the body. The sugar units in polysaccharides are linked together by chemical bonds in straight chains, which take more time to break down, or branching arrangements, which break down more readily. (See Figure 37-3.)

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A
H

CH2OH C C OH H O C C H C OH OH H CH2OH C O C OH H OH C H O C CH2OH H

Glycogen
By contrast, the complexity of the branching chains of the glycogen molecule enables enzymes to break down glycogen molecules more quickly in the body. The body uses glycogen as a storage form of energy. It is the primary source of glucose (in storage) and releases glucose into the bloodstream to raise blood glucose in times of fasting, such as during sleep. The primary storage site for glycogen is the liver and muscles. Although meats contain glycogen, they are not a signicant dietary source.

OH

(Oxygen linkage) Glucose + Fructose CH2OH O H C OH H HO H C C OH (Oxygen linkage) Glucose + Galactose CH2OH O H C OH H HO H C C OH (Oxygen linkage) Glucose + Glucose HO C O C H OH C C H OH O H C C H H C O C OH H C C OH OH C C O H

Fiber
Although ber is a kind of complex carbohydrate, most dietary ber is not digestible. Thus, it does not contribute energy to the diet. However, although we do not digest ber, it is important because it provides bulk to feces and promotes intestinal motility (movement of feces through the intestines). There are two main types of ber:

B
H

CH2OH C

insoluble soluble.

C
H

CH2OH C

FIG 37-2 Chemical structures of disaccharides. (A) Sucrose. (B) Lactose. (C) Maltose.

Insoluble Fiber Fiber that does not break down in water is classied as insoluble. There are three types of insoluble ber: cellulose, hemicellulose, and lignin. These bers are the structural components of plants. Although cellulose is made up of a straight chain of glucose molecules, similar to amylose, the molecules are linked together by beta bonds, which human enzymes cannot break down. Hemicellulose is made up of glucose but also galactose, xylose, and other monosaccharides. As with cellulose, human enzymes cannot break the bonds of the hemicellulose molecule; thus, it is also indigestible. Cellulose and hemicellulose are found in such foods as whole wheat breads, bran, oatmeal, lentils, and black beans. Lignin does not contain glucose; it is made up of alcohols and acids and is the woody ber found in wheat bran and the seeds of many fruits and vegetables. Soluble Fiber There are three kinds of soluble ber:

Starch
Starch is found in plants. There are two kinds of starch molecules: amylose and amylopectin. Amylose is a straight chain of glucose units. Amylopectin is a mostly linear molecule of glucose units with some branching. Although their chemical structures differ, both types of molecules have alpha bonds, which are the links between the simple sugar units. Salivary and later pancreatic enzymes break down the alpha bonds that link the sugar units, enabling the bloodstream to absorb the sugar. Starch is the main type of digestible complex carbohydrate. Examples of food sources of starch include wheat, rice, potatoes, and legumes, such as beans and peas.

pectin gum mucilage.

Human enzymes cannot break down any of these types of ber either. However, they are an essential food source for bacteria in the large intestines of the body. Thus, soluble ber is important in maintaining normal bacteria in the intestine. (See Fiber and colorectal health, page 782.) Pectin and gums are more common in the American diet than mucilage. Pectin is found in citrus fruits, strawberries, apples, carrots, jams, and jellies. Gums are found in oats, legumes, and barley. Mucilage is found in axseed and kelp. All three types are made up of various combinations of monosaccharides and acids.

CHAP TER 37

Nutrition

781

A
Amylose Straight chains of glucose 500 to 20,000 glucose units

Amylopectin Amylose chains connected in branches Up to 30 amylose branches

Glycogen Many more branches than amylopectin Approximately 60,000 glucose molecules

Fiber Linked by indigestible beta bonds FIG 37-3 Chemical structures of polysaccharides. (A) Starches. (B) Glycogen. (C) Fiber.

Carbohydrate Digestion
The process of carbohydrate digestion begins in the mouth with the release of salivary enzymes. Salivary amylase mixes with food products and breaks some starches into smaller units. Then the carbohydrates reach the stomach, where the acidic environment of the stomach inactivates the amylase. The carbohydrates then pass through the stomach and into the small intestine, where most digestion and absorption occurs. The pancreas and walls of the small intestine secrete digestive enzymes. The enzyme pancreatic amylase breaks starch into disaccharides and small polysaccharides. Enzymes from the cells of the intestinal wall break down the remaining polysaccharides and disaccharides into their monosaccharide components (glucose, fructose, and galactose). Then the cells of the small intestines absorb these monosaccharides. After absorption, the monosaccharides travel to the liver, where the liver converts fructose and galactose into glucose molecules. Then the liver releases glucose into the bloodstream or links the molecules together to form glycogen for storage. Dietary ber is not digested and passes into the colon unchanged, providing bulk to form stools.

Regulation of Blood Glucose

Carbohydrates are the main food source of glucose, stored in the liver and muscles as glycogen. Storage of a large amount of glucose enables blood glucose regulation when a person is not eating. How quickly different types of food deliver glucose to the bloodstream is indicated in the glycemic index, which rates foods on a scale from slowest to fastest delivery of glucose to the bloodstream. (See Glycemic index, pages 784 and 785.) Carbohydrates that are slower are recommended for inclusion in the diet, especially for people trying to lose weight. Slower carbohydrates take longer to affect blood glucose levels. Therefore, they create less of an insulin response, resulting in a longer period before a person becomes hungry again. (See Figure 37-4.)

Proteins
Proteins are amino acids linked together in chains and branching arrangements by peptide bonds. A protein consists of these long peptide chains that can range from 50 amino acids to thousands. Peptide bonds break down spontaneously in water, although slowly. Digestive enzymes, called proteases, help speed up the process somewhat; however, the breakdown

782

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Patient Education

Fiber and Colorectal Health

Most patients who develop colon cancer, diverticulitis (weakening of the intestine), diverticulosis (infection of weakened areas of the intestine), hemorrhoids, stulae, and ssures have a history of chronic constipation or irregular bowel habits. The most common cause of chronic constipation is inadequate dietary ber. The medical assistant can educate patients on the need for adequate dietary ber by explaining how it functions to preserve colorectal health. For optimal bowel function, a person must ingest 25 to 30 g of ber each day. After the body digests food, the colon receives approximately 1 pint of liquid stool along with the undigested ber. Normally, the colon gradually removes the remaining water, and forms a shaped stool. The ber in the stool retains some water, making the stool soft and bulky, enabling it to move easily toward the rectum for elimination. When dietary ber is scarce, the stool becomes hard, dry, and small and requires more force to move through the colon for elimination. Because the patient must strain to defecate, he causes damage to the intestinal wall. The straining produces pressure on the walls of the colon, creating diverticulitis and diverticulosis. Hemorrhoids and anal stulae and ssures can also be caused by damage to the tissues from straining. Colorectal cancers can be caused by hard, dry stool remaining in the colon too long, resulting in reabsorption of carcinogens into the surface of the colon. Also, because straining to defecate is painful, many patients may take over-the-counter stool softeners or laxatives. Long-term use of these products can render the colon unable to eliminate feces without the help of a laxative or stool softener (dependence). The medical assistant should educate her patient that he should use laxatives only for a short-term correction of bowel health to avoid becoming dependent on them. She should recommend that the patient use laxatives only with the physicians consent. She should also encourage the patient to correct the dietary ber inadequacy to achieve normal bowel movements. She can suggest incorporating the following foods into the diet to increase ber intake: beans, including baked, kidney, pinto, black, and lima beans bran cereals, whole wheat breads, and pastas dried fruits, including apricots, prunes, and raisins fruits, including raspberries, blackberries, cherries, strawberries, plums, pears, and apples vegetables, including broccoli, spinach, collard greens, and peas

of peptide bonds is slow compared to that of alpha and beta bonds. In addition, proteins are found in numerous body tissues in the form of cellular components, enzymes, and hormones. The human body contains over 10,000 different types of these proteins, called body proteins. Protein is an important component of a healthy diet. Although proteins are energy-yielding nutrients, their main function is to provide amino acids to build various body tissues. Because the body does not store amino acids as it does carbohydrates, it needs adequate supplies of protein in the diet every day. The Institute of Medicine recommends that adults get a minimum of 0.8 g of protein per day for every 20 lb of body weight. The body uses this amount of protein to maintain body tissues and ensure that the body is not breaking down its own tissues for fuel. (See Food sources of protein, pages 785 and 786.)

Essential and Nonessential

There are 20 different amino acids that make up proteins. The name amino acid is derived from the structure of an

amino acid molecule. At one end, the molecule has an amine group (containing nitrogen) and at the other end, an acid group (containing carboxylic acid). The two ends are connected to a central carbon atom. The type of amino acid is determined by the side group, or molecule attached to the central carbon atom, including hydrogen (forming the amino acid glycine), a methyl group (forming the amino acid alanine), or a larger heterocyclic group (forming the amino acid tryptophan). (See Figure 37-5.) Amino acids are categorized as essential or nonessential. Essential amino acids are those that the body cannot synthesize (or create on its own) to build necessary body tissues. Thus, dietary sources of these amino acids are necessary (essential) for health. An adults diet has eight essential amino acids. Another four amino acids are essential in a childs diet because a childs body has not yet developed the metabolic pathways to synthesize these amino acids. Nonessential amino acids may be synthesized by the body or supplied in dietary sources.

CHAP TER 37

Nutrition

783

Amino acid structure Hydrogen H H N Food Amino group H R Side group (R is always used to represent a side chain that is not specified.) FIG 37-5 Amino acid structure with side group (R). C C O OH Carboxylic acid group

Intestines release glucose into bloodstream

The eight essential amino acids adults need are:

Raises blood sugar

High blood sugar

isoleucine leucine lysine methionine phenylalanine threonine tryptophan valine. The nonessential amino acids are:

Liver

Stimulates breakdown of glycogen Glucagon

Promotes insulin release

Glycogen Glucose

Stimulates formation of glycogen Insulin Stimulates glucose uptake from blood

Pancreas

alanine arginine (essential in children) asparagine aspartate cysteine (essential in children) glutamate glutamine glycine histidine (essential in children) proline serine tyrosine (essential in children).

Protein Digestion
Promotes glucagon release

Tissue cells (muscle, kidneys,fat)

Lowers blood sugar FIG 37-4 Blood glucose regulation in the body.

Low blood sugar

The first phase of protein digestion takes place in the stomach. Stomach acid begins to break down some of the protein molecules into amino acids. Then pepsin, an enzyme secreted in the stomach, begins to digest those amino acids. However, only a few protein molecules break down into amino acids in the stomach; most remain connected together. In the duodenum (first segment of the small intestine), the pancreas secretes the enzymes trypsin and chymotrypsin. Like pepsin, these enzymes break the bonds between individual amino acids through a process called hydrolysis, because it requires a water molecule to unlink the amino acids. When amino acids are not linked, they are small enough to pass through the

784

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Glycemic index
The glycemic index (GI) is a scale that rates foods based on how fast they raise blood glucose levels. Pure glucose is given the value of 100, and the index compares how fast each food delivers glucose to the bloodstream compared to pure glucose. For example, carbohydrates that break down quickly during digestion have a high GI of 70 or more. Carbohydrates that break down slowly have a low GI of 55 or less. Medium GI range is 56 to 69. The following table lists a sampling of foods and their glycemic index.

Food
Low Vegetables Artichoke, asparagus, broccoli, cauliower, celery, cucumber, eggplant, onion, spinach Lima beans, chick peas, kidney beans, lentils Carrots, fresh or boiled Sweet corn Beets, peas Fruit Prunes Cherries Apple, plum, pears, strawberries Orange, peach, grapes Kiwi Mango, bananas, fruit cocktail (in syrup) Pear, papaya, apricots Raisins, cantaloupe Pineapple Watermelon Dates Dairy Products Plain yogurt Whole milk Skim milk Chocolate milk Yogurt (fruit avored) Ice cream, vanilla Grains, Breads, and Pastas Fettuccine Spaghetti Linguini, rye bread, multigrain bread Pita bread, brown rice White rice Wheat bread, taco shells White bread Plain bagel Saltine crackers Prepared Foods and Snacks Peanuts, walnuts Cashews 15 22 32 40 49 56 58 68 14 30 32 35 36 60 15 22 38 43 52 55 58 64 66 30 49 56 65 15 Medium

Glycemic Index
High

72 103

70 72 74

CHAP TER 37

Nutrition

785

Glycemic indexcontd
Food
Low Peanut M&Ms Fish sticks Chocolate chip cookies, sponge cake Cheese tortellini, strawberry jam, chocolate bar Snickers bar, popcorn (light), potato chips, oatmeal cookies Cheese pizza Macaroni and cheese, corn chips Angel food cake, croissant French fries, doughnuts, graham crackers, wafes Rice cakes, jelly beans Pretzels Tofu frozen dessert Beverages Tomato juice Apple juice Pineapple juice, carrot juice Grapefruit juice Orange juice Cola Cranberry juice cocktail Gatorade 38 41 46 48 52 65 68 78 60 64 67 75 80 83 115 32 38 44 50 55 Medium

Glycemic Index
High

intestinal wall into the capillaries that surround the intestines, which distribute them via the bloodstream. Amino acids in the bloodstream are used to build many body proteins.

Food sources of protein

Cells synthesize proteins according to their specic needs. Adequate dietary protein delivers the amino acids necessary to build complex proteins with a variety of functions. Foods high in protein include meats, dairy, eggs, nuts, and seeds. The following table lists some of these foods along with a typical serving size and the quantity of protein it contains.

Body Protein Manufacturing

After amino acid distribution in the body, cells link amino acids back together again in different arrangements to make specic proteins for their needs. Examples of proteins that the body manufactures include:

insulin, a protein made by the pancreas to deliver glucose to cells ferritin, a protein made in the intestinal mucosa through the union of iron with the protein apoferritin (Ferritin stores iron and will release it as needed by the body.) hemoglobin, a protein made in red bone marrow and used by red blood cells to deliver oxygen to cells myoglobin, an iron-containing protein found in muscle cells that stores oxygen for use in cell respiration

Food Source
pecans cashews chicken wings (2) egg sunower seeds almonds

Serving Size
1 1

Quantity of Protein
2.5 g 5g 6g 6g 6g 8g

4 cup 4 cup 4 oz

1 large
1 1

4 cup 4 cup

Continued

786

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Food sources of proteincontd

Food Source
beans (black, pinto, lentils) milk peanut butter soy milk swiss or Cheddar cheese peanuts chicken thigh parmesan cheese yogurt chicken drumstick cottage cheese ham tofu turkey (white meat) sh llet (cod, haddock) or salmon steak pork chop hamburger patty roast beef steak pork tenderloin chicken breast canned tuna one, average size 4 oz 3.5 oz 4 oz 4 oz 3.5 oz 6 oz 28 g 28 g 28 g 29 g 30 g 40 g 22 g
1 1

Patient Education

Serving Size
1

Quantity of Protein
8g 8g 8g 8g 8g 9g 10 g 10 g 10 g 11 g 15 g 19 g 20 g 21 g 22 g

Protein and Bone Health

In the past, health care providers and others thought that high-protein diets increased urinary output of calcium and, therefore, were detrimental to bone health. However, recent studies now show that patients who habitually consume low-protein diets demonstrate decreases in bone density and increases in bone loss. Thus, the medical assistant must educate her patients on this new information to combat misconceptions about proteins effects on bone health. The medical assistant should explain to patients that to build and repair bone, the body needs protein to create the matrix that will be mineralized by calcium, phosphorus, magnesium, and uoride. Without adequate protein, the body is unable to utilize the minerals for bone maintenance, so calcium supplements or bone-density-enhancing drugs such as Fosamax will not increase bone mineralization.

2 cup

1 cup 2 Tbs 1 cup 1 oz 4 cup 3 oz 1 oz 1 cup one drumstick, average size

1

2 cup 3 oz 2 cup 3 oz

3.5 oz

Fatty Acids
A fatty acid is an organic acid made up of a chain of carbon atoms with hydrogen atoms attached and an acid group at one end. Fatty acids can be saturated or unsaturated based on the number of hydrogen atoms attached to the carbon atoms on the chain. A saturated molecule has as many hydrogen atoms as it can hold. Unsaturated molecules are missing hydrogen atoms. If a hydrogen atom is missing between two carbon atoms, a double bond is created between those carbon atoms. This double bond is a site where there is no saturation, and the fatty acid is considered monounsaturated. If more than one double bond occurs in a fatty acid, it is polyunsaturated. (See Figure 37-6.) Polyunsaturated fats are better sources of dietary fat because their consumption reduces the incidence of coronary artery disease and cholesterol levels in the blood. Although the exact mechanisms are unclear, the body can use polyunsaturated fat molecules to make cell membranes. Saturated fat molecules, which contain only single bonds, are not exible enough to be incorporated into cell membranes. In addition, saturated fat molecules are larger and less dense because they have more hydrogen attached. Therefore, they can lodge in arteries, contributing to coronary artery disease. Fatty acids are necessary components of the structural portion of cells. They also participate in the immune response to injury and help regulate blood pressure as well as many other functions. The body is able to synthesize all fatty acids except two, which are called essential fatty acids. The essential fatty acids are linoleic acid and linolenic acid. Inclusion of food sources of the essential fatty acids or

antibodies, giant protein molecules manufactured to combat invaders (pathogens) in the blood bone sialoprotein, osteocalcin, and osteonectin, used, among other functions, to keep calcium in bone matrix, contributing to its strength. (See Protein and bone health.)

Fats
Although fat is commonly associated with obesity and thought to be a bad component of food, fats, or lipids, perform important functions as part of a balanced diet. Structurally, lipids look different from carbohydrates. They are chains or branched chains of carbons or contain four rings (as in cholesterol). There are four types of lipids:

fatty acids triglycerides phospholipids sterols.

CHAP TER 37

Nutrition

787

HO C O

H C

H H H C H H H C C H H H H C C H H H H H H C C H H H Double bonds, site of unsaturation H C H C H H C H H C H H C H C H H C H C

H H

C
C

Only one site of double bond

O C HO H C

H C

H H C C

H H C C

H C

H C C

H C

H C C

H C

H C C

H H C H H

C H H H H

H H

H H

FIG 37-6 Fatty acids. (A) Monounsaturated (oleic acid). (B) Polyunsaturated (linolenic acid).

supplements containing them is vital to a complete diet. (See Food sources of essential fatty acids.)

Triglycerides
Most foods do not contain single fatty acids, called free fatty acids. More commonly, they contain triglycerides, which are three fatty acid chains attached to one glycerol unit. (The

Food sources of essential fatty acids

Because the body is unable to synthesize linoleic and linolenic acids, the healthy diet must include sources of these fatty acids.

glycerol converts to glucose for energy needs.) Triglycerides, the most common form of fat in the diet, are the major storage form of fat in the body. Triglycerides are used by the body as a source of energy and as insulation in their storage form as body fat. Because a triglyceride molecule contains three fatty acid chains, it is a larger molecule than a free fatty acid. The degree of unsaturation on the fatty acids also impacts the use of the triglyceride in the body and, therefore, health. The more saturated the molecule, the larger it is and the more likely it will contribute to stagnation in the bloodstream and the formation of fatty streaks.

Phospholipids
Phospholipids are structurally similar to triglycerides; however, instead of three fatty acids, there are two fatty acids and a phosphate group. The phosphate group on the phospholipids makes the molecule soluble in water; the fatty acid component makes it soluble in fat. This dual solubility is unique in the body and allows the molecule to create cell membranes. Without phospholipids in the diet, cell membrane integrity suffers. This dysfunction can lead to structural damage within the body and promote the likelihood of cancer and other disorders. Because the cell membrane structure is water and fat soluble, it can help lipids move in and out of cell membranes into the watery uid on both sides. Thus, hormones and fat-soluble vitamins can pass into the cell as needed. Phospholipids can also keep fat-soluble substances suspended in a watery media by a process called emulsication. Emulsied fats are broken down into components that are small enough

Linoleic Acid
Corn oil Safower oil Soybean oil Chicken fat Turkey fat

Linolenic Acid
Flaxseed oil Canola oil Soybean oil Soybeans Walnuts

788

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to become suspended in water. They are not dissolved in water but are suspended in the watery media. An excess of fat in the diet will cause the emulsied fat to be transported to adipose cells (fat cells). For most people, the number of cells does not increase; however, the size of the cells does. Thus, as a person increases intake of fatty foods, the amount of fat stored in the adipose cells also increases, causing weight gain and increased body size. Some research indicates that, in cases of morbid obesity (body weight 50% greater than normal or higher), the total number of fat cells will increase as well as the size of the cells.

Normal

Sterols
Sterols are lipids that contain a sterol group, which is a fourring carbon structure. Bile acids found in the liver and gallbladder, vitamin D, and sex hormones are all made from sterols. The most well known sterol is cholesterol.

Cholesterol
Although people commonly talk about good cholesterol and bad cholesterol, there is only one chemical known as cholesterol. The compounds mistaken for cholesterol are actually lipoproteins, which are compounds made of lipids and proteins. High-density lipoproteins (HDLs) are helpful blood constituents that carry cholesterol to the liver for breakdown and excretion. Low-density lipoproteins (LDLs) circulate in the bloodstream and transport cholesterol and triglycerides from the liver to the peripheral tissues. Thus, too much LDL in the blood enables too much cholesterol and too many triglycerides to reach body tissues. The ratio of HDL to LDL dictates how much cholesterol is excreted and how much is stored. Chylomicrons (large lipoproteins) and very-low-density lipoproteins (VLDLs) contain even more cholesterol than LDLs. Cholesterol is derived only from animal sources, such as eggs, meats, sh, and poultry. Plant food sources may contain sterols, but not cholesterol. Surprisingly, most cholesterol is synthesized in the liver, not found in the diet. Cholesterol becomes harmful when it forms deposits of fatty streaks and brous plaques along artery walls. (See Figure 37-7.) High levels of LDLs, which contain a large percentage of cholesterol, are associated with obesity and overeating. Excessive intake of any food can cause obesity and higher levels of the more dangerous lipoproteins. (See Food and cholesterol.
Fat and cholesterol accumulate FIG 37-7 Build-up of cholesterol along artery walls.

enough to be absorbed through the walls of the intestines. After they are absorbed into the bloodstream, they reassemble into triglycerides. Chylomicrons then carry them through the lymph system to the liver. The liver uses cholesterol to manufacture bile acids and bile salts. Various tissues also use cholesterol and other sterols to produce hormones. Cholesterol and other sterols ingested in foods do not provide any calories in adults and children. Only about 25% of the cholesterol in food is absorbed and even fewer amounts of sterols. Infants absorb more cholesterol because their bodies are building more tissues, especially in the brain and central nervous system. Fat digestion in infancy is quite different than in children and adults, especially if the infant is ingesting breast milk. Digestion of fat in breast milk begins in the infants mouth with enzymes that are only present in the mammary gland and are delivered with the milk.

Micronutrients
Vitamins and minerals are also essential components of a complete diet. Because these substances do not contribute calories (energy), they are called micronutrients. They are essential to body functions in various ways. Vitamins facilitate the release of energy from carbohydrate, fat, and protein; minerals provide building materials for body structures and inuence blood and pH. Water provides the environment for body processes to occur, acts as a transport medium for materials in and out of cells, and keeps organs and tissues lubricated and pliable.

Digestion of Fat
Digestion of fat begins in the stomach, where stomach acid breaks some short-chain triglycerides into glycerol and fatty acids. The longer-chain triglycerides are more abundant in the diet and are broken down in the small intestine (by bile acids manufactured in the liver and lipases manufactured in the pancreas) and delivered to the duodenum by the gallbladder. Bile acids emulsify triglycerides into individual fatty acids and monoglycerides so that the molecules are small

CHAP TER 37

Nutrition

789

Patient Education

Vitamins
Vitamins are complex organic molecules that contain carbon and several different elements needed by the body to support chemical reactions. They are essential for health because they facilitate the release of energy from macronutrients. Vitamins are present in many food sources, sometimes in an inactive form, such as in vitamin B12 and vitamin D, that the body must convert to an active form. Many vitamins work together in complex chemical reactions in the body. Thus, a deciency of one vitamin can negatively impact the absorption of another vitamin. For example, an insufcient intake of vitamin B12 causes a deciency of folate, which depends on vitamin B12 to facilitate its absorption. Also, adequate intake of vitamin C aids reactivation of oxidized vitamin E so it can serve as an antioxidant. Paying close attention to inclusion of all vitamins in a balanced, healthy diet promotes proper function of organs and tissues, production of hormones and neurotransmitters, and healthy growth, maintenance, and repair. (See Vitamin functions and food sources.)

Food and Cholesterol

Patients can reduce high levels of low-density lipoproteins (LDLs), commonly known as the bad cholesterol, with diet modication, exercise, and weight reduction. Although lipid-lowering medications are available (statins), the patient should attempt to correct a poor diet before adding medication. Patients may not realize that their poor food choices and sedentary lifestyle not only contribute to high LDL levels but also to cardiovascular disease, onset of diabetes, orthopedic injuries due to obesity, and lack of muscle mass. Carbohydrates that have a low glycemic index and are high in ber can reduce serum cholesterol by inhibiting the intestinal absorption of cholesterol in foods. The medical assistant can advise her patients to include oats, bran, and apples in their diets. In addition, telling them to substitute polyunsaturated fats for saturated fats will help to lower their serum cholesterol levels as well. Polyunsaturated fats are found in safower, corn, soybean, sesame, and sunower oils and can be used for cooking in place of saturated fats, such as butter. Saturated fat is concentrated in the white streaks of fat in meats. The medical assistant can advise patients to choose lean cuts of meat and trim fat or drain fat while cooking to reduce saturated fat in the diet. They should also avoid oils that are hydrogenated, which means that the polyunsaturated fat has been converted to a saturated fat to increase its shelf life and stability. Foods to avoid include egg yolk, organ meats, whole milk, and ice cream.

Minerals
Minerals are inorganic elements that do not contain carbon as vitamins do. They are made up of only themselves and are very small in relation to vitamins, carbohydrates, fats, and proteins. Minerals are commonly divided into two groups:

major minerals, which appear in the body in amounts greater than 5 g trace minerals, which are in smaller quantities.

Although the body only needs small amounts of trace minerals, a deficiency in these minerals can cause health

Vitamin functions and food sources

The table shown here lists vitamins along with their major functions and common food sources.

Vitamin
Vitamin A**

Function
Promotes vision Participates in protein synthesis Supports growth

Source
Fortied milk, cheese, eggs, beef liver, spinach, broccoli, apricots, carrots, cantaloupe, sweet potatoes, squash, pumpkin

B Vitamins Thiamine* (B1) Assists in energy metabolism Peas, tomato juice, watermelon, acorn squash, soy milk, pork chops, ham Riboavin* (B2) Coenzyme needed for release of energy from nutrients in body cells Spinach, broccoli, mushrooms, milk, yogurt, eggs, beef liver, clams

Continued

790

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Vitamin functions and food sourcescontd

Vitamin
Niacin* (B3)

Function
Two major coenzymes that enable energy transfer in cells

Source
Peas, corn, potatoes, peanut butter, shrimp, chicken, ham, tuna, liver, halibut Egg yolks (cooked), soybeans, sh, beef liver, whole grains (also produced by GI bacteria) Mushrooms, avocado, broccoli, beef liver, whole grains Meat, sh, chicken, potatoes, legumes, fortied cereals, liver, soy milk Spinach, broccoli, pinto and kidney beans, asparagus, lentils

Biotin* (B7)

Coenzyme of the citric acid cycle, involved in gluconeogenesis and fatty acid synthesis

Pantothenic acid* (B5)

Synthesis of lipids, neurotransmitters, steroid hormones, and hemoglobin

Vitamin B6*

Amino acid metabolism, synthesis of heme, nucleic acids and lecithin

Folate* (B9)

Coenzyme complex that helps to synthesize DNA

Vitamin B12*

Part of coenzyme system that synthesizes new cells, maintains nerve cells, and breaks down some fatty acids and amino acids

Meat, sh, chicken, shellsh, milk, cheese, eggs, fortied cereals

Vitamin C*

Collagen synthesis Provides matrix for bone growth Antioxidant Thyroxin synthesis Amino acid metabolism Strengthens resistance to infection Aids in the absorption of iron

Citrus fruits, spinach, broccoli, cantaloupe, strawberries, tomatoes, papaya, mangoes

Vitamin D**

Aids in the mineralization of bone

Fortied milk, cereals, veal, beef, egg yolks, salmon, sardines, sh oils (also synthesized in the body with the help of sunlight)

Vitamin E**

Antioxidant that stabilizes cell membranes Inhibits oxidation reactions that can cause cellular damage

Spinach, broccoli, wheat germ, whole grains, beef liver, eggs, nuts, seeds

Vitamin K**

Aids in synthesis of blood-clotting proteins

Beef liver, spinach, broccoli, cabbage, milk (also synthesized by GI bacteria)

* Water-soluble vitamins ** Fat-soluble vitamins

problems. Eating a variety of whole foods that include vegetables, meats, and whole grains will probably supply adequate quantities of major and trace minerals. In addition, intake of a multimineral supplement may ensure that all minerals are present in adequate amounts; however, such supplements should not replace healthy food choices. Vitamin and mineral supplements are safe when taken in amounts that do not exceed toxicity levels and can be used as a guarantee of vitamin and mineral intake. The medical assistant should urge her patients to tell the physician what supplements they are taking because some

supplements can affect prescribed medications or blood testing results. (See Minerals and their functions.)

Water
Water is an essential non-energy-yielding nutrient. Water is the most abundant molecule in the body and makes up 65% of body weight in males and 55% in females. Without adequate water intake, the body cannot survive for long. Water is a component of intracellular uids that allow chemical reactions to occur within cells and of extracellular uids that allow transport of nutrients to cells.

CHAP TER 37

Nutrition

791

Minerals and their functions

The following table lists minerals along with their function, minimum dietary requirements, major food sources, and symptoms of deciency.

Mineral
Calcium (Ca)

Major Functions
Mineralization of bones and teeth Muscle contraction and relaxation Nerve function Blood clotting Blood pressure maintenance

Minimum Requirements
Adults: 1000 mg/day Adolescents: 1300 mg/day

Major Food Sources

Milk, yogurt, cheese, tofu, sardines, spinach, broccoli

Deciency Symptoms
Osteoporosis in adults, rickets in children

Phosphorus (P)

Mineralization of bones and teeth Part of phospholipids (which is important to each cell of the body) Used in energy transfer and buffer system (acid-base balance)

Adults: 700 mg/day

Beef, eggs, sh, chicken, turkey

Weakness, bone pain

Potassium (K)

Fluid and electrolyte balance Assistance with nerve impulses and muscle contractions

Adults: 2000 mg/day

Bananas, potatoes, sweet potatoes, avocado, acorn squash, soybeans, chicken, beef

Muscle weakness, paralysis, confusion

Sulfur (S)

Part of proteins (creates disulde bridges that stabilize protein structures)

No requirement alone (part of B vitamins)

All protein-containing foods, including meats, eggs, cheese, legumes, and nuts

No known deciency (because severe protein deciency would occur rst) No known deciency (because of its abundance in foods)

Chloride (Cl)

Fluid and electrolyte balance Part of stomach acid

Adults: 750 mg/day

Table salt, soy salt, meats, eggs, processed food

Magnesium (Mg)

Mineralization of bones and teeth Muscle contraction Nerve transmission Immune system function

Adults: 350 mg/day

Nuts, legumes, whole grains, dark vegetables, seafood, chocolate

Weakness, confusion, convulsions, eye and facial muscle twitching, hallucinations, dysphagia, lack of growth in children

Iron (Fe)

Part of hemoglobin protein that carries oxygen to tissues Part of myoglobin protein in muscles

Men: 8 mg/day Women: 18 mg/day (ages 19 to 50); 8 mg/day (ages 51 and over)

Red meats, sh, chicken, shellsh, eggs, legumes

Reduced immune system function, poor wound healing, impaired cognitive function in children, lethargy, fatigue, itchy skin, inability to regulate body temperature

Continued

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Minerals and their functionscontd

Major Functions
Part of many enzymes Involved in making proteins Necessary for taste perception Transport of vitamin A Normal fetal development Copper (Cu) Necessary for absorption and use of iron Part of many enzymes Manganese (Mn) Necessary for building various enzymes Men: 2.3 mg/day Women: 1.8 mg/day Nuts, whole grains, broccoli, spinach Poor growth, neurological symptoms, inability to reproduce (adults) Iodine (I) Component of thyroid hormones, which regulate growth, development, and metabolic rate Selenium (Se) Antioxidant Regulation of thyroid hormones Adults: 55 mcg/day Seafood, meat, whole grains Heart disease, increased risk of cancer Adults:150 mcg/day Iodized salt, seafood, bread, dairy foods Goiter, cretinism Adults: 900 mcg/day Seafood, nuts, whole grains, legumes

Mineral
Zinc (Zn)

Minimum Requirements
Men: 11 mg/day Women: 8 mg/day

Major Food Sources

Meat, sh, chicken, turkey, whole grains, vegetables

Deciency Symptoms
Growth retardation in children, weak sense of smell and taste, night blindness, decreased appetite, hair loss, slow wound healing, rough, dry skin Bone loss, anemia

Water in the body is responsible for:

carrying nutrients and waste products in the body aiding in the regulation of body temperature through sweat and thirst mechanisms maintaining the structure of large molecules, such as proteins and glycogen participating in metabolic reactions within cells maintaining blood volume and blood pressure acting as a lubricant in eyes, joint capsules, the spinal cord, and the amniotic sac in pregnancy serving as a solvent for vitamins, minerals, amino acids, and glucose in the blood, cells, and extracellular uid.

water intake. Infants and toddlers are susceptible to dehydration when they have diarrhea. Treatment with electrolytebased drinks or intravenous uids will correct water loss. Hot weather can cause dehydration if a person does not continue to drink water in the heat. Avoiding diuretic drinks, such as those containing alcohol or caffeine, will help avoid dehydration.

Planning for Good Nutrition

Adequate calories from healthy food sources promote healthy body weight, growth in children, maintenance and repair of injured tissues, and overall good health. A diet that supplies the necessary nutrients in adequate amounts requires planning. References, such as the food pyramid, can guide a person in making good food choices. The number of servings in the food pyramid refers to portions of each food. Balancing amounts of nutrients is just as essential as including necessary nutrients. The food pyramid provides adequate intake of macronutrients and micronutrients for good health and weight control. It also recommends whole grains to include adequate ber and varying colors of vegetables to ensure a variety of vitamins in vegetable selections. It recommends primarily fresh fruit to

Intake of water is principally driven by thirst. The body derives water from liquids and solid foods, such as vegetables, fruits, and, to a lesser degree, meats and grains. Dehydration, when water output exceeds water intake, may occur rapidly and can result in death if not treated immediately. Symptoms of dehydration start with thirst, fatigue, loss of appetite, dry mouth, and reduced urine output and progress to include irritability, sleepiness, and, later, dizziness, loss of balance, muscle spasms, delirium, and collapse. Dehydration is a complication of infections that cause diarrhea, where water loss exceeds

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include ber from fruits. Canned, dried, and frozen fruits, while better than no fruit, are a secondary option. Dairy recommendations specify low-fat and nonfat products, which will add calcium to the diet without adding unnecessary fats. Meat and bean recommendations specify low-fat, lean meats and poultry, and the inclusion of beans, nuts, and legumes for protein to limit, once again, unnecessary fat in the diet. The pyramid also recommends cooking methods that do not add fat to foods, such as broiling and baking, rather than frying. The new pyramid also includes recommendations for exercise practices that not only promote weight control but also contribute, along with ber intake, to intestinal motility. (See Figure 37-8.) In addition, restaurants and people cooking at home commonly serve portions that are equal to two to three times the recommendation for a serving or portion. The medical assistant should counsel patients on portion control to maintain their ideal weight. (See Portion control and eating out.) Finally,

FIG 37-8 USDA food pyramid.

Patient Education

Portion Control and Eating Out

Although some patients eat healthy foods, they commonly eat a larger portion than is healthy. The medical assistant should explain the amount of food that the patient should eat, based on these averages: fruitapproximate size of a tennis ball vegetables1 cup cooked (approximately the size of a closed st) meat3 oz (about the size of a deck of cards) cheese1 oz (about the size of four dice) ice cream12 cup (half the size of a closed st). In addition, the medical assistant should advise a patient to use his bread plate to put aside excess food when eating in a restaurant. She should tell the patient to eat a healthy serving of each food, based on appropriate portion sizes, and then ask the server to wrap the leftover food to bring home. Finally, the medical assistant should encourage patients to avoid restaurants that do not offer healthy food choices.

Unhealthy portions

Healthy portions

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the medical assistant can caution her patients about choosing foods that contribute calories to their diet without contributing many necessary nutrients. (See Making calories count.)

Nutrition for Special Populations

Nutritional needs vary for people in different stages of life and are impacted by health status. Calorie intake and specic demands for vitamins, minerals, and protein change based on health, need for growth and development, weight reduction measures, and activity levels. Such changes or adjustments are common for pregnant women, children from infancy through adolescence, and older adults.

pregnant woman can lessen nausea by eating small, frequent meals; eating dry toast or crackers; and avoiding foods with strong odors. She can lessen constipation by eating highber foods, such as cereals and fruits; drinking plenty of water; and exercising daily.

Children
From infancy through adolescence, childrens nutritional needs change. The medical assistant must have an understanding of a childs nutritional status in relation to overall nutritional health in the developing child. A childs nutritional needs can be summarized in three basic phases: infancy, age 2 to 12, and adolescence.

Infancy to Age 2

Pregnancy
During the second and third trimesters of pregnancy calorie needs increase by approximately 300 kcal per day. Pregnant teenagers and underweight women may require even more of an increase. Extra calories should be nutrient-dense foods with an emphasis on increasing levels of nutrients needed for fetal growth and development. (See Dietary needs during pregnancy.) The medical assistant should advise pregnant women to limit processed foods, because nutrients are less available in those foods than in whole foods. Problems associated with pregnancy can include nausea and constipation. The

From birth to age 6 months, an infant should receive breast milk or formula exclusively. Studies have shown that introducing solid foods before 6 months leads to an increased risk of food allergies. From age 6 months to 1 year, breast milk or formula should still make up most of an infants diet. However, at 6 months, the parent or caregiver can begin introducing solid foods, such as cereals, vegetables, and fruit. By age 1, the child can transition from breast milk or formula to whole milk and partake of an expanded diet that includes whole wheat crackers, cheese, applesauce, bananas, scrambled or hard boiled eggs, vegetables, fruits, and meats.

Patient Education

Make Calories Count

Some food choices are empty calories; they are foods that contain many calories but little or no ber, vitamins, minerals, or other essential nutrients. Junk foods, such as candy, processed meats, potato chips, and soda commonly contain large amounts of sodium or saturated fat. The medical assistant should explain to her patient that these empty calories should be a very small part of his diet. For example, the table shown here comparing an apple and a cupcake as a snack shows the apple to be the nutrient-dense, lower-calorie, low-fat choice. Per calorie, the apple supplies eight times the ber, three and one-half times the potassium, and no sodium. The cupcake contains 140 mg of sodium (0.91/kcal). The apple has no fat, while the cupcake has 5 g of fat. The apple represents a more nutrient-dense choice for a snack. Educating patients in healthy diet and exercise habits will improve their overall health. The healthy medical assistant is not only an educator but leads by example. Encouraging and praising patients as they lose weight or begin an exercise regimen will help them stay focused on improving their overall health.

Apple
Calories Fiber Potassium Sodium Fat 125 kcal 6 g (0.048/kcal) 244 mg (1.95/kcal) 0 mg (0/kcal) 0 g (0/kcal)

Cupcake
154 kcal 1 g (0.006/kcal) 84 mg (0.55/kcal) 140 mg (0.91/kcal) 5 g (0.03/kcal)

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Dietary needs during pregnancy

The following table lists dietary components of which a woman should increase her intake during pregnancy, along with the amount of the increase and the function of each.

Dietary Component
Dairy foods for added calcium and vitamin D Protein

Increase
To 600 mg/day (calcium); to 5 mcg/day (vitamin D) Additional 10 g/day

Function
Fetal bone and tooth development

Development of fetal muscles, hemoglobin, and brain

Essential fatty acids Folate Iron

To 1.4 g/day To 600 mcg/day To 30 mg/day

Fetal brain development Prevention of neural tube defects Hemoglobin synthesis; prevention of reduced maternal stores of iron

Vitamin B12

To 26 mcg/day

Activation of folate; assistance with digestion

Ages 2 to 12
Starting at age 2, the childs diet should include a variety of dairy products, meats, beans, vegetables, fruits, bread, pasta, and cereals. As the child ages and tastes vary, the diet can grow to include more seasonings and varied avors. Portion sizes will increase as the child grows, requiring more calories. (For more information, see Chapter 33, page 641.)

Adolescence
Adolescents experience periods of rapid growth, such as the onset of puberty, that require more energy. The appetite of teenagers varies but should always include healthy foods, not empty calories that offer limited nutritional value. The medical assistant can advise her young patients to drink milk to build strong bones and to avoid soda, which adds unnecessary sugar to the diet. She can also advise adolescent female patients that additional iron in the diet is necessary to replace iron lost in menstrual blood; this additional dietary iron may help symptoms of fatigue during menses.

foods (such as yogurt or soft cheese) provide the needed calcium. incomePatients on a xed income are sometimes forced to reduce food expenditures to afford prescription medications or rent. Because carbohydrates are cheap, they may not get the protein and fresh fruits and vegetables needed for good health. The medical assistant can investigate government assistance (such as food stamps) for patients in need. sense of tasteAs a person ages, sense of taste decreases. Because the sweet taste is strongest for elderly patients, they may crave sweets. Thus, the medical assistant must emphasize to patients the importance of balancing sweets in the diet. digestive disordersDigestive enzymes and stomach acids decrease as a person ages. These changes may create symptoms of heartburn, gas, and acid reux that can discourage eating. Treatment for digestive disorders will allow more balanced food choices.

Older Adults
As a person ages, he may become less active. A decrease in activity slows metabolism and, thus, decreases the need for calories. If eating habits of early adulthood do not change, weight gain will ensue. A decrease in activity is commonly due to painful arthritis or other medical complications. The medical assistant should encourage patients to exercise within their ability in order to decrease weight gain and promote good health. Special nutritional concerns of the aging adult include:

Medical Conditions
In addition to the various stages of life, medical conditions can change nutrient needs and tolerance. Dietary adjustments are commonly necessary for patients who have HIV or AIDS, cancer, or diabetes or have a restricted diet, such as a diet that is soft, bland, sodium-restricted, or aimed at weight loss.

HIV and AIDS

Patients with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) should have a high-protein diet. Protein, along with adequate vitamins and minerals (especially vitamins A, B12, and C;

dentitionPatients with ill-tting dentures may have trouble chewing and swallowing. High-nutrition soft

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zinc; and copper), will help the patient support the compromised immune system. Because a reduced appetite is common, due to infection or medication, patients with HIV and AIDS commonly experience malnutrition and wasting. Thus, the patient should consume frequent, small meals consisting of nutrient-dense foods to minimize weight loss.

salt. Although there are low-sodium processed foods available, such as tomato sauces, soups, and pretzels, patients must read labels and understand the sodium per serving that is included in the food. High-sodium condiments include ketchup, pickles, mustard, mayonnaise, and salad dressing. Patients must pay close attention to the salt content of any condiments they may use. Spices can be added to foods to enhance avor as long as no sodium is added.

Cancer
Chemotherapy causes many adverse effects, including nausea and loss of appetite, which can lead to malnutrition and wasting as seen in patients with AIDS. Small, frequent meals can help the patient consume sufcient calories and prevent weight loss. Such patients should also avoid fatty foods, spices, and strong odors, because these foods are not well tolerated when the patient feels nauseous.

Weight-Loss Diets
Weight-loss diets are abundant and can vary in composition. Low-fat or low-carbohydrate diets can yield weight loss; however, patients may tolerate them differently. A healthy weight-loss diet does not promise dramatic weight loss in a short period of time and does not compromise nutrient supply. Patients seeking weight loss should be educated in balancing nutrition and exercise to lose weight safely and keep weight off in the future. (See Fad diet hazards.)

Diabetes
The physician will prescribe a diabetic diet to a patient with diabetes, whether the patient is using oral or injectable insulin. The focus of the diet is to eat frequent, small meals that will decrease uctuations in blood glucose levels. The diet also emphasizes foods with a lower glycemic index. Foods to avoid include candy, donuts, cakes, syrups, and alcohol. The physician may prescribe exercise along with a special diet for weight loss (if needed). The medical assistant can suggest that patients contact the American Diabetes Association to learn about their disease and get information on healthy eating habits.

Common Nutritional Diseases and Disorders

Deciencies in energy-yielding and non-energy-yielding nutrients can lead to disease and dysfunction. Although clinical symptoms may appear slowly, inadequate nutrition always compromises health.

Soft Diet
Foods in a soft diet produce low residue and are easy to digest. The soft diet is commonly prescribed for GI problems to reduce strain on the GI tract. The diet consists of dairy products such as milk, yogurt, and soft cheeses; cooked and pureed vegetables and fruits; pastas; and ground beef or chicken. The diet excludes any foods that require a lot of chewing and produce a large residue, such as raw fruits and vegetables and fried foods.

Macronutrient Disorders
Macronutrients supply the calories that the body needs to perform functions. Growth, maintenance, and repair of tissues depend on adequate calories from food sources. If dietary sources provide insufcient calories, called undernutrition, the body goes through a process called catabolism, in which it breaks down its own tissues to perform necessary functions. In catabolism, the body destroys complex structures to convert them to simpler structures, which usually releases energy. Malnutrition is a condition caused by insufcient intake of nutrients, even if the amount of food eaten is adequate. Poor food choices leave the body lacking key nutrients, such as protein, vitamins, and minerals. Undernutrition and malnutrition lead to diseases of catabolism, such as kwashiorkor and marasmus. These two conditions are referred to as protein energy malnutrition (PEM). Undernutrition is a less prevalent problem in the United States. Conversely, overnutrition is a big problem in the United States, as shown by the growing number of obese children, teens, and adults in the country. Overnutrition is a condition caused by excess intake of food in general, nutrients, or both. Interestingly, an overfed person can also be lacking in specic vitamins and minerals and be malnourished.

Bland Diet
The bland diet is used for patients with irritation to the digestive tract such as ulcers and colitis. It includes foods that are low in ber, dairy products, eggs, cooked vegetables, pasta, and boiled chicken. In addition, the diet prohibits adding spices or salt to foods to decrease irritation.

Sodium-Restricted Diet
Patients with kidney disease, high blood pressure, edema, or cardiovascular disease may benet from a sodium-restricted diet. Because many processed foods contain a lot of sodium, the diet consists of natural foods and no addition of table

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Patient Education

Fad Diet Hazards

Weight loss in the United States is a multibillion-dollar industry. Many people are overweight or obese and are seeking ways to lose weight. Unfortunately, many diet strategies are unsafe. Although they yield initial weight loss, they commonly promote weight gain after the diet ends. Revising eating habits to control portions, limiting empty fat and sugar calories, and incorporating exercise into the patients lifestyle are the best ways to lose weight. In general, people should be wary of: diets that promise rapid weight loss of more than 2 lb per week weight-loss pills that contain large amounts of caffeine, which can cause diuresis and affect the kidneys and heart unbalanced diets that limit calories or carbohydrates to very low levels diets that require purchasing special foods, which will not teach the patient how to eat after the diet use of junk-science terms such as starch blockers or fat burners programs that require a large amount of money to sign up (Most reputable weight-loss clinics earn the bulk of the fee after the weight loss.) use of liquid diets, which can cause diarrhea or constipation, lack of motility, and rarely include all the nutrients needed for health.

to thrive. It usually affects children ages 1 to 4 years, although it can occur in older children and adults. Adult patients in nursing homes may develop kwashiorkor due to neglect or lack of appetite. Symptoms of kwashiorkor include a swollen abdomen, alternating bands of light and dark hair, weight loss, dermatitis, and depigmented skin. Because antibodies that ght infection are made of protein, the child with kwashiorkor is at high risk for infection. Additionally, children with kwashiorkor fail to produce antibodies after vaccination against diphtheria and typhoid. Lack of protein carriers that transport fat out of the liver cause the liver to become fatty, and the abdomen swells. Diagnosis is based on physical examination, which shows an enlarged liver and generalized edema in the abdomen. Urinalysis shows decreased renal function with an increase in specic gravity due to poor urinary output. Complete blood count (CBC) shows anemia, reduced blood urea nitrogen (BUN), serum creatinine and hypoalbuminemia (less than 2.8 g/dl). Treatment is directed at feeding the patient increased calories in the form of carbohydrates, sugars, and fats. When calorie sources have provided adequate energy, protein may be added to the diet and then vitamin and mineral supplementation after protein. Prognosis is based on how long the child has been without adequate protein. Early intervention can produce good results with no permanent complications. Children with more advanced kwashiorkor may suffer permanent physical and intellectual disabilities or death.

Marasmus
ICD-9-CM code: 261 Marasmus is severe muscle wasting and loss of subcutaneous fat associated with lack of calorie intake. It occurs most commonly in children ages 6 to 18 months who are living in overpopulated urban conditions. The World Health Organization estimates that deaths attributable to marasmus approach 50% of the more than 10 million deaths of children under age 5 who die of nutritional deficiencies. Signs and symptoms include emaciated appearance and reduced body weight that may be lower than 80% of the normal weight for that height. Adipose tissue normally found on the buttock and thighs is absent. The child is irritable and voraciously hungry. Marasmus most commonly occurs prior to age 1, whereas kwashiorkor occurs after age 18 months. The diet of such children commonly is diluted cereals, which do not provide enough protein, vitamins, minerals, and calories to sustain life and promote proper growth and development. Treatment consists of feeding the child at least 150 kcal/ kg/day. Children with marasmus are commonly dehydrated

Intake of a sufcient quantity of food or too much food does not guarantee adequate nutrient intake. Excess calorie intake causes weight gain. Lack of exercise commonly accompanies poor eating habits and adds more weight gain.

Kwashiorkor
ICD-9-CM code: 260 Kwashiorkor is a severe protein deciency seen in young children in developing countries. Approximately 13 million children worldwide suffer from severe acute malnutrition either kwashiorkor (protein deciency) or general calorie deciency, known as marasmus. Of these 13 million victims, 10 million die each year, approximately 4 million from kwashiorkor. Kwashiorkor occurs after the child is weaned from breastfeeding, commonly after the birth of another sibling. The change in diet from protein-rich breast milk to starchy cereal causes lethargy, apathy, irritability, and failure

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and require oral rehydration therapy. Micronutrient deciencies are addressed after establishment of adequate calories. As with kwashiorkor, calories initially must come from carbohydrates, sugars, and fats. When calorie sources have provided adequate energy, protein is added to the diet. Repeat immunizations may be necessary if malnutrition prevented the child from manufacturing antibodies to previously immunized infections. Early intervention with feeding will prevent death, but patients with marasmus most commonly have permanent physical and intellectual disabilities. If marasmus is not treated early enough, the body will have lost the ability to synthesize necessary proteins and, even with food or protein, the patient will die. Marasmus is uncommon in the United States, except in cases of severe child neglect.

Calculating BMI
A body mass index (BMI) of 18.5 to 24.9 is considered healthy. A BMI of 25 to 29.9 is considered overweight, and 30 or greater is considered obese. To calculate a persons BMI, the medical assistant should use this formula: Body weight in pounds Height in inches2 703

The BMI formula and values are constant across all patient populations. However, the medical assistant may advise patients differently, depending on their age group.

Adults
To calculate BMI on an adult, the medical assistant must use the BMI formula. Thus, the BMI for a man who is 6 1 tall and weighs 226 lb would be: 216 732 703 28.5

Morbid Obesity
ICD-9-CM code: 278.01 Morbid obesity is a condition in which the person has a body mass index (BMI) of 40 or greater. The normal BMI range for healthy adults is 18.5 to 24.9. (See Calculating BMI.) Obesity increases such health risks as cardiovascular disease, development of type II diabetes, orthopedic injuries to stressed knee and hip joints, sleep apnea, and osteoarthritis. Obesity in the United States is generally caused by sedentary lifestyle and an abundance of high-calorie food. Certain medications can contribute to weight gain, such as antidepressants, anticonvulsants, and corticosteroids. Genetic factors may include a deciency of leptin, a neurotransmitter in the brain that tells the person to stop eating. Treatment for obesity includes a decreased intake of calories and increased exercise. For patients who are morbidly obese, diet and exercise may not be enough to lose weight. Surgical procedures, such as gastric bypass, can dramatically decrease food intake and, therefore, body weight. The medical assistant may be required to educate a gastric bypass patient on eating after the procedure. Compliance with reduced consumption of food is vital for the longterm success of the procedure. (See Gastric bypass surgery.)

The medical assistant can advise the patient that his BMI of 28.5, while not an indication of obesity, does indicate that he is overweight. She should also discuss healthy weight loss strategies with the patient.

Pediatric Patients
A boy who weighs 65 lb and is 48 inches tall would have a BMI of 19.8, as shown below: 65 482 703 19.8

After calculating the childs BMI, the medical assistant can chart his progress on a BMI growth chart. These charts are used for patients ages 2 and over and are different for girls and boys. Each chart indicates the percentile of growth for that population.

Syndrome X, or metabolic syndrome, is a combination of risk factors that greatly increase a persons risk of developing heart disease. Syndrome X includes four conditions:

Syndrome X
Insulin resistanceICD-9-CM code: 277.7 HypertensionICD-9-CM code: 401 to 405 (code specic conditions) HyperlipidemiaICD-9-CM code: 414 (use 4th digit for specic conditions) ObesityICD-9-CM code: 278.00 (nutritional obesity) When poor dietary habits and lack of exercise lead to obesity, a multitude of health risks accompany that weight gain. Obese people are more likely to suffer from diabetes, hypertension, cardiovascular disease, sleep apnea, osteoarthritis, some forms of cancer, gallbladder disease, and respiratory problems.

Insulin resistance. Insulin is produced in the pancreas. Its release is triggered by increased blood levels of glucose. With insulin resistance, the insulin is unable to deliver the glucose to the cells of the body because the cells have become resistant to the insulin. Thus, body tissues do not get the needed glucose for energy. Consequently, the person feels tired and hungry. Polyphagia, or overeating, results adding to the problem of weight gain. Hypertension. Hypertension (increased blood pressure) accompanies obesity and insulin resistance or diabetes. Higher than normal pressure in artery walls can cause damage to the lining of the arteries. In an effort to heal

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Patient Education

Gastric Bypass Surgery

The gastrointestinal system is responsible for getting vital nutrients into the body. People who eat too much food will store the excess calories as fat and compromise good health. Exercise and healthy eating habits are recommended for all people, but sometimes more aggressive treatment is necessary for weight loss. Patients who are morbidly obese (with a BMI of 40 or greater) may choose gastric bypass surgery to achieve major weight loss. Physicians perform this procedure to treat severe obesity in adults. However, some physicians are also performing the procedure on teenagers. The gastric bypass procedure greatly reduces the size of the stomach and prevents the patient from eating a lot of food. Weight loss after gastric bypass surgery is usually dramatic, with most patients losing 50% of their body weight. The patients ability to keep the weight off in the long term depends on her ability to comply with the dietary restrictions. If the patient overeats, her stomach can stretch, allowing her to consume more food. The long-term safety of the gastric bypass procedure is not yet established. Gastric bypass patients who eat too much may suffer from dumping syndrome, where food is forcefully vomited.

B A
Stomach (bypassed)

Pouch

Stomach

Duodenum (bypassed) Jejunum Duodenum

Jejunum

itself, the artery wall will line itself with a fatty plaque, as if it were a bandage. This plaque leads to atherosclerosis (fatty accumulations of plaque that clog the arteries). Hyperlipidemia. Hyperlipidemia (increased levels of lipids in the blood) occurs in response to arteries damaged by chronic hypertension. High levels of LDLs and VLDLs are associated with increased risk of coronary artery disease. Obesity. Having a BMI of 30 or higher is considered obese. Obesity in combination with the other three factors in syndrome X greatly increases the risk of coronary artery disease.

A weight-loss program for the patient with syndrome X should include a well-balanced diet, an exercise program, and supervision by a physician. Insulin resistance, hypertension, and hyperlipidemia will decrease with weight loss. Medication to reduce blood pressure and blood lipids may be necessary; however, the loss of body weight will offer the most beneficial results. Dietary changes should include lowering fat and sugar intake, and patients should avoid artificial sweeteners. (See Artificial sweeteners and weight loss, page 800.) The medical assistant can educate her patients to take charge of their health using weight reduction and exercise.

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Patient Education

Articial Sweeteners and Weight Loss

Although many people use articial sweeteners to reduce calorie intake, some studies have shown that intense sweeteners, such as aspartame, may stimulate the appetite and cause weight gain. Instead of diet soda, which contains phosphorus and can compromise calcium uptake into bone, medical assistants can advise their dieting patients to drink water, herbal tea, or unsweetened iced tea.

Micronutrient Disorders
Diets that lack adequate vitamins or minerals result in various disorders. These vitamin and mineral deciencies will eventually lead to a diagnosed disorder; however, signs and symptoms of mild deciency will be present prior to the full illness. Such diseases include rickets, scurvy, pellagra, and beriberi.

Rickets
ICD-9-CM code: 268 Rickets is a weakening and softening of bone caused by a lack of vitamin D, calcium, or phosphate. It is uncommon in developed countries because calcium and phosphorous are found in milk and green vegetables. Rickets is very rare in the United States and is most likely to affect children during periods of rapid growth, when demand for calcium and phosphorous for new bone development is at its peak. It is uncommon in neonates but may be seen in young children ages 6 to 24 months. When the body is decient in vitamin D, it is unable to control calcium and phosphate levels. Proper levels of calcium and phosphate are necessary to keep the heartbeat regular. If blood levels of calcium and phosphate get too low, the body will remove calcium and phosphate from bone to replenish blood levels. Vitamin D is found in foods and is also produced by the skin upon exposure to sunlight. Lack of vitamin D and lack of sunlight can lead to a deciency and, eventually, the patient will develop rickets. In addition, because vitamin D is fat soluble, digestive disorders that reduce the bodys ability to absorb fats can cause a deciency, even if the patient is eating adequate amounts of foods rich in vitamin D. For example, vegetarians who do not drink milk products due to lactose intolerance or a strict policy of no animal products in the diet are at an increased risk for rickets. Rarely, rickets is due to a hereditary disorder, in which the kidneys are unable to retain phosphorous, or disorders of the liver, in which the patient cannot convert vitamin D to its active form.

Symptoms of rickets include bone pain and tenderness in the arms, legs, spine, or pelvis. Skeletal deformities are common, including bowed legs (bowleg), a forward-projecting breastbone (pigeon chest), an odd-shaped skull, and such spinal deformities as scoliosis or kyphosis. The patient may have multiple bone fractures due to demineralization, causing bone weakening. Delays in formation of teeth and defects in the structure of teeth, including increased cavities and holes in the enamel, are common. Decreased muscle tone and strength are also present. Diagnosis is based on physical examination, which reveals tenderness and pain in the bones rather than joints or muscles. Blood testing will show low serum calcium and serum phosphorous. Serum alkaline phosphatase may be elevated. X-rays will show bone loss and changes in the shape and structure of bones. Treatment with replacement calcium, phosphorous, and vitamin D will eliminate most symptoms. A combination of foods rich in these substances and supplemental vitamins and minerals will correct early signs of rickets. If rickets is caused by metabolic abnormalities, a prescription for a high dose of vitamin D is necessary to overcome the bodys inability to utilize the vitamin. With treatment, laboratory values and x-ray ndings will begin to improve after 1 week. If rickets is corrected early, no permanent abnormalities are observed. Skeletal deformities diminish and commonly disappear with time. Severe skeletal deformities may be treated with bracing or corrective surgery. If rickets is not corrected when the child is growing, permanent skeletal deformities and stunted height may result. (See Figure 37-9.)

Scurvy
ICD-9-CM code: 267 Scurvy is a deciency disease caused by an insufcient intake of vitamin C. Scurvy is rare in the United States, with a few documented cases due to poor dietary choices. Historically, scurvy was common in sailors and pirates, who were unable to store fruits and vegetables aboard ships for extended periods of time. Vitamin C is necessary for collagen synthesis. A diet decient in vitamin C will take 4 to 8 months to develop clinical signs. Signs and symptoms of scurvy include formation of dark purple spots on the skin and bleeding from the gums and the nose. The patient looks pale, may be depressed, and lacks energy. In advanced scurvy, there are open wounds and loss of teeth. Pasteurization destroys vitamin C, so babies fed with ordinary bottled milk sometimes suffer from scurvy if they are not provided with adequate vitamin supplements. All commercially available baby formulas contain added vitamin C for this reason. Human breast milk contains sufcient vitamin C if the mother has an adequate intake. The medical assistant can inform parents to give infants breast milk or baby formula and to never feed an infant under age 1 cows milk.

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FIG 37-9 Rickets.

A person can easily prevent developing scurvy by including foods rich in vitamin C, such as oranges, lemons, tomatoes, strawberries, carrots, broccoli, and spinach. Because vitamin C is destroyed by cooking and canning, fresh raw fruit is the best source of vitamin C. Vitamin C is so abundant, it is even found in some candy. Need for vitamin C increases after injury, surgery, and burns due to the need to repair tissues and build collagen. People who smoke, women who take oral contraceptives, and people who live in cities with high carbon monoxide levels require extra vitamin C. If left untreated, scurvy is always fatal due to bleeding and infection.

China among the very poor who do not have adequate food resources. In the United States, pellagra is commonly seen in poor persons who do not have access to adequate nutrients, in psychiatric patients who refuse food, and as a secondary condition related to alcoholism. Symptoms of the disorder include redness and swelling of the mouth and tongue, diarrhea, skin rash, and memory loss. Early symptoms will begin as a light rash, which over time makes the skin grow thicker and more pigmented and, possibly, slough off. The skin also becomes prone to bacterial infection. Abdominal bloating occurs and abdominal symptoms progress to nausea, vomiting, and bloody diarrhea. Initially, mental changes present as insomnia, fatigue, and apathy. Later, these mental changes progress to memory loss, depression, confusion, and hallucinations. Severe progression of pellagra includes stiffness in the arms and legs and involuntary sucking and grasping motions called encephalopathic syndrome. Pellagra symptoms can be summarized as the four Ds: dermatitis, diarrhea, dementia, and, nally, death. Diagnosis of pellagra is based on the patients symptoms and appearance. There are no blood or chemical tests to conrm the diagnosis. Treatment of pellagra is feeding the patient niacin supplements and niacin-rich foods, such as liver, meat, sh, wholegrain cereals and breads, and legumes. The frequency and amount of niacin administered depends on the degree to which the condition has progressed. Dietary requirements for niacin depend on the age, sex, size, and activity level of the patient. Niacin requirements range from 5 mg in infants up to 20 mg in adults with diseases that compromise niacin uptake. Untreated, the disease can be fatal within 4 or 5 years.

Beriberi
ICD-9-CM code: 265.0 Beriberi is a disease caused by a lack of dietary thiamine (vitamin B1). It is seen in areas of the world where the main staple is white rice, such as poor regions of China. White rice is very low in thiamine because the thiamine-rich husk of the grain has been removed. Beriberi is now rare in the United States because most foods are vitamin-enriched. However, it may be seen in chronic alcoholism, which decreases the absorption of thiamine. It is also seen as an adverse effect of gastric bypass surgery and in patients on dialysis or receiving high doses of diuretics. Infants breastfed from a mother with beriberi may also develop beriberi. Rarely, beriberi is an inherited genetic disorder where absorption of thiamine is impaired. Symptoms of beriberi include weight loss, impaired sensory perception, edema, emotional disturbances, weakness, and pain in the limbs. Diagnosis of beriberi is based on physical examination, which reveals swelling of the legs, uid in the lungs, rapid heart rate, and difculty breathing. Late-stage beriberi will include memory loss, delusions, and

Pellagra
ICD-9-CM code: 265.2 Pellagra is a vitamin-deciency disease caused by a lack of niacin (vitamin B3). The deciency may be caused by a diet that lacks niacin or a diet low in protein, especially the essential amino acid tryptophan, which can be converted into niacin in the body. Foods that contain tryptophan but not niacin, such as milk, can prevent pellagra. However, if the dietary tryptophan is used for protein production (its primary function), the niacin deciency will still be present. Pellagra is commonly seen in Africa, Mexico, Indonesia, and

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decreased vibratory sense. Decreased reflexes and gait changes are common. Chemistry testing will reveal decreased thiamine levels in the blood and urine. Genetic beriberi progresses slowly and is not symptomatic until adulthood. It is commonly misdiagnosed because it is rare in adults who are not alcoholics. Treatment involves oral or IM administration of thiamine hydrochloride. A rapid, dramatic recovery is typical within hours of administration. Heart damage is usually not permanent and a regular heartbeat returns within hours of administration. Nervous system damage is also reversible if treated early; memory loss with early treatment is minimal. Food sources of thiamine include unrefined cereals, meats, legumes, green vegetables, fruit, and milk. If left untreated, heart and neurological decits are permanent and eventually beriberi is fatal.

Chapter Summary

carbohydrates, fat, and protein and determine the vitamin and mineral content of each meal. 2. Separate into groups of three or four students each. Each team will be assigned one of these patients: a. morbidly obese 53-year-old male with type II diabetes b. pregnant 16-year-old girl c. 7-year-old boy with type I diabetes d. 42-year-old woman who is receiving chemotherapy for breast cancer e. 31-year-old AIDS patient f. 74-year-old widower who lives alone g. 20-year-old male college student on a limited budget h. 20-year-old female college student on a limited budget. Each team must create a 7-day diet for their patient. Include specic food choices and estimate the cost of the weeks food. Calculate the calories from carbohydrates, fat, and protein and determine the vitamin and mineral content for each day. Then the team must present its ndings to the class as a poster or computer presentation.

Nutrients can be divided into macronutrients (carbohydrates, proteins, and fats) and micronutrients (vitamins, minerals, and water). Digestion of nutrients occurs in the mouth, stomach, and small intestines with the aid of digestive enzymes and acids. Inclusion of all of the vital dietary nutrients will promote good health and prevent disease. Because weight management is a lifelong commitment, the medical assistant can help patients of all ages maintain a sensible diet that promotes health by including all of the nutrients needed for their age and physical condition. Patients with specic health concerns may require diet modication. Although deciency diseases are rare in the United States, the medical assistant should have an understanding of these conditions and be able to educate her patients to avoid nutrient deciency. Diet aids that promise quick results are potentially dangerous; educating patients on the hazards of junk science can help them make good nutritional choices.

Case Studies
1. Mr. Rodriquez has been a patient in the ofce for many years. He is 52 years old and has gained considerable weight in the last 10 years. He tells the medical assistant that he has been fatigued, thirsty, and experiencing lower back pain. What blood and urine tests will the doctor order? What should the medical assistant expect the results to show? How can the medical assistant educate Mr. Rodriquez to achieve a healthier lifestyle and weight loss? 2. Monica Durdan is a 14-year-old who comes in for her yearly physical. Although Monica has grown 1" since her last visit, she has also gained 27 lb. She does not participate in sports and talks to the medical assistant about her interest in online games. She states that she hates physical education class at school and usually goes to the nurses ofce to avoid class. She tells the medical assistant that by the end of the school day, she is so tired that she comes home and takes a nap or watches television. She wants to lose weight, but because her mom and dad both work late, she snacks and rarely eats dinner. What strategies can the medical assistant give to Monica to help her lose weight and increase energy?

Team Work Exercises

1. Separate into groups of four to six students each. Each team must create two dinners consisting of the same basic foods: a meat or protein source, a starch, and a vegetable. One meal is healthy, with a balance of carbohydrate, protein, and fat and includes vitamins and minerals. The other meal is high in saturated fat and low in vital nutrients. Create a poster or computer presentation comparing the two meals. Calculate the calories from

Resources

American Diabetes Association: www.diabetes.org American Dietetic Association: www.eatright.org FDA information on cholesterol: www.fda.gov/fdac /features/1999/199_chol.html General nutrition information: www.nlm.nih.gov /medlineplus/nutrition.html

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Guidelines for a healthy diet during pregnancy: www .pregnancyfoodguide.org Healthy food choices for diabetics: www.diabetes.org /nutrition-and-recipes/nutrition/healthyfoodchoices.jsp Healthy People 2010: www.health.gov/healthypeople Information on vitamins: www.nlm.nih.gov/medlineplus /vitamins.html WHO diet and exercise guidelines for preventing obesity: www.who.int/dietphysicalactivity/diet/en/index.html

Bales, C.W., and Ritchie, C.S. (eds.): Handbook of Clinical Nutrition on Aging. New York: Springer-Verlag, 2008. Borushek, A.: Calorie, Fat, and Carbohydrate Counter, 20th ed. Costa Mesa, CA: Allan Borushek and Associates, Inc., 2007. Holzmeister, L.A.: The Diabetes Carbohydrate and Fat Gram Guide. New York: McGraw Hill, 2006.

CHAPTER

Introduction to Pharmacology
Learning Objectives
Upon completion of this chapter, the student will be able to: dene, spell, and pronounce terminology related to pharmacology identify the role of the medical assistant in pharmacology understand government regulation of drugs identify proper disposal of drugs differentiate between over-thecounter (OTC) and prescription drugs identify controlled substances utilize drug reference books differentiate chemical, generic, and trade names for drugs list major sources of drugs identify medical uses of drugs identify effects of drugs identify classications of drugs differentiate various drug forms identify special considerations for geriatric and pediatric patients safeguard against drug abuse identify patient education regarding drug therapy. Patient Instruction
Instruct individuals according to their needs

38
Drug Names
Chemical Name Generic Name Trade Name

ABHES Competencies
Communication
Adapt what is said to the recipients level of comprehension Serve as a liaison between the physician and others

Drug Classications Drug Effects

Therapeutic Effect Adverse Effects and Reactions Allergic reaction Idiosyncratic effect Cumulative effect Toxic effect Tolerance

Legal Concepts
Dispose of controlled substances in compliance with government regulations Monitor legislation related to current health care issues and practices

Drug Interactions
Synergism Antagonism Potentiation Contraindications

Instruction
Teach patients methods of health promotion and disease prevention

Drug Regulation
Drug Enforcement Agency DEA registration Controlled substances Record keeping Food and Drug Administration OTC drugs

Chapter Outline
Pharmacology and the Medical Assistant
Drug Forms Drug Categories Prescription Over the counter Natural Drug Sources Plants Animals Minerals Laboratories

Drug Safety
Drug Disposal Drug References United States Pharmacopeia-National Formulary Physicians Desk Reference Drug handbooks Package inserts Patient prescription information

CAAHEP Competencies
Clinical Competencies Fundamental Principles
Dispose of biohazardous materials

Drug Action and Uses

Pharmacokinetics Absorption Distribution Metabolism Excretion Pharmacodynamics Pharmacotherapeutics Cure Treatment Diagnosis Prevention Replacement

Teaching Patients About Drugs Special Considerations

Geriatrics Pediatrics

Patient Care
Apply pharmacology principles to prepare and administer oral and parenteral (excluding IV) medications

General Competencies Legal Concepts

Document appropriately Demonstrate knowledge of federal and state health care legislation and regulations

Chapter Summary Team Work Exercises Case Studies Resources

805

Key Terms
absorption

over-the-counter

Type of drug that can be obtained without a prescription Passage of a drug into the bodys bloodstream through the digestive system, mucous membranes, or skin
action pharmacodynamics

Study of the bodys biochemical and physiological response to drugs

pharmacokinetics

Ability of a drug to act on body processes at the cellular level

administer

Study of the action of drugs as they move through the body, including absorption, distribution, metabolism, and excretion
pharmacology

To give a medication to a patient as directed by a physician

adverse effect

Study of drugs and their origin, nature, properties, and effects on living organisms
pharmacotherapeutics

Result of taking a drug that is not therapeutic and may be unpleasant or harmful
allergy

Study of the use and effect of drugs in the treatment and prevention of disease
polypharmacy

Immune response to a medication that results in inammation and organ dysfunction

anaphylaxis

High-risk situation in which a patient is taking multiple medications, thus increasing the risk of adverse effects
prescribe

Severe allergic reaction

contraindication

To indicate a drug to be administered

systemic effect

Condition under which a drug should never be used

cumulative medication action

Impact of a medication throughout the body

teratogenic effect

Action of repeated doses of a medication that are not immediately eliminated from the body
dispense

Adverse effect of a drug on a developing embryo or fetus

therapeutic effect

To prepare or deliver medicines

distribution

Desired response in the body from a prescribed drug

tolerance

Transport of a drug to body uids, tissues, and cells

dosage

Need for increased dose of a drug to produce the same effect

toxic

Physicians indication of how much and how often a patient should take a drug
dose

Poisonous or harmful

Amount of a drug a patient takes each time

drug

Any substance that, when taken into a living organism, may modify one or more of its functions
drug class

Grouping of drugs by their therapeutic effect, the body system affected, or their action
efcacy

Ability of a medication to produce a desired effect

excretion

Elimination of waste products from the body

indication

Approved use of a drug, as approved by the Food and Drug Administration

interaction

Effect in the body as the result of a combination of a drug with food or another drug
local effect

Impact of a medication that is specic only to a certain part of the body

metabolism

Change to a medication by the body, which converts it to an inactive water-soluble compound for excretion
opiate

Class of analgesic drugs that depress the central nervous system; also called narcotic

CHAP TER 38

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807

Pharmacology and the Medical Assistant

Pharmacology is the study of drugs and their origin, nature, properties, and effects on living organisms. A drug is any substance that, when taken into a living organism, may modify one or more of its functions. Drugs are used to treat, prevent, diagnose, and cure disease. A health care provider will prescribe, or indicate, a drug to be administered, or given to a patient. The prescription indicates the drugs dosage, which is the dose (amount of the drug to be taken each time) and the number of times the drug should be taken (such as twice per day or once per week). The medical assistant is responsible for understanding the various drugs that can be prescribed as well as the drug dispensing laws in the state where she practices. She must also have the skills to prepare and administer medications to patients safely. For more information on preparing and administering drugs, see Chapter 39, Dosage Calculation and Medication Administration, page 825.)

form of a written prescription. In order to obtain a prescription, the person must consult with a physician, who deems the drug necessary and safe for that person to use. Prescription drugs vary in their use and safety; however, all require monitoring by a physician. Examples of prescription drugs include oral contraceptives, antibiotics, opiates (narcotics), and medications for hypertension.

Over the Counter

Drugs that a person can purchase without a prescription are called over-the-counter (OTC) drugs. An OTC drug does not require a physician to monitor its use. Examples of OTC drugs include acetaminophen (Tylenol), ibuprofen (Motrin), antacids (Tums, Rolaids), and diphenhydramine (Benadryl Allergy).

Natural
Natural products are those such as herbal remedies and vitamin or mineral supplements. Natural products are also sold without a prescription and do not require the monitoring of a physician. Examples include red yeast rice (monascus purpurea) and aspalathus linearis (Rooibos) to lower cholesterol and white willow (salix alba) for headaches.

Drug Forms
There are two basic forms of drugs: solids and liquids. Some forms are actually semisolid but are placed in the solids category. Categories are based on how easily the medication dissolves. Solids include tablets, chewable tablets, sublingual tablets, enteric-coated tablets, capsules, sustained-release capsules, caplets, lozenges, creams, ointments, suppositories, and the transdermal patches. Liquids include elixirs, emulsions, liniments, lotions, solutions, spirits, sprays, suspensions, aerosol suspensions, syrups, and tinctures. Tinctures and elixirs are preparations that contain alcohol. The medical assistant must explain to a patient recovering from substance abuse that alcohol is present in such preparations and that an alternate preparation may be indicated.

Drug Sources
The active chemicals found in drugs are from four main sources: plants, minerals, animals, or synthetic drugs developed in laboratories. Drugs that are prescribed by a physician, over-the-counter (OTC) preparations, and herbal supplements all contain active ingredients that allow the drug or supplement to create a physiological change in the body.

Plants
The chemicals that make up drugs can develop naturally in plants and can be found in the roots, leaves, or flowers of the plant. For example, the drug digitalis is found in the foxglove plant and is used to treat certain heart conditions. Morphine and codeine, opiates that can be used to treat moderate to severe pain, originate from the poppy plant.

Drug Categories
There are three categories of drugs:

prescription over the counter natural.

Animals
Some drugs come from animals. In the past, insulin was obtained from the pancreas of cows and pigs. Today most insulin is made synthetically in laboratories. Cod liver oil is obtained from codsh liver and is rich in vitamins A and D. Heparin, a drug used to slow the clotting process, is obtained from the intestines of cattle and pigs.

All drugs affect the body in some way, regardless of how patients purchase them. The medical assistant must ask her patient what drugs, including herbal remedies and vitamin or mineral supplements, they currently use. The physician must have this information to properly diagnose and treat the patient.

Prescription
Prescription drugs are drugs that are only distributed to persons who have the permission of a physician, usually in the

Minerals
Drugs are also derived from minerals. Examples of minerals with pharmaceutical properties include iron, potassium,

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calcium, magnesium, and gold. A patient who has low levels of iron, a mineral necessary for the formation of red blood cells, may have to take an iron supplement. Calcium, found in milk and dairy products, is another common mineral supplement.

Laboratories
Most drugs today are developed synthetically in the laboratory. New drugs are made using biotechnology and genetics. An example of a synthetic drug is co-trimoxazole (Bactrim), which is used to treat bacterial infections such as urinary tract infections. Pharmaceutical companies spend a great deal of time and money on drug research, development, and marketing. As a result, new medications frequently become available, making it essential for medical assistants to continually educate themselves regarding new medications.

amount of drug (For example, a physician will commonly prescribe a loading dose, or large initial dose, of penicillin for a patient with an infection in order to establish therapeutic penicillin levels more quickly in the bloodstream.) route of administration (For example, the body will absorb more slowly a medication given by mouth than one that is injected because it must go through the digestive system before it is absorbed into the bloodstream.) bioavailability of the drug, or a percentage that expresses the amount of the drug that reaches the bloodstream and the length of time needed to reach it (For example, uoxetine hydrochloride (Prozac) has a high bioavailability of 72% with a peak concentration in the bloodstream within 6 to 8 hours of administration.)

Distribution
After absorption of the drug into the bloodstream, the circulatory system distributes it into body uids, tissues, and cells, carrying it to the intended site of action. Distribution of the drug may be slow or fast, depending on the patients size and the amount of the drug given. Circulation impairment can also affect the ability of the medication to be distributed to the intended site.

Drug Action and Uses

A drugs action is the ability of the drug to act on body processes at the cellular level. A drugs use is the therapeutic effect it has on a persons body. Drugs can stimulate (speed up) cellular function or depress it (slow it down). Some drugs can destroy cells or replace substances. However, drugs cannot make a cell function in a new or different way. It is important for medical assistants to understand the action of a drug from the time it enters the patients body until the time that it is excreted from the body. A drugs action and use can be broken down into three main categories:

Metabolism
After the body uses the drug, it must inactivate it (or break it down chemically) in order to eliminate it. Such a process is called metabolism, or biotransformation. Chemical reactions break down the drug into different substances that the body can easily use and excrete. If these substances are harmful to the body, the body must also detoxify the substances before elimination. The liver is the major organ involved in drug metabolism. Several factors can affect metabolism, including age, the presence of liver disease, and characteristics of the drug.

pharmacokinetics pharmacodynamics pharmacotherapeutics.

Pharmacokinetics
Pharmacokinetics is the study of the action of drugs as they move through the body. These actions include absorption, distribution, metabolism, and excretion.

Excretion
Excretion is how the body eliminates a drug. Similar to food, after the body has used the drug, it must be eliminated. Most drugs are excreted in urine; thus, the kidneys are the major organs involved in drug excretion. However, the body may also excrete drugs via feces, hair, lungs, breast milk, and skin.

Absorption
Absorption is the passage of medication through some surface or opening of the body at the site of administration of the drug into the bodys bloodstream. Key factors that affect absorption include:

Pharmacodynamics
Pharmacodynamics is the study of the bodys biochemical and physiological response to a drug. In other words, pharmacodynamics studies what the drug does to a persons body and how that effect is achieved. Many factors affect pharmacodynamics, or the drugs action in a persons body, including the patients size, age, and genetic makeup. (See Factors that affect drug action.)

type of drug (For example, adequate absorption of the beta-blocker propranolol depends on normal blood circulation through the liver. Thus, absorption of propranolol in patients with liver disease will be decreased, while absorption of other drugs in such patients will not be impaired.)

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Factors that affect drug action

Because each patient is different, the medical assistant must have a sound knowledge of factors that can affect the action of drugs prescribed for her patients. These factors include: ageInfants and young children require smaller doses of a drug because of their smaller body mass as well as their immature body systems. Older adults may suffer from declining liver function, which makes them vulnerable to drug toxicity. Thus, they may also require smaller drug doses. body mass (weight)The average adult dosage is based on an approximate body mass of 150 lb. Patients who are less than 100 lb or more than 300 lb will require a dosage adjustment. sexMen and women have different proportions of body fat and water, which are factors that affect drug absorption and action. pregnancyMost drugs are contraindicated during pregnancy because of their potential for causing birth defects (teratogenic). environmentExtremes of heat or cold will affect circulation and, therefore, the distribution of medication. High-stress environments such as a patients workplace or a stressful home life will affect digestion and, therefore, drug absorption. foodThe presence of food in the digestive tract will decrease absorption of most drugs but may enhance the absorption of some. Patients may need to take some drugs with food because they cannot tolerate the drug on an empty stomach. uidsInsufcient uid intake may delay the breakdown of oral drugs in tablet or capsule form. pathological statesDiseases that affect digestion, circulation, or renal function will decrease absorption, distribution, or excretion. Intense pain will decrease the effect of opioid analgesics. Thus, patients with underlying disease states may require adjustment of drug dosages. genetic factorsEnzyme deciencies that inhibit drug metabolism are commonly genetic and will cause idiosyncratic effects. Asking a patient if a family member has had an adverse or unusual reaction to a medication before its administration may avoid adverse reactions. psychological factorsSome patients strong belief in the efcacy of a drug therapy will cause the placebo effect, in which ingestion of a placebo yields a positive benet. Other patients may distrust drugs or the physician to the extent that the drug is less effective. In addition, heightened emotional states affect adrenalin levels, which will impact a drugs action. Understanding a patients emotional or psychological status is important when selecting the proper course of treatment. If the physician suspects that the patient will not be able to comply with a drug regimen that involves four daily doses, she may select a drug that only requires two daily doses.

Pharmacotherapeutics
Pharmacotherapeutics is the study of the use and effect of drugs in the treatment and prevention of disease. (See Kinetics, dynamics, or therapeutics? page 810.) The medical reasons physicians and other health professionals prescribe drugs are:

a diagnosis of ringworm, a fungal infection, the patient is cured and no longer has the infection.

Treatment
Drugs used to treat a disease without curing it seek to relieve or alleviate symptoms of that disease. This type of treatment is sometimes called palliative care. For example, at present, there is no cure for arthritis. However, the physician may prescribe an anti-inammatory drug to reduce the inammation caused by arthritis, thereby decreasing pain. Although the patients pain decreases, she still has arthritis. Also, an antihistamine will not cure allergies but will reduce and relieve some symptoms associated with allergies.

to cure disease to treat symptoms of a disease to diagnose disorders and diseases to replace a deciency to prevent disease.

Cure
Some drugs can cure disease. When a patient has been diagnosed with a disease or disorder and the physician prescribes a drug to eliminate the disease, the patient is cured of that disease. For example, a bacterial throat infection known as Strep throat can be cured by taking an antibiotic, such as penicillin. Also, after a full course of an antifungal drug for

Diagnosis
Drugs can help diagnose a disease or disorder. For example, a radiopaque dye, also called a contrast medium, is injected into patients for certain tests. The dye aids visualization of glands and organs, helping the physician make a diagnosis.

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Kinetics, dynamics, or therapeutics?

Pharmacokinetics, pharmacodynamics, and pharmacotherapeutics may be confusing terms at rst. However, the medical assistant can use some clues to help remember the meaning of each. for what the drug does to the body. Pharmacodynamics describes what the drug does to the body, or how the drug can speed up or slow down a body process. In the same example of an antibiotic drug, the pharmacodynamic action of the drug is to target the bacteria and destroy the wall of the bacteria, killing the organism.

Pharmacokinetics
To remember the meaning of pharmacokinetics, the medical assistant can remember that the word kinetic means movement. Pharmacokinetics describes the movement of the drug through the body, or how the body processes the drug. The body absorbs and eliminates drugs in the same way that it absorbs and eliminates food. For example, an antibiotic drug acts to kill pathogenic (harmful) bacteria in the body. The pharmacokinetic action of the drug is oral ingestion of the drug, absorption of the drug into the bloodstream in the intestinal tract, its distribution throughout the body via the bloodstream, and excretion of its by-products in urine.

Pharmacotherapeutics
Unlike pharmacokinetics and pharmacodynamics, pharmacotherapeutics does not describe a drugs action. Rather, pharmacotherapeutics describes the use of a drug for treating a disorder. Thus, the medical assistant can remember pharmacotherapeutics contains the word therapeutic, or therapy, which is a treatment for disease. Thus, in the example of an antibiotic drug, the pharmacotherapeutic effect of the drug is to cure the infection by eradicating the harmful bacteria from the body.

Pharmacodynamics
To help remember the meaning of pharmacodynamics, the medical assistant can remember the D in dynamics stands

Prevention
Drugs can help prevent conditions and diseases. Such drugs are commonly called prophylactic drugs. For example, oral contraceptives help prevent pregnancy and vaccinations prevent tetanus, diphtheria, measles, mumps, rubella, hepatitis B, and chickenpox.

Chemical Name
The chemical name of a drug indicates the chemical composition of the drug. For example, butanoic acid is the chemical name for the drug known as lovastatin. Such information is included in the Physicians Desk Reference (PDR) or in the package insert. Medical assistants will not use the chemical names of drugs.

Replacement
Drugs can replace a decient substance in the body. For example, diabetic patients, whose pancreas lacks the ability to produce adequate insulin, may take replacement insulin by injection. Calcium supplements help achieve adequate levels of calcium when the patients diet does not contain a sufcient amount. Patients with hypothyroidism (low thyroid hormone production) can take Synthroid, a synthetic form of thyroid hormone.

Generic Name
The generic name of a drug, also called the ofcial or nonproprietary name, is not protected by a trademark. It usually is not capitalized and is much easier to pronounce than the chemical name. For example, lovastatin is the generic name for butanoic acid. Generic forms of drugs may be cheaper than trade name products. Most drug directories or handbooks list drugs by their generic name.

Drug Names
All drugs have a chemical name, a generic name, and a trade (or brand) name. The medical assistant must know the many names each drug has to avoid confusion, especially if two drugs have similar names. Additionally, the medical assistants experience with medical terminology helps her understand some of the drug names. For example, the trade name Cardizem has the word root cardi, which means heart.

Trade Name
A drugs trade name, or brand name, is the name developed and marketed by a pharmaceutical company under a registered trademark. Although a medication has only one chemical name and one generic name, it may have several trade names. The trade name of a drug is indicated with a capital letter at the beginning. For example, the trade names for lovastatin include Mevacor, Advicor, Altocor, Altoprev, and Statosan.

CHAP TER 38

Introduction to Pharmacology

811

When a company trademarks a drug, it has exclusive rights to manufacture and sell that drug for 17 years. Within that time period, no other company can develop the drug. After 17 years, other companies can market the same drug using the generic name or another trade name. Because some trade name forms of drugs are so commonly used, that name enjoys the same type of brand recognition as BandAids or Coca-Cola. For these drugs, people do not recognize the generic name as readily as the trade name. For example, Coumadin is the trade name for the anticoagulant warfarin sodium, which is used to prevent and treat embolism, venous thrombosis, and recurrent myocardial infarction (MI). Use of Coumadin is so common, many physicians and nurses simply call the drug Coumadin, rather than warfarin sodium. Thus, medical assistants must become familiar with a drugs generic and trade names, including correct spelling and pronunciation.

The pharmacologic class of a drug groups drugs by their chemical characteristics and describes what the drug does to the body. For example, the drug Prozac is grouped in the pharmacologic class serotonin-reuptake inhibitors. Prozac increases the quantity of serotonin in the brain, which alleviates symptoms of depression. The therapeutic class of a drug groups drugs by their therapeutic effect, or use. For example, the same drug, Prozac, is grouped in the therapeutic class antidepressants because it is used to treat depression. It is essential for the medical assistant to learn and understand the therapeutic drug classes in order to care for and educate patients about why the patient is taking the drug and how it will affect him. (See Common drug classes.) Although remembering all the drug classes and their effects may seem challenging, the new medical assistant can sometimes use the drugs name as a clue to its effects. (See Drug classication clues, page 814.)

Drug Classications
Drugs are categorized by two classication systems, or classes:

Drug Effects
A drugs effect is the biological, physical, and psychological impact that it has on the body. Drug effects include therapeutic (beneficial) effects as well as adverse (harmful) effects.

pharmacologic class therapeutic class.

Common drug classes

The following table lists common therapeutic drug classes grouped by body system and includes examples and their therapeutic effect.

Class and Examples

Cardiovascular System Drugs Antiarrhythmics propranolol (Inderal), procainamide (Procanbid, Promine) Anticoagulants warfarin (Coumadin), heparin Antihypertensives enalapril (Vasotec), captopril (Capoten) Antiplatelet drugs ticlopidine (Ticlid), clopidogrel (Plavix) Cardiac glycosides digoxin (Lanoxin) Electrolytes and replacement solutions potassium chloride (K-Dur), calcium (Caltrate, Rolaids), zinc

Therapeutic Effect
Promote regular heart rhythm

Increase clotting time

Prevent high blood pressure

Inhibit platelet aggregation

Strengthen and slow heartbeat

Replace minerals or electrolytes

Continued

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Common drug classescontd

Class and Examples
Lipid-lowering drugs lovastatin (Lescol), simvastatin (Zocor, Pravachol), uvastatin (Lipitor), niacin (Niacor, Niaspan), gembrozil (Lopid, Tricor) Thrombolytics streptokinase (Streptase), urokinase (Abbokinase) Vasoconstrictors norepinephrine (Levophed) Vasodilators nitroglycerine (NitroBid) Respiratory System Drugs Antihistamines diphenhydramine (Benadryl) Bronchodilators albuterol (Proventil), epinephrine Gastrointestinal System Drugs Antacids calcium carbonate (Tums), simethicone (Mylanta), milk of Magnesia (MOM) Antidiarrheal diphenoxylate and atropine (Lomotil), kaolin-pectin Antiemetic prochlorperazine (Compazine) Antiulcers omeprazole (Prilosec), cimetidine (Tagamet), ranitidine (Zantac) Laxatives psyllium (Fiberall, Metamucil), bisacodyl (Bisco-Lax), docusate (Kaopectate) Central Nervous System Drugs Antianxiety drugs alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan) Anticonvulsants phenobarbital, valproic acid (Depakene), phenytoin (Dilantin) Antidepressants sertraline (Zoloft), uoxetine (Prozac), amitriptyline (Elavil) Antiparkinson drugs carbidopa-levodopa (Sinemet) CNS stimulants amphetamine mixtures (Adderall), methylphenidate (Ritalin) Produce general CNS stimulation Treat Parkinson disease Prevent or relieve depression Decrease incidence and severity of seizures Produce generalized central nervous system (CNS) depression Induce bowel movement Decrease acid secretion Inhibit nausea and vomiting Slow intestinal motility Neutralize stomach acid Dilate the bronchi Block effect of histamine Dilate blood vessels Constrict blood vessels Dissolve clots

Therapeutic Effect
Decrease blood cholesterol

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Common drug classescontd

Class and Examples
Nonopiate analgesics and antipyretics aspirin (Bayer, St. Joseph), acetaminophen (Tylenol), ibuprofen (Motrin, Advil) Opiate analgesics codeine-APAP (Tylenol with codeine), meperidine (Demerol), hydrocodone-APAP (Vicodin), oxycodone-ASA (Percodan) Endocrine System Drugs Antidiabetic agents (hypoglycemics) insulin (injectable), glipizide (oral) Hormones estrogen (Estradiol), progesterone (Endometrin), somatropin (Posilac), testosterone (Nilvear), insulin (Humulin), glucagon Urinary System Drugs Diuretics furosemide (Lasix), hydrochlorothiazide (Microzide, Capozide), spironolactone (Aldactone) Musculoskeletal System Drugs Skeletal muscle relaxants diazepam (Valium), cyclobenzaprine (Flexeril) Multisystem Drugs Anesthetics lidocaine (Xylocaine), novocaine (Novocain) Antibiotics (anti-infectives) amoxicillin (Amoxil), azithromycin (Zithromax), cephalexin (Keex) Antifungals nystatin (Mycostatin), uconazole (Diucan), miconazole (Monistat) Antineoplastics tamoxifen (Nolvadex), methotrexate (Amethopterin) Antivirals acyclovir (Zovirax) Corticosteroids prednisone (Pediapred, Prelone), hydrocortisone (Colocort, Cortef) Immunosuppressants cyclosporine (Gengraf, Neoral), methotrexate (Folex) Nonsteroidal anti-inammatory drugs (NSAIDs) naproxen (Aleve), ibuprofen (Motrin, Advil) Reduce inammation Suppress the immune response Suppress inammation Inhibit viral replication Kill or destroy malignant cells Kill or stop growth of fungi Kill or inhibit growth of bacteria Produce loss of pain sensation (local) Relax skeletal muscle Increase urine excretion Replace hormones Lower blood glucose levels Alter pain perception

Therapeutic Effect
Reduce fever and decrease pain sensation without causing drowsiness

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Drug classication clues

The ending of a drug name can give the medical assistant a clue to its class. The table shown here lists common drug classes along with a drug name ending that is commonly used in that class and an example of each.

an injured knee, it would not alleviate the pain of her stubbed toe.

Adverse Effects and Reactions

Unfortunately, even if a prescribed drug provides the desired therapeutic effect, it can also produce other effects. Adverse effects, or side effects, of drug therapy are effects other than the therapeutic or desired effect. For many drugs, their adverse effects are well known, and a physician will take into account such adverse effects before prescribing a drug. Most adverse effects are merely a nuisance; however, some may be harmful and even life-threatening. The medical assistant should encourage patients to report unexpected or severe adverse effects to the physician immediately so that she can determine if a change is required. Common adverse effects include nausea, vomiting, diarrhea, headache, dry mouth, and constipation. An adverse reaction is an unexpected, usually dangerous, response to a drug. Adverse reactions can occur as a result of a patients health status, the number of drugs the patient is taking, or the length of time he has been taking them. Such reactions can be classied as allergic reaction, idiosyncratic effect, cumulative effect, toxic effect, and tolerance.

Drug Class
Antihypertensives

Common Ending
-olol -pril

Examples
propanolol benazepril diazepam alprazolam penicillin tetracycline gentamicin erythromycin ciprooxacin lovastatin acyclovir furosemide hydrochlorothiazide

Antianxiety drugs

-lam -pam

Antibiotics

-cillin -cycline -micin -mycin -oxacin

Antilipemics Antivirals Diuretics

-statin -vir -mide -zide

Allergic Reaction
An allergic reaction is an immune response to a drug that results in inammation and organ dysfunction. Reactions can occur immediately or even days later. Reactions range from itching, sneezing, and a mild rash to life-threatening symptoms. In a severe allergic reaction, called anaphylaxis, the patient will experience swelling of the face and throat, shortness of breath, or an inability to breathe. Anaphylaxis can occur within minutes of drug administration. A patient who is exhibiting symptoms of anaphylaxis requires emergency treatment.

Local anesthetics

-caine

novocaine, lidocaine

Opioid analgesics

-done -phone

primidone hydromorphone estradiol

Oral contraceptives Steroids

-diol

-sone

cortisone

Idiosyncratic Effect

Therapeutic Effect
Physicians prescribe drugs for their therapeutic, or desired, effect. The therapeutic effect is the predicted effect that the drug will have in the body. It is also sometimes called a drugs indication. Therapeutic effect can be further classied as a systemic effect, such as a drug given for generalized pain, or local effect, such as a drug used to numb an area of the mouth. Whether the drug has a local or systemic effect depends largely on the route of administration. For example, oral drugs almost always have a systemic effect. If a patient takes a pain reliever for a headache and then stubs her toe, the pain reliever will also help to alleviate pain from the toe injury. However, a topical drug, such as Flexall 454 or trolamine salicylate (Aspercreme) rubbed on the skin only affects the local area. Thus, if a patient rubbed the cream on

An idiosyncratic effect is an abnormal drug response in a patient with a peculiar defect in his body chemistry. Because of the defect, administration of the drug causes effects that are totally unrelated to the drugs normal pharmacological action. Unlike an allergy, the chemical defect of the patient is not part of a hypersensitivity reaction. The drug will have the same idiosyncratic effect when administered at another time. Because body chemistry errors are commonly hereditary, the medical assistant should ask the patient if any relatives have had an unusual reaction to drugs. In addition, she should instruct patients to report unusual drug effects to the physician immediately. (See Neuroleptic malignant syndrome.)

Cumulative Effect
Sometimes the body cannot metabolize and properly excrete a drug, causing a cumulative drug action. The drug stays in

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Neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is a rare, sometimes fatal idiosyncratic reaction to administration of neuroleptic (antipsychotic) drugs. The features of the reaction include extreme hyperthermia, with body temperature rising up to 104F; marked muscle rigidity; coma; and, sometimes, death. About 5% to 11% of all patients with neuroleptic syndrome die from the disorder. Drugs that can induce this syndrome include haloperidol (Haldol), levodopa-carbidopa (Sinemet), and chlorpromazine (Thorazine).

develop a tolerance over time to the drugs carbidopalevodopa (Sinemet) and amantadine hydrochloride (Symmetrel) used to treat the disease. Because of the risk of tolerance with these drugs, physicians will commonly counsel their patients to take a drug holiday, which is a temporary discontinuance of the drugs, so that when they resume administration, the drugs will have a renewed effect. However, developing a tolerance to some drugs can actually be benecial. For example, some patients who take antihistamines for allergies develop less sleepiness when taking the drug after using it for 5 to 6 days.

Drug Interactions
the body and when the patient takes subsequent doses, the drug level in the blood rises, becoming unsafe for the patient and causing symptoms of overdose. For example, preparations containing lead, silver, and mercury tend to accumulate in the body and can produce symptoms of poisoning. Also, patients with impaired kidney and liver function and some elderly patients may have cumulative effects of drug therapy because of an impairment in their ability to clear drugs from the body. These patients require smaller or less frequent dosages. A drug interaction happens when the combination of a drug with food or other drugs creates an effect in the body. (See Drug interactions with foods, page 816.) When patients take more than one drug, the combination of drugs can affect the actions of the drugs in harmful or benecial ways. The combination of two or more drugs can cause three different effects:

synergism antagonism potentiation.

Synergism
Synergism, or a synergistic drug effect, occurs when two drugs taken together have a greater therapeutic effect together than the expected effects of each drug. Thus, the effect of the drugs is enhanced by their concurrent administration. For example, a physician may begin treating a patient with hypertension (high blood pressure) by prescribing hydrochlorothiazide (Hydrodiuril) to lower his blood pressure. However, to achieve better results, the physician may add a prescription for enalapril (Vasotec), another drug for treating high blood pressure. When taken together, these drugs lower the patients blood pressure to a greater degree than a higher dosage of one of the drugs taken alone. Because taking two drugs for the same indication increases the effect, the medical assistant should remind the patient to tell the physician what medications she is currently taking to avoid an unintended synergistic effect of drugs from different prescribers. For example, a patient taking eszopiclone (Lunesta) prescribed by one physician for her insomnia should not take zolpidem tartrate (Ambien) prescribed by a second physician. The combined effect of two sleep aids will cause dangerous central nervous system (CNS) depression.

Toxic Effect
Some drug therapy can cause toxic effects that are so harmful that the patient must discontinue use of the drug immediately. Some drugs are inherently toxic, such as chemotherapeutic drugs, which cause the death of healthy tissue and may cause heart attack and brain inammation. Other drugs, while not inherently toxic, can cause toxic effects even when used as directed. For example, antidepressants increase the patients risk of suicide, cancer, diabetes, and osteoporosis. Nonsteroidal anti-inammatory drugs (NSAIDs) can also increase the risk of heart attack. The physician must monitor the dosage closely and look for signs and symptoms of toxicity to avoid causing a toxic effect. In addition, some patients, whether knowingly or not, may take too much of any drug (overdose). The medical assistant must educate patients regarding the signs and symptoms of drug overdose, toxicity, or poisoning. The occurrence of toxic effects may be a medical emergency.

Tolerance
When a patient has taken a drug for an extended period of time, the desired effect may lessen or will not occur at all. This effect is called tolerance. Because the body of a patient who has developed a tolerance is accustomed to the drug, the physician may have to increase the dose to achieve the desired effect or change drugs completely. Tolerance is a common reaction in patients with Parkinson disease, who

Antagonism
Antagonism, or an antagonistic effect, happens when drugs work in opposition to one another. For example, antibiotics negate the effects of most oral contraceptives. When the

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Drug interactions with foods

A patients diet can affect a drugs therapeutic effect. The physician and medical assistant may need to advise a patient to alter his diet during the course of drug therapy. Doing so will ensure the drugs proper absorption and intended effects. The following table shows common interactions between drugs and food.

Drug
acetaminophen (Tylenol) amoxicillin ampicillin aspirin erythromycin levodopa methotrexate phenobarbital tetracycline warfarin (Coumadin)

Food
High-pectin foods Any food

Interaction
Delayed absorption Decreased absorption

Diets rich in vitamin K (for example, broccoli, liver, beans, rice, pork, and sh)

Decreases the effect of the drug (antagonistic effect) Increases absorption, prolongs caffeine half-life, delays excretion of the metabolized form of warfarin

cyclosporine caffeine warfarin (Coumadin) diazepam phenytoin digoxin lovastatin digoxin warfarin (Coumadin) levodopa lovastatin

Grapefruit juice

Dietary fats

Increases absorption

High-ber meals

Decreases absorption

High-fat meals

Reduces absorption

High-protein diet Grapefruit juice

Decreases absorption Increases lovastatin and delays excretion of metabolized form of lovastatin

methyldopa quinidine

Iron Grapefruit juice

Decreases absorption Delays absorption, inhibits metabolism of quinidine

physician prescribes antibiotics to a patient taking oral contraceptives, the medical assistant should advise the patient to use an alternative form of birth control during the course of antibiotic therapy. In addition, many stomach acid reducers inhibit drug absorption as well as absorption of nutrients from food. Even so, an antagonistic effect is not always harmful. Physicians can use this same effect to save the life of a patient who is suffering from a drug overdose. For example, the physician can give sedatives to a patient who is suffering a cocaine overdose to control his rapid heart rate and help return blood pressure and pulse to normal levels to avoid heart attack and stroke.

Potentiation
Potentiation is an interaction between two drugs that enhances the effect of either drug, producing a heightened response similar to an overdose. Unlike synergism, in potentiation, the two drugs are taken for different conditions. For example, a patient taking the anticoagulant warfarin (Coumadin) for MI may wish to take aspirin for a headache. However, because aspirin potentiates the anticoagulant effect of warfarin to dangerous levels, the patient risks internal bleeding if he takes the two drugs together. The physician must adjust drug dosages when a patient is taking more than one drug with a risk of potentiation.

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Potentiation may be so severe in some drug combinations that the physician should always avoid the combination, as in the case of aspirin and warfarin. The medical assistant should instruct patients who have been prescribed more than one drug to report an increased effect of either drug to the physician immediately. Although potentiation can be dangerous, it can also be benecial in such cases as the treatment of headache. Caffeine, when taken with aspirin, will potentiate the analgesic effect of the aspirin.

indicate a prescription (drug to be administered) after she has registered and obtained a DEA number. A physicians DEA number is listed on her blank prescription pads. A licensed pharmacist can prepare drugs prescribed by physicians, and patients can purchase them at a pharmacy. The physicians ofce may also give samples of drugs to patients at no cost. Without a DEA license, prescribing, dispensing, or selling drugs is illegal. The DEA is responsible for prosecuting drug possession and distribution offenses. Many states have mandatory prison sentences for drug offenses.

Contraindications
An indication is the reason why a physician might prescribe a drug; a contraindication is a condition under which a drug should never be used. Contraindications identify for a physician situations in which she must never prescribe a certain drug to a certain patient. For example, patients with liver disease should never receive a prescription for lipidlowering drugs because the mechanism of such drugs is to prevent formation of cholesterol in the liver, which stresses the liver, making it harder for the liver to manufacture bile, metabolize amino acids, and detoxify the blood. Also, patients with glaucoma cannot take some drugs that affect the urinary system because antidiuretics that decrease urinary output can increase uid retention in the eye, raising intraocular pressure. In addition, many drugs are contraindicated in patients who are pregnant because they can cause birth defects. These drugs are described as teratogenic, or causing defects to the developing embryo or fetus. Drugs known to cause severe birth defects include CNS stimulants and depressants and alcohol in any form. Because many drugs are contraindicated during pregnancy, the medical assistant should ask the female patient if she might be pregnant before the physician prescribes a drug.

DEA Registration
Physicians must register with the DEA by filling out Form 224, which is available online. The DEA assigns the physician a number that must be printed on each prescription the physician writes. This registration must be renewed every 3 years.

Controlled Substances
The Controlled Substances Act of 1990 identies ve schedules, or categories, of drugs that have potential for abuse and illegal use. Thus, when a physician prescribes opiates for severe pain, he must do so thoughtfully and cautiously. (See Drug abuse.) The legislation provides regulations for prescribing, relling, dispensing, and medical use of these drugs. The drugs have mood-altering effects and the potential for physical dependence; therefore, they have the potential for abuse. For example, although physicians can prescribe opiates for severe pain, they must take care to avoid overprescribing them and causing addiction in the patient. (See Controlled substance schedules, page 818.)

Drug Regulation
The United States government regulates all drugs approved for patient use, including OTC and prescription drugs. Two government agencies that work together to ensure our safety are the Drug Enforcement Agency and the Food and Drug Administration.

Patient Education

Drug Abuse
Drug abuse, also called substance abuse, is the misuse of alcohol and other drugs. Abuse of drugs may involve legal or illegal medications and can occur suddenly or develop over time. Psychological dependence (when a person merely thinks he needs the drug) can turn into physical dependence (when a persons body needs the drug to prevent adverse effects, including death). Commonly abused drugs include alcohol, marijuana, nicotine, central nervous system stimulants (such as Ritalin), and central nervous system depressants (such as opiates). The medical assistant can direct a patient who abuses drugs to a treatment facility or a support group, such as Alcoholics Anonymous or Narcotics Anonymous.

Drug Enforcement Agency

The purpose of the Drug Enforcement Agency (DEA) is to enforce drug laws. The DEA was formed under the Department of Justice in 1973. Physicians and pharmacists are licensed by each state to practice but must register with the DEA to receive a number if they prescribe (indicate a drug to be administered) or dispense (prepare or deliver a drug) controlled substances. The physician has the lawful right to

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Controlled substance schedules

The full schedules of controlled substances in the Controlled Substances Act of 1990 describe the medical uses, potential abuse level, prescription requirements, and safety of each group of drugs. The table shown here lists each schedule number along with a description of the drugs uses and potential for abuse and examples of the drugs included in that schedule.

Schedule
I

Description
No currently accepted medical use in the United States High potential for abuse

Examples
heroin lysergic acid diethylamide (LSD) MDMA (ecstasy) marijuana* mescaline peyote

II

Currently accepted medical use in United States with severe restrictions High potential for abuse Written prescription must be provided to pharmacist within 7 days No rells allowed for a prescription

cocaine hydromorphone (Dilaudid) meperidine (Demerol) methylphenidate (Ritalin) morphine (MS Contin) oxycodone (OxyContin) acetaminophen (Tylenol) with codeine acetaminophen and hydrocodone (Vicodin) anabolic steroids, such as oxandrolone (Oxandrin)

III

Currently accepted medical use in the United States Potential for abuse is less than for Schedules I and II Telephone orders allowed Can be relled 5 times within 6 months of prescription date

IV

Potential for abuse is less than for Schedule III Telephone orders allowed Can be relled 5 times within 6 months of prescription date

diazepam (Valium) alprazolam (Xanax) zolpidem (Ambien) phentermine (Fastin) cough suppressants with restricted amounts of codeine diphenoxylate and atropine (Lomotil)

Potential for abuse is less than Schedule IV Telephone orders allowed Number of rells determined by physician

* Some states have adopted a Schedule VI, which includes only marijuana that is prescribed for limited medicinal purposes, such as to alleviate nausea from chemotherapy treatment.

Record Keeping
In addition to obtaining a DEA registration number, physicians who prescribe controlled substances must keep records for 2 years of drugs dispensed, including the patients full name and address, date prescribed, dosage (amount to be taken), route of administration, and the reason the drug was given. The physician must also maintain proper security for these records, which are subject to inspection by the DEA. In addition, the medical ofce must keep a progress note in the patients medical record that includes the prescription.

Controlled Substances Inventory

If a physicians ofce keeps a supply of controlled substances, the staff must conduct a controlled substances inventory at the date of DEA registration and every 2 years thereafter. In addition, the ofce must keep a separate inventory record for Schedule II drugs. With the inventories, the ofce must include the name of the physician or practice, address of the medical ofce, DEA number, date and time of inventories, and the signature of the person checking the inventories. The ofce must keep these inventory records on le for

CHAP TER 38

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2 years. The ofce must keep controlled substances in a locked cabinet, separate from other drugs, such as samples and OTC drugs. Because the inventory must be complete and accurate, the medical assistant and other staff members should log the administration of a controlled substance in the inventory log at the time of administration to avoid forgetting to log the drugs. If an opioid analgesic is accidentally broken or spilled, two staff members must witness the disposal and sign the inventory log. The ofce must report any theft of a controlled substance to local police and the DEA and complete a police report and Form DEA-116.

Patient Education

Buying Drugs Outside the Country

Because of the rising costs of prescription drugs in the United States, many patientsespecially elderly patientsseek to obtain prescription drugs from other countries in which drug costs are signicantly lower. In addition, drugs sold only by prescription in the states, such as antibiotics, are sold over the counter (OTC) in other countries. However, because the Food and Drug Administration (FDA) can only ensure the purity of drugs manufactured and sold in the United States, patients seeking drugs from abroad are at greater risk for suffering adverse effects as well as fraud. Enforcement of laws that ensure purity and proper labeling and drug dosages can vary greatly from country to country. The medical assistant should encourage a patient who is considering purchasing medication from another country to talk to the physician or a pharmacist about the safety and efcacy of the specic drug in the country of purchase. In addition, the medical assistant should explain to the patient that many generic drugs are available at a lower price. Patients without prescription drug coverage can save a lot of money by asking for generic drugs. Even for patients who have drug coverage, the copayment for the generic drugs is commonly lower than for trade name drugs. The medical assistant should tell the patient to ask the physician if a drug with a lower cost might be available.

Food and Drug Administration

Through testing, labeling, and enforcing laws regarding the sale and distribution of drugs, the FDA, a department of Health and Human Services, is responsible for ensuring the safety and efcacy of all new drugs, regardless of the source of the drug (plant, mineral, animal, or synthetic). The Pure Food and Drug Act of 1906 prohibits mislabeling of food and drugs. Thus, the FDA must test and verify that a drug whose label claims to relieve pain does have analgesic (painrelieving) effects before the manufacturer can sell the drug as a pain reliever. In addition, the act mandates that labels on drugs and food are accurate and that all ingredients are listed. Such information is important for people with severe food or drug allergies. In 1938, this law was extended to include cosmetics and to mandate drug testing before granting permission to market a drug.

OTC Drugs
Over-the-counter (OTC) drugs are available without a prescription in the United States. The FDA tests these drugs for safety and regulates the marketing and sale of these drugs, including accurate labeling. The consumer must read the label, decide if the drug is right for her needs, and follow the directions for use. Although the consumer does not need a prescription, she could suffer harm from an OTC drug if she misuses it. Patients commonly call the physicians office for information regarding OTC drugs. Because patients will have varied drug regimens and health histories, the medical assistant should check with the physician or nurse before answering questions about OTC drugs. (See Buying drugs outside the country.)

in preparing and administering them. Serious harm or death can occur if a health care provider administers a drug incorrectly. To safely administer a drug, the medical assistant must have a basic understanding of pharmacology and follow the instructions of the physician. She must read the drug label three times prior to administration to ensure the proper drug is prepared. In addition, she must always follow the seven rights of drug administration:

Drug Safety
Although the DEA and FDA have created laws to protect consumers, the administration of drugs to individual patients is made safe by medical personnel adhering to rules for drug administration. Because drugs modify body functions, the medical assistant and others must use extreme care

right drug right dose right time right route right patient right technique right documentation.

If the medical assistant closely follows each of these steps every time she administers a drug, she can eliminate medication errors. Even when the medical assistant becomes

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familiar with common drugs, she must follow the seven rights to ensure drug accuracy and patient safety.

Drug Disposal
The medical ofce must dispose of expired drugs in a safe manner. Specic laws for drug disposal vary from state to state and each medical ofce must establish a procedure for disposing of drugs and include it in its policies and procedures manual. For disposal of an expired controlled substance or a portion of a prelled syringe with a controlled substance, a staff member must discard the drug and a second staff member must witness the procedure. Disposal of expired samples of such drugs as antibiotics, nonopiate analgesics, and OTC medications does not require a witness unless specied by ofce policy.

(FDA), including a drugs indication, action, dosage, administration, warnings, hazards, contraindications, drug interactions, adverse effects, and precautions. The PDR is divided into six sections, which are color-coded for ease of use. In addition, it contains an alphabetical product identication guide that includes actual-size color photos of tablets and capsules by manufacturer. Most medical ofces keep a current PDR. A PDR for OTC drugs is also available. (See Figure 38-1.)

Drug Handbooks
Drug handbooks, such as Daviss Drug Guide for Nurses, is a handy reference that provides much of the same information as the PDR, yet is smaller and easier to use. It is written for the nonphysician provider (nurse or medical assistant) and omits such data as chemical structure and a manufacturers index. It can be used as a quick reference when administering a drug for the rst time or to answer a patients question.

Drug References
The medical assistant can never memorize all there is to know about every drug, as pharmaceutical companies release new drugs almost daily. Therefore, the medical assistant must learn to use drug references as a resource for important information about drugs. Drug references contain such vital information as drug names, classifications, indications, action, dosages, adverse effects, contraindications, and drug interactions. Some books are large, heavy, and sometimes difcult to use. There are several smaller pocket guides that are easier to use and understand. Publishers of drug references update them annually and supply information regarding the most commonly used drugs. Most references are also available in software form and the medical assistant can download them onto a handheld computer or data organizer.

Package Inserts
Package inserts are also quick sources of information. These inserts are provided in drug samples that a manufacturer provides to physicians to give to patients. Information in the package insert includes generic and trade name of the medication, drug class, clinical studies conducted, contraindications, common adverse reactions that the patient should report to the physician, how the medication should be taken, other drugs to avoid, and adverse effects.

Patient Prescription Information

Because patients need direct, written information about their prescription drugs, pharmacies attach patient prescription information sheets to the drug container when the patient lls the prescription at the pharmacy. Many pharmacy personnel will ask the patient to sign for his prescription and will ask him, Do you need to speak to the pharmacist? The pharmacy should make an effort to inform patients about their prescriptions. The medical assistant, in turn, should encourage the patient to read patient prescription information when lling their prescriptions. (See Figure 38-2.)

United States Pharmacopeia-National Formulary

The United States Pharmacopeia-National Formulary (USP/NF) is the ofcial source of drug standards in the United States. This reference book lists by their ofcial (generic) name all the medications approved for dispensing. It lists only drugs that have been tested and certied as having met established standards of quality, purity, and potency. The USP/NF is issued every 5 years by the Council on Pharmacology of the American Medical Association, with periodic supplements. It is prepared under the supervision of a national committee of pharmacists, pharmacologists, physicians, chemists, biologists, and allied personnel.

Teaching Patients About Drugs

An important part of preparing and administering drugs is educating the patient about the drug prescribed for them. Physicians prescribe a certain dosage to best treat the patients problem. Patients must be sure to take the correct dose at the correct time to achieve the benecial effects of the drug. If a patient understands why and how the drug works, he is more apt to take it correctly, enabling him to succeed in his recovery. Patient education regarding drug

Physicians Desk Reference

The Physicians Desk Reference (PDR) is an annual publication concerning prescription medications and diagnostic products. The information listed is generally the same information the manufacturer includes in the labeling or package insert as required by the Food and Drug Administration

CHAP TER 38

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821

URSO 250 TRADE NAME URSO FORTE GENERIC NAME (Ursodiol Tablets, USP) 250 mg and 500 mg DOSAGES Rx only

ROUTE OF ADMINISTRATION

DESCRIPTION URSO 250 (ursodiol, 250 mg) and URSO Forte (ursodiol, 500 mg) are available as film-coated tablets for oral administration. Ursodiol (ursodeoxycholic acid, UDCA) is a naturally occurring bile acid found in small quantities in normal human bile and in larger quantities in the biles of certain species of bears. It is a bitter-tasting white powder consisting of crystalline particles freely soluble in ethanol and glacial acetic acid, slightly soluble in chloroform, sparingly soluble in ether, and practically insoluble in water. The chemical name of ursodiol is 3, 7-dihydroxy-5-cholan-24-oic (C24H40O4). Ursodiol has a molecular weight of 392.56. Its structure is shown below. CHEMICAL FORMULA CH3 MECHANISM OF ACTION OH H Inactive ingredients: microcrystalline cellulose, povidone, sodium starch glycolate, magnesium stearate, ethylcellulose, dibutyl sebacate, carnauba wax, hydroxypropyl methylcellulose, PEG 3350, PEG 8000, cetyl alcohol, sodium lauryl sulfate and hydrogen peroxide. CLINICAL PHARMACOLOGY Ursodiol (UDCA) is normally present as a minor fraction of the total bile acids in humans (about 5%). Following oral administration, the majority of ursodiol is absorbed by passive diffusion and its absorption is incomplete. Once absorbed, ursodiol undergoes hepatic extraction to the extent of about 50% in the absence of liver disease. As the severity of liver disease increases, the extent of extraction decreases. In the liver, ursodiol is conjugated with glycine or taurine, then secreted into bile. These conjugates of ursodiol are absorbed in the small intestine by passive and active mechanisms. The conjugates can also be deconjugated in the ileum by intestinal enzymes, leading to the formation of free ursodiol that can be reabsorbed and reconjugated in the liver. Nonabsorbed ursodiol passes into the colon where it is... HO CLINICAL STUDIES A U.S., multicenter, randomized, double-blind, placebo-controlled study was conducted to evaluate the efficacy of ursodeoxycholic acid at a dose of 13 to 15 mg/kg/day, administered in 3 or 4 divided doses in 180 patients with PBC (78% received QID dosage). Upon completion of the double-blind portion, all patients entered an open-label active treatment extension phase. INDICATIONS AND USAGE INDICATIONS AND USAGE URSO 250 and URSO Forte (ursodiol) tablets are indicated for the treatment of patients with primary biliary cirrhosis. CONTRAINDICATIONS CONTRAINDICATIONS Hypersensitivity or intolerance to ursodiol or any of the components of the formulation. H3C
CH3

COOH

PRECAUTIONS Patients with variceal bleeding, hepatic encephalopathy, ascites or in need of an urgent liver transplant, should receive appropriate specific treatment. Drug Interactions Bile acid sequestering agents such as cholestyramine and colestipol may interfere with the action of URSO 250 and... ADVERSE REACTIONS ADVERSE EVENTS (AEs) The following table summarizes the AEs observed in the two placebo-controlled clinical trials. ADVERSE EVENTS VISIT AT 12 MONTHS UDCA n (%) Diarrhea Elevated creatinine Elevated blood glucose Leukopenia Peptic ulcer Skin rash 1 (1.18) Placebo n (%) VISIT AT 24 MONTHS UDCA n (%) 1 (1.32) 1 (1.32) 1 (1.32) 2 (2.63) 1 (1.32) 2 (2.63) Placebo n (%)

DOSAGE AND ADMINISTRATION The recommended adult dosage for URSO 250 and URSO Forte in the treatment of PBC is 1315 mg/kg/day administered in two to four divided doses with food. Dosing regimen should be adjusted according to each patients need at the discretion of the physician.

FIG 38-1 Example entry from the Physicians Desk Reference.

822

UNIT 3

Clinical

#0785 Ph:860.487-2034 Mall Pharmacy

604 REEDY TURNPIKE BLUEVILLE, CT 060100000

HARTVEIL, SADIE 7 LINECREST ROAD WILLBURGTON, CT 06665 PH: 860.123.3245

CLAY-PARK LABS.

11-05-09 Prscbr: PIECEK, SHARON Refills: 0

PATIENT PRESCRIPTION IF YOU HAVE ANY QUESTIONS AB MEDICATION, PLEASE CONTACT PROUST, MARK, RPH

IBUPROFEN 600 MG TABLET CPL

TAKE 1 TABLET EVERY 6 HOURS AS NEEDED This is a WHITE, ELLIPTICAL-shaped, TABLET imprinted with L167 on the front. IBUPROFEN - ORAL (eye-byou-PRO-fen) COMMON BRAND NAME(S): Advil, Motrin, Nuprin WARNING: This drug may infrequently cause serious (rarely fatal) bleeding from the stomach or intestines. Also, related PRECAUTIONSand strokes. This medication might also rarely cause similar problems. Talk to your doctor or pharmacist about the benefi you notice any of the following rare but very serious side effects, stop taking ibuprofen and seek immediate medical atten coffee grounds, chest pain, weakness on one side of the body, sudden vision changes, slurred speech. USES: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID), which relieves pain and swelling (inflammation). It is u INDICATIONS menstrual cramps, arthritis, or athletic injuries. This medication is also used to reduce fever and to relieve minor aches a enzyme in your body that makes prostaglandins. Decreasing prostaglandins helps to reduce pain, swelling, and fever. HOW TO USE: Read the Medication Guide provided by your pharmacist before you start using ibuprofen and each time y your doctor or pharmacist. Take this medication by mouth with a full glass (8 oz or 240 ml) of water unless your doctor di HOW TO USE this drug. If stomach upset occurs while taking this medication, take it with food, milk, or an antacid. The dosage is based needed, they are usually given 6 or 8 hours apart; or as directed by your doctor. When ibuprofen is used in children, the the appropriate dose for your childs weight. Consult the pharmacist or doctor if you have questions or if you need help in arthritis), it may take up to two weeks, taken regularly, before the full benefits of this drug take effect. If you are taking thi that pain medications work best if they are used as the first signs of pain occur. If you wait until the pain has significantly for migraine headache, and the pain is not relieved or worsens after the first dose, tell your doctor immediately. For medication to a child for undiagnosed fever or pain, consult the doctor immediately if symptoms do not improve within 24 reduce your risk of stomach bleeding and other side effects, take this medication at the lowest effective dose for the sho take it for a longer time than prescribed. Do not take the over-the-counter product for more than 10 days unless otherwise SIDE EFFECTS: Upset stomach, nausea, vomiting, heartburn, headache, diarrhea, constipation, drowsiness, and dizzin or pharmacist promptly. If your doctor has directed you to use this medication, remember that he or she has judged that t SIDE (ADVERSE) this medication do not have serious side effects. Tell your doctor immediately if any of these serious side effects occur: st EFFECTS gain, ringing in the ears (tinnitus). Tell your doctor immediately if any of these unlikely but serious side effects occur: visio DRUG INTERACTIONS: Ibuprofen is associated with several suspected or probable interactions that can affect the action of other drugs. Ibuprofen may increase the blood levels of lithium (Eskalith) by reducing the excretion of lithium by the kidn Increased levels of lithium may lead to lithium toxicity. Ibuprofen may reduce the blood pressure-lowering effects of drugs t DRUG INTERACTIONSare given to reduce blood pressure. This may occur because prostaglandins play a role in the regulation of blood pressure. When ibuprofen is used in combination with aminoglycosides (for example, gentamicin [Garamycin]) the blood levels of th aminoglycoside may increase, presumably becasue the elimination of aminoglycosides from the body is reduced. This ma lead to aminoglycoside-related side effects. Individuals taking oral blood thinners or anticoagulants (for example, warfarin [Coumadin]) should avoid ibuprofen because ibuprofen also thins the blood, and excessive blood thinning may lead to ble

FIG 38-2 Patient prescription information insert.

administration is an important responsibility of the medical assistant. The medical assistant should share all considerations about the drug with the patient, such as important adverse effects or special instructions on when and how to take the drug. For example, a patient should take some drugs on an empty stomach to aid absorption. Other drugs cause photosensitivity, so the medical assistant must advise the patient to avoid the sun. The medical assistant should use drug references as needed to provide information to the patient that will help him with his drug therapy. Key teaching points include:

importance of taking all of the prescription, even after feeling better importance of using a back-up contraceptive method in addition to oral contraceptives, if appropriate importance of using sunscreen if drug causes photosensitivity determining the female patients pregnancy status before prescribing a drug.

Special Considerations
Some groups of patients require special consideration for drug administration. Two of the major groups requiring special consideration include elderly patients and children

generic and trade name of drug how, when, and how many times per day to take the drug adverse effects and what to report to the physician possible drug interactions and food-drug interactions

CHAP TER 38

Introduction to Pharmacology

823

because they do not necessarily respond to a drug in the same way an adult patient would. Patients who are extremely small (under 100 lb) or large (over 300 lb) will also require different dosages to achieve the desired effect of the prescribed drug.

extra time with geriatric patients to explain drug therapy and answer any questions they may have.

Pediatrics
Pediatric patients include neonates, infants, and children up to about age 18. This group requires special consideration because medications are based on body weight or body mass. A pediatric patients body weight and body mass are lower than average for regular drug dosages, so the medical assistant should take care to properly weigh and measure pediatric patients and record their vital signs. The pediatrician or medical assistant must calculate pediatric dosages by milligrams per kilogram of body weight. When calculating pediatric dosages, the medical assistant should double-check her results and ask the physician or other allied health professionals for assistance, if needed. (For more information on calculating pediatric dosages, see Chapter 39, Dosage Calculation and Medication Administration, page 825.) In addition, some children have trouble swallowing tablets or capsules. If doing so is difcult or impossible, the physician may need to prescribe the drug in a liquid form. Finally, the medical assistant should provide clear instructions to parents or caregivers and speak at the childs level of understanding when explaining drug therapy. She should emphasize that a drug is not candy, even if it tastes good, and that only a parent or caregiver, school nurse, medical assistant, or physician in the ofce should give drugs to the child.

Geriatrics
Patients ages 65 and older are categorized as geriatric. The physician must give special consideration to drugs prescribed to geriatric patients for several reasons. First, as the body ages, body processes slow down. These changes in the body effect a change in the pharmacokinetics of a drug, including its absorption, distribution, metabolism, and excretion. In addition, cumulative effects may occur if drugs are not dosed properly (usually lower than in adults) or eliminated effectively. Second, the medical assistant should ask the patient if he has dysphagia (difculty swallowing), because the physician may need to indicate that the pharmacy should provide an oral drug in liquid form. Third, many geriatric patients are taking multiple medications, a situation called polypharmacy, which increases the risk of drug interactions and adverse effects. As a patients hearing and vision decrease, the pharmacy or medical assistant should provide information in large print and speak clearly and slowly, asking the patient to repeat the information to ensure accurate understanding of the instructions. In addition, the patient may need help from a family member to administer drugs correctly. The medical assistant should recommend that the patient use a pill container, which separates pills into individual compartments by day or time, to ensure that he is taking the required drugs at the appropriate time and dosage. If the patient can put a weeks worth of drugs into a marked container, he will more easily remember to take them on time. (See Figure 38-3.) The medical assistant should also encourage patients to rotate injection sites and use mapping for daily injection therapy to avoid scarring and infection. Finally, the medical assistant should take

Chapter Summary

FIG 38-3 Pill container with drugs separated by days of the week.

The role of the medical assistant in pharmacology is to safely and accurately prepare and administer medications as directed by a physician. Drug sources include plants, animals, minerals, and laboratories. Drugs come in basically two forms: solids and liquids. The medical assistant must have an understanding of the pharmacotherapeutics, pharmacodynamics, and pharmacokinetics of drugs to educate her patients and understand how the body uses drugs. Medical uses of drugs include to cure, treat, prevent, and diagnose disease or replace a substance that is missing or lost. Prescription drugs are obtained when the physician writes a prescription for that specic medication. Over-thecounter medications are available without a prescription. Natural products are also OTC products and include vitamins, minerals, and herbal supplements. Many factors inuence drug action, including age, body mass, sex, environment, presence of food in the digestive tract, and genetics.

824

UNIT 3

Clinical

Drugs have an ofcial name, a chemical name, a brand or trade name, and a generic name. Drugs can be classied according to their pharmacologic action or therapeutic effect. Drug effects include therapeutic effect, adverse effect, cumulative effect, tolerance, and toxic effect. Drug reference materials include USP/NF, PDR, nursing drug handbooks, package inserts, and software. These materials provide vital information for medical assistants and patients. Government regulation of drugs is overseen by the DEA and FDA. Controlled substances are listed in ve schedules, categorized according to abuse potential. The medical assistant must be familiar with drug storage and proper drug disposal. Patient education is an important part of drug therapy. The medical assistant is a source of information for patients, so she must provide safe, accurate, up-to-date information regarding drugs and drug therapy. Geriatric and pediatric patients metabolize drugs differently, so the medical assistant must consider adjustments in dosages and choices of drugs.

manufacture. Does this company have a program that provides medications to patients free of charge? If so, describe the program. c. Federal Drug Enforcement AgencyLog onto the DEA website and read and report on the current press releases. d. Food and Drug Administrationlog onto the FDA website and report on the recalls and safety alerts posted, any current job opportunities, and information on medical devices.

Case Studies
1. Ricardo is a 34-year-old male patient who complains of nausea whenever he takes his medication. He tells the medical assistant that he just started this new medication a couple of days ago. What type of effect is Ricardo describing? What will the physician likely talk to Ricardo about? 2. Mary, a 10-year-old female patient, has Strep throat. The physician treated her the day before with penicillin. After the rst dose, Marys mother noticed a red rash on her neck and chest. Mary does not complain of itching, but her mother thought she should call the physician anyway. Did Marys mother do the right thing? What is the likely cause of Marys rash?

Team Work Exercises

1. Divide into groups of two to three students. The instructor will provide each group with a drug class. Each group must research various drugs within the class and create a poster about the drug that includes: a. generic names of drugs b. trade names of drugs c. uses for each drug (such as disease, body system, and so on) d. actions of each drug e. adverse effects and adverse reactions of each drug f. contraindications for each drug. 2. Divide into groups of two to three students. Each group must research and report to the class on one of the following topics, as assigned by the instructor: a. Doctor of Pharmacy ProgramLook at programs in the area and provide a list of colleges that offer the program and the requirements. b. Pharmaceutical ManufacturerResearch one pharmaceutical company and provide a list of the drugs they

Resources

DEA forms: www.dea.gov Information on clinical drug trials and substance abuse: www.nih.gov Information on vaccines, drug-resistant antibiotics, and methadone dispensing: www.cdc.gov U.S. Food and Drug Administration: www.fda.gov Deglin, J.H., and Vallerand, A.H.: Daviss Drug Guide for Nurses, 11th ed. Philadelphia: F.A. Davis Company, 2008. Katzung, B.G.: Basic and Clinical Pharmacology, 10th ed. New York: McGraw-Hill Co., 2006. Physicians Desk Reference online: www.pdr.net Ritter, J.M., et al.: Textbook of Clinical Pharmacology and Therapeutics, 5th ed. New York: Oxford University Press, USA, 2008. Swanson, T.A., and Kim, S.I.: Pharmacology Flash Cards. Philadelphia: Lippincott Williams & Wilkins, 2004.

CHAPTER

Dosage Calculation and Medication Administration

Learning Objectives
Upon completion of this chapter, the student will be able to: dene and spell terms related to dosage calculation and medication administration identify the role of the medical assistant in medication administration understand state laws and guidelines for medication administration identify systems of measurement identify common conversions between systems calculate drug dosages practice safety in dosage calculation and medication administration identify routes of administration identify parts of a prescription accurately use accepted abbreviations associated with prescriptions and medication administration rell telephone prescriptions per a physicians order identify special considerations in dosage calculation and medication administration differentiate between types of medication orders identify supplies used in medication administration educate the patient regarding medication administration.

39
Legal Concepts
Dispose of controlled substances in compliance with government regulations

CAAHEP Competencies
Clinical Competencies Patient Care
Apply pharmacology principles to prepare and administer oral and parenteral (excluding IV) medications Maintain medication and immunization records

Procedures
Administering an oral medication Preparing a parenteral medication from a vial Preparing a parenteral medication from an ampule Administering a subcutaneous injection Administering an intradermal injection Administering an intramuscular injection Administering a transdermal patch

General Competencies Legal Concepts

Perform within legal and ethical boundaries Document appropriately Demonstrate knowledge of federal and state health care legislation and regulations

Patient Instruction
Instruct individuals according to their needs

Chapter Outline ABHES Competencies

Professionalism
Evidence a responsible attitude Conduct work within scope of education, training, and ability

Dosage Calculation
Systems of Measurement Metric system Apothecary and household systems Calculation Methods Dose on hand Ratio and proportion Fractional equation Using conversions Calculating infant and child dosages

Communication
Adapt what is said to the recipients level of comprehension Serve as a liaison between the physician and others

Clinical Duties
Apply principles of aseptic techniques and infection control Prepare and administer oral and parenteral medications as directed by the physician Dispose of biohazardous materials Practice standard precautions

Medication Administration
Parts of a Prescription Routes of Medication Administration Oral Parenteral

Chapter Summary Team Work Exercises Case Studies Resources

825

Key Terms
apothecary

Dosage Calculation
When a physician orders a medication, the medical assistant must administer the correct amount of the medication. Because the dosage ordered will not always match the available doses, the medical assistant must calculate the proper dosage for her patient.

System of weights and measures based on the yard

buccal

Route of administration that involves placement of a drug between the cheek and gum
capsule

Special container made of gelatin sized to contain a single dose of an oral medication
enteric-coated

Systems of Measurement
In order to accurately calculate dosages, the medical assistant must have an understanding of the metric, household, and apothecary systems of measurement. No matter what system is used, medications dispensed to patients are measured in quantities of liquid (volume) or solid (weight).

Drug formulation in which tablets or capsules are coated with a compound that does not dissolve until exposed to the uids of the small intestine
household

System of volume measurement using the teaspoon and tablespoon

intradermal

Route of administration that involves injection of a drug just under the epidermis
intramuscular

Metric System
The metric system is a system of weights and measures based on the meter. It is the most commonly used system for drug dosages. Within that system, the milliliter (ml), sometimes called a cubic centimeter (cc), is used for liquid medications and milligram (mg) is used for solid medications. (See How to remember metric x unequal word/units.)

Route of administration that involves injection of a drug into the muscle

intravenous

Route of administration that involves injection of a drug into a vein

meniscus

Apothecary and Household Systems

Although the metric units of milligrams and milliliters are most common in medication dosages, the apothecary and household systems are sometimes used. The apothecary system is a system of measurement based on the yard. The units of weight in this system include grain and ounce. Volume measures in the apothecary system include minim, uidram, pint, and quart. The household system measures for liquids are drop, teaspoon, tablespoon, uid ounce, pint, cup, and quart. Household measures for weight are ounce and pound. Some of the units of measure for apothecary and household units are the same, which can cause confusion. In addition, teaspoon and tablespoon containers are commonly poorly calibrated; thus, the patient may get too much or too little of the medication. In addition, these units of measure are used to measure liquid and dry ingredients, adding more confusion. For these reasons, medications are most commonly ordered in metric doses and should be calculated in metric doses. In addition, household measures do not provide precise measurement of smaller quantities of prescribed drugs. For example, 60 mg of a drug would equal less than 14 teaspoon, the smallest unit in the household system. If the medical assistant must convert from apothecary or household to metric, she must pay careful attention to the conversions to avoid overmedicating or undermedicating her patient. (See Converting to metric.)

Curved upper surface of a liquid in a container

metric

System of weights and measures based on the meter

oral route

Route of administration of a medication through the mouth and into the GI tract
route of administration

Way in which medication is introduced into the body

subcutaneous

Route of administration that involves injection of a drug into the fatty layer under the skin
sublingual

Route of administration that involves placement of a drug under the tongue

suspension

Solid particles mixed in a liquid but not dissolved

syrup

Concentrated solution of sugar and water to which medicine is added and taken orally
tablet

Small, disklike mass of medicine in compressed powder form taken orally

Z-track injection

Intramuscular injection technique where the skin is pulled to one side to prevent medication from leaking into the subcutaneous tissues

CHAP TER 39

Dosage Calculation and Medication Administration

827

How to remember metric units

To help remember the metric units of measure, the medical assistant can use this mnemonic: King Henry Died While Drinking Chocolate Milk:

King
Kilo 1000

Henry
Hecto 100

Died
Deca 10

While
Whole 1

Drinking
Deci 0.1

Chocolate
Centi 0.01

Milk
Milli 0.001

Calculation Methods
To administer the correct amount of medication to the patient, the medical assistant must calculate the correct dose. There are several methods for calculating the dose. For example, the medication order reads Dilantin 50 mg PO t.i.d. The drug available is Dilantin 125 mg/5 ml. Methods for calculating the dosage include:

For each method, the medical assistant must remember a formula containing these elements:

dose ordered or desired dose (D) dose on container label or dose on hand (H) form and amount in which the drug is available, such as tablet, capsule, or liquid (V) amount to give (A).

dose on hand method ratio and proportion method fractional equation method.

Dose on Hand
To calculate the dose using the dose on hand method, the medical assistant must remember this formula: D V A H 50 mg 5 ml A 125 mg 250 ml 2 ml 125

Converting to metric
The following table provides conversions from apothecary and household units into metric units. The medical assistant can use a table such as this to quickly convert measurements, aiding timely, accurate dosage calculations.

Household
Dry
1

Apothecary
1 gr 15 grains (gr) 4 drams (dr) 1 oz

Metric
60 milligrams (mg) 1 gram (g) 15 g 30 g 1 kilogram (kg) (1000 mg)

Ratio and Proportion

To calculate the dose using the ratio and proportion method, the medical assistant must remember this formula: HA DV 125 mg A 50 mg 5 ml 125 mg A 250 mg/ml 250 mg/ml A 125 mg A 2 ml

4 teaspoon (tsp)

1 tablespoon (Tbs) (3 tsp) 1 ounce (oz) 2.2 pounds (lb) Liquid 1 drop (gt) 15 drops (gtt) 1 tsp 1 Tbs 1 uid ounce ( oz) (2 Tbs) 1 pint (pt) or 2 cups (c) 4 c (1 quart)

1 minim (m) 15 m 1 dr (uidram) 4 dr 1 oz (8 dr) 1 pint (pt) 1 quart (qt) (2 pt) 1 milliliter (ml) 5 ml (5 cubic centimeters) 15 ml 30 ml 480 ml 960 ml

Fractional Equation
To calculate the dose using the ratio and proportion method, the medical assistant must remember this formula: H D V A 125 mg 50 mg 5 ml A 125 mg A 50 mg 5 ml 50 mg 5 ml A 125 mg A 2 ml

828

UNIT 3

Clinical

Using Conversions
If the dose on hand and the dose ordered are measured with different systems, the medical assistant must perform some conversions before she can calculate the correct dose. For example, if the order contains the dosage Nitrostat gr 1/400 prn for angina pain and the dose on hand is Nitrostat 0.3-mg tablets, the medical assistant must rst convert grains to milligrams. Using the conversion table, the medical assistant will know that 1 grain equals 60 mg. Using this conversion, the medical assistant can calculate the dose using the dose on hand method: 1 grain 60 mg gr 1 60 mg 3 mg 0.15 mg 400 400 20 0.15 mg 0.5 tablet 0.3 mg Also, some doses are measured with the same system but with different units within the system. The medical assistant must also perform conversions in this case. For example, if the order says 0.5 g amoxicillin and the dose on hand is 250-mg tablets, the medical assistant must first convert grams to milligrams. Using the conversion table, the medical assistant will know that 0.5 g equals 500 mg. Using this conversion, the medical assistant can calculate the dose: 500 mg 2 tablets 250 mg

Body Surface Area Method

The medical assistant can also use the body surface area (BSA) of the infant or child to calculate an accurate dose for a pediatric patient. In order to calculate BSA, the medical assistant must use a chart called a nomogram. On the chart, the medical assistant enters the height and weight of the child. Then she must draw a straight line from the point on the chart where the height is plotted to the point where the weight is plotted. The intersection of that line on the BSA line is the body surface in square meters. (See Figure 39-1.) For example, if the childs height is 45" and his weight is 38 lb, his BSA equals 0.74. Thus, if the adult dose of the medication is 500 mg, the medical assistant can calculate the desired dose by using this formula: (BSA2 1.7) adult dose desired dose (0.742 1.7) 500 mg (0.55 1.7) 500 mg 0.32 500 mg 160 mg

Nomogram Height cm in For children of normal height for weight

90 80 70 90 85 80 75 70 65 60 55 50 Weight in pounds 45 40 35 30 28 26 24 22 50 20 19 18 17 16 15 14 13 12 5 4 3 .15 0.2 20 15 60 50 40 30 1.30 1.20 1.10 1.00 .90 .80 .70 .60 .55 .50 .45 .40 .35 .30 10 9 8 7 6 .25

BSA
M2

Weight lb
180 160 140 120 100 90 80 70 60 50 45 40 35 30 25 20 18 16 14 12 10 9 8 7 6 5 4 3 2.0 1.5 10 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.5

kg
80 70 60 50 40 30 25 20 15

240 220

2.0 1.8 1.6 1.5 1.4 1.3 1.2 1.1 1.0 0.9 Surface area in square meters 0.8 0.7 0.6 0.5 0.4

Calculating Infant and Child Dosages

The medical assistant must calculate dosages for pediatric patients according to their body size. Administering an adult dose of a medication to an infant or child would increase the risk of overdose and would not be therapeutic. Two main methods of calculating pediatric dosages include the weight method and the body surface area method.

200 190 180 170 160 150 140 130 120 110 100 90 80 70 60

Weight Method
The medical assistant can calculate infant and child dosages according to the patients weight. Because most dosages are expressed using kilograms (kg), the medical assistant must also convert pounds to kilograms in order to calculate accurately. For example, the medical assistant is calculating a dosage for a 6-year-old patient who weighs 55 lb. The physicians order reads lidocaine 1 mg/kg. In order to provide the accurate dose, the medical assistant must convert 55 lb into equivalent kilograms. Using the conversion table, she will know that 1 kg equals 2.2 lb. Using this conversion, the medical assistant can calculate the dose: 55 2.2 kg 25 kg 25 1 mg 25 mg

0.3

.20

40

.10 2

0.1

1.0

30

FIG 39-1 Nomogram plotting BSA of a child.

CHAP TER 39

Dosage Calculation and Medication Administration

829

Medication Administration
Administering medication to patients must be done carefully and properly. Medication errors can harm patients, so great care must be taken to administer medications correctly and educate patients on the correct self-administration techniques when necessary.

her prescription pad in her pocket, not in a patient treatment room. Easy access to prescription pads may tempt some patients to use them in order to obtain opiates or barbiturates fraudulently.

Routes of Medication Administration

The route of administration is the way in which medication is introduced into the patients body. The route of administration is chosen according to the speed of absorption desired and the site of drug action. For example, a physician may choose the oral route for a drug so it can be absorbed through the GI tract, which happens at a relatively slow rate. Conversely, the patient cannot take some medications orally, such as insulin, because gastric secretions will destroy them. In addition, administering medication by injection enables faster delivery of the drug to the patients system and is the more appropriate route if the effect of the medication must be immediate. For example, epinephrine, used to counteract an extreme allergic response, is delivered via an injection. The respiratory route, involving inhalation of medication, is also effective in emergencies, such as in bronchial spasm to open airways within seconds.

Parts of a Prescription
A medical assistant may ll out a written prescription. However, it must be signed by the ordering physician. The prescription must be accurate, complete, and legible. Some abbreviations are commonly used on prescription pads; the medical assistant must ask the prescriber if she cannot interpret the abbreviations. (See Common abbreviations in medication orders, page 830.) The medical ofce may transmit the prescription to the pharmacy by telephone or the patient may present the written prescription at the pharmacy. However, the patient must present prescriptions for opiates in person. (The pharmacy will not accept telephone orders for such drugs.) The medical assistant must indicate rells for prescriptions on the original prescription. (See Figure 39-2.) In addition, the physician should always keep

Blueville Family Medicine

15 Main Street Blueville CT 06000 860-555-3212

Name Address

Sadie Hernandez 27 Maple Ave. Blueville, CT

Date

10-14-08

Erythromycin 500 mg, 3 times per day

NAME OF DRUG AND DOSAGE

MD:

Sharon Piecek, APRN

LABEL

PRESCRIBERS SIGNATURE

REFILLS 0 1 2 3

DO NOT DISPENSE GENERIC CT Lic. no.: DEA no.:

CHECK IN BOX TELLS THE PHARMACIST THAT THE PRESCRIBER APPROVES A GENERIC SUBSTITUTE. PRESCRIBERS LICENSE NUMBER PRESCRIBERS DEA NUMBER

03081994 CT04141992

FIG 39-2 Sample prescription.

830

UNIT 3

Clinical

Common abbreviations in medication orders

The following table lists common abbreviations used in medication orders along with their meanings. Although these abbreviations are common, many health care professional organizations, such as the American Association of Medical Transcriptionists, recommend writing out medication orders to avoid mistakes. Many of these abbreviations may appear in patients records from previous years when abbreviations were more common, thus the well-prepared medical assistant should be aware of the abbreviated and fully written form of medication orders.

Abbreviation
a ac ad lib aq bid c cap cc* cm DC, disc, dc EC , d gr g, G, Gm gtt h, hr hs, HS* IM IU* IVPB kg, Kg L mEq g*, mcg mg ml, mL mm NaCl noc, noct, n NPO, npo OD* OS* os OTC OU* oz

Meaning
before before meals as desired water twice a day with capsule cubic centimeter centimeter discontinue enteric-coated uid grain gram drop hour at bedtime, at hour of sleep intramuscularly International Unit intravenous piggyback kilogram liter milliequivalent microgram milligram milliliter millimeter sodium chloride night nothing by mouth (nil per os) right eye (oculus dexter), overdose left eye (oculus sinister) mouth over the counter both eyes (oculus uterque) ounce

Abbreviation
pc PM, pm Po, PO PRN, prn qd* qh q2h q3h qid QNS qod* qs R Rx SC, subcu, subq SL sol SR stat supp syr T tab Tbsp, T, Tbs tid tinct, tr TO TPR Tsp, t, tsp U* ung vag VO

Meaning
after meals afternoon by mouth, orally (per os) whenever necessary (pro re nata) every day every hour every 2 hours every 3 hours four times a day quantity not sufcient every other day quantity sufcient rectal prescription subcutaneously sublingual solution sustained release immediately suppository syrup temperature tablet tablespoon three times a day tincture telephone order temperature, pulse, respiration teaspoon unit ointment vaginal verbal orders

* The Joint Commission has identied these abbreviations as the cause of many errors and much confusion. Thus, they strongly recommend their discontinuance.

CHAP TER 39

Dosage Calculation and Medication Administration

831

There are two main routes of medication administration: oral and parenteral.

Oral
The oral route, or ingestion through the mouth and into the GI tract, is the most common route of medication administration. It is safe and convenient and most patients are able to take medications in this manner. In addition, it requires no special equipment. However, a patient with dysphagia (difculty swallowing) should not take oral medications because of the risk of aspirating an oral medication into the respiratory tract. Oral drug forms include:

tablets, which are compressed, disklike masses of medication manufactured from a powder form and require the patient to drink enough liquid so that the tablet does not stick in his throat capsules, which are medication surrounded by a gelatin container that will not dissolve until it reaches the acidic environment of the stomach, thus preventing the patient from tasting the medication syrups, which are concentrated solutions of sugar, water, and the medication that make it easier for the patient to tolerate swallowing drugs with a bitter avor suspensions, which are solid particles mixed in a liquid but not dissolved and require shaking before use because the medication will not be equally dispersed in the liquid due to settling.

The stomach or small intestine digests and absorbs an oral drug. The rate of absorption for oral drugs is fairly slow, approximately 20 minutes. Other factors may cause acceleration or delay of oral drug action, including food in the stomach, the patients emotions, or physical activity. In addition, some oral medications are safe to administer with food, while others are not. The medical assistant must pay careful attention to recommendations regarding food with oral medications. Whenever administering drugs, the medical assistant must always conrm the seven rights. (See Seven rights of medication administration.) Some oral drugs can be irritating to the stomach, causing nausea or heartburn. Enteric-coated capsules or tablets are coated with a compound that does not dissolve until exposed to the uids of the small intestine. The medication passes through the stomach into the intestines without causing irritation to the upper GI tract. Thus, the medical assistant

Seven rights of medication administration

The medical assistant can ensure proper medication administration by always following the seven rights, including: 1. Right PatientThe medical assistant can make errors in dispensing medications when the patient is unfamiliar to her. Thus, she should be sure to conrm the patients name on the medication order with the patient in front of her. If the patient is unable to identify himself, as with infants and patients with a language barrier or confusion, she can ask a caregiver to identify the patient. She must be extremely careful when administering medications to patients with the same or similar names. In such a case, the medical assistant should ask each patient for his date of birth or address. 2. Right DrugBecause drug names may sound similar or be spelled similarly, the medical assistant must check the spelling and read the label three times before administering the drug to a patient. She should do her rst check before removing the drug from storage, her second check before preparing the medication, and her third check before returning the drug to storage. 3. Right DoseMedication dosages are based on body weight, age, sex, general state of health, and previous known reactions to medications. The medical assistant may need to calculate the dosage of the medication ordered. Because medications come in various dosages, she must be sure to calculate the proper dose to be administered to the patient.

Physicians commonly prescribe syrups and suspensions to young children because they may not be able to swallow tablets or capsules. When a liquid medication is poured into a container, the surface of the liquid, called the meniscus, will curve slightly due to surface tension with the sides of the container. When measuring a liquid dose, the medical assistant must be at eye level with the meniscus to ensure accurate dosing. (See Figure 39-3.)

FIG 39-3 Measuring liquid medication at eye level. Continued

832

UNIT 3

Clinical

Seven rights of medication administrationContd

4. Right RouteBecause the route of administration of a medication affects its effectiveness and rate of absorption, the medical assistant must take care to administer medication via the right route. For example, because absorption in the gastrointestinal route is slow, oral medication administration would not be an appropriate route for an emergency dose of epinephrine. The medical assistant should check the package or medication order to ensure the right route. 5. Right TimeThe medical assistant must administer medications at proper intervals in order to maintain proper blood levels of the medication and avoid exceeding the therapeutic dosage. For example, some oral medications must be taken on an empty stomach (between mealtimes) and others are better tolerated with food (at mealtimes). 6. Right DocumentationThe medical assistant must properly document medication administration in the patients medical record. She should do so immediately after administering the medication and include the date, time, route, dosage, lot number (if applicable), and the patients reaction to the medication. 7. Right TechniqueThe medical assistant may administer medication via an injection. There are many routes for administering an injection, including subcutaneously, intradermally, and intramuscularly. The medical assistant must ensure that she performs the correct injection technique for the desired route, such as inserting the needle at the proper angle so that the medication will be delivered to the intended site. For example, if the medical assistant must administer an injection into the dermal area of the skin but uses a 45-degree angle to insert the needle, she will not deliver the medication into the dermal layer of the skin, which will most likely lessen or nullify the drugs therapeutic effect.

inhalation injection topical vaginal rectal.

Sublingual and Buccal

Sublingual (under the tongue) and buccal (between the cheek and gum) administration of drugs involves placing the medication in the patients mouth without his swallowing it. Unlike oral drugs, sublingual and buccal medications do not travel to the GI tract for absorption. Instead, the mucous membranes in the interior of the mouth absorb it and deliver it to the bloodstream. Thus, absorption through these routes is more immediate. For example, nitroglycerine, a strong vasodilator, is commonly administered sublingually for patients experiencing acute angina pectoris. Opiate analgesics are commonly administered buccally for severe breakthrough pain in cancer patients.

Inhalation
Patients can inhale medications for delivery to the respiratory tract using a nebulizer, a machine that mixes room air with a medication. The nebulizer uses an atomizer to mix the medication with water to create a vapor that the patient can inhale. The patient can sleep or sit quietly in the room with the nebulizer and breathe in the medication with the humidied air. Patients with asthma or emphysema can also use portable metered-dose inhalers (MDIs) for immediate relief of respiratory distress.

Injection
For a parenteral administration via injection, the medical assistant must rst measure the correct amount of the drug by drawing it into a syringe. She may draw the medication from a vial or an ampule. A vial is a relatively small glass bottle used to store liquid medication. It has a metal or rubber removable cap to allow the medical assistant to push a needle through the rubber top and draw out the drug. (See Procedure 39-2: Preparing a parenteral medication from a vial, pages 834 and 835.) An ampule is made of glass like a vial. However, it has no rubber or metal seal; it is made entirely of glass. To open the ampule, the medical assistant must break the glass neck of the ampule to access the drug. (See Procedure 39-3: Preparing a parenteral medication from an ampule, pages 836 and 837.) In addition to withdrawing the correct amount of medication into a syringe, the medical assistant must have an understanding of the different methods of injection, of which there are four:

must never cut an enteric-coated tablet or capsule or the medication could produce irritation and change the intended site of absorption. (See Procedure 39-1: Administering an oral medication.)

Parenteral
Any route other than the oral, or enteral, route is considered a parenteral route. Parenteral routes of administration include:

subcutaneous intradermal intramuscular (IM) intravenous (IV).

sublingual buccal

The medical assistant must also develop skill in performing subcutaneous, intradermal, and IM injections. However,

CHAP TER 39

Dosage Calculation and Medication Administration

833

PROCEDURE 39-1

Administering an oral medication

Task Properly interpret a physicians order and apply pharmacological principles to prepare and administer an oral medication. Conditions Medication ordered by the physician Medication cup (for liquid administration) Water, when appropriate Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully read the medication order and prepare and administer an oral medication to a patient. Performance Standards 1. Wash your hands to ensure infection control. 2. Review the seven rights of medication administration. 3. Assemble equipment and supplies and read the medication order to check the written order for clarication of the oral route and to determine if enough time has passed since the last dose, if appropriate. If in doubt, check with the physician. 4. Select the right drug and check the medication label. If the medication is unfamiliar, read the package insert or use a drug referencethe rst of three checks to ensure that you are administering the correct medication. 5. Check the expiration date of the medication because administering expired medication could be hazardous. 6. Read the dosage information on the label and calculate the correct dose. For example, if the physician orders 50 mg and 25-mg tablets are on hand, calculate the dose using the formula: Dose ordered Dose on hand 50 mg 25 mg amount to give 2 tablets 7. Check the medication label again for the second of three checks for the right medication. 8. Prepare the dose needed. a. For solids, such as capsules and tablets, pour the medication from the bottle into the bottle cap and then transfer it to a medication cup. Do not touch the medication or the inside of the cup with your hands to ensure infection control. b. For liquids, pour syrups and mix suspensions as directed on the bottle. Pour the medication into the medication cup, measuring the meniscus to ensure an accurate measurement. 9. Check the medication label a third and nal time before returning it to the cabinet. 10. Carry the medication to the treatment room taking care not to spill it and using a tray if needed. 11. Administer the medication to the patient, being sure to conrm the right patient once more. 12. Offer the patient some water, as appropriate, to help him swallow solid oral medication. 13. Remain with the patient until he swallows the medication. 14. Wash your hands to ensure infection control. 15. Document the procedure in the patients medical record.
Date 09/23/08; 9:25 a.m. Two 200-mg ibuprofen tablets administered to patient for pain. ---------------------------------------------------- C. Chapin, CMA

medical assistants are not legally permitted to perform IV injections. Subcutaneous When administering a subcutaneous injection, the medical assistant injects the drug into the subcutaneous layer of the integument (skin), which is the fatty layer beneath the dermis and above the muscle tissue. Because the fatty layer is less vascular than muscle, the drug absorption rate is moderate with this type of injection. However, the site of

subcutaneous injection can affect the rate of absorption. (See Figure 39-4.) For example, injection of a drug in the abdomen or arm offers quicker absorption than one in the thigh or upper buttocks. Subcutaneous injection sites are in areas where a substantial amount of connective tissue is present between the muscle and skin to absorb the medication without hitting nerves, muscle, bone, or blood vessels. (See Procedure 39-4: Administering a subcutaneous injection, page 839.)

834

UNIT 3

Clinical

PROCEDURE 39-2

Preparing a parenteral medication from a vial

Task Measure the correct amount of medication from a vial into a 3-ml hypodermic syringe for injection. Conditions Vial of medication ordered by physician 70% isopropyl alcohol wipes Appropriate syringe for ordered dose Needle with safety device appropriate for site injection 2" 2" sterile gauze pads Sharps container Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure the correct medication dose from a vial into a syringe for injection. Performance Standards 1. Wash your hands. 2. Assemble the equipment and supplies and verify the order. 3. Check the expiration date of the medication to avoid using expired medication, which may cause injury. 4. Follow the seven rights of medication administration. 5. Check the medication against the physicians order to perform the rst of three checks. 6. Check the patients medical record for allergies or conditions that may contraindicate the medication. 7. Calculate the correct dose to be given (if not already provided). 8. Check the medication against the physicians written order to perform the second of three checks. 9. If the vial is new, remove the hard plastic or metal cover. If it is a multidose vial that has already been used, wipe the top of the vial with an alcohol wipe to ensure infection control. 10. Allow the top of the vial to dry before withdrawing the medication to avoid contaminating the medication with alcohol. 11. If the medication needs mixing, rotate the vial between the palms of your hands. 12. To prepare the needle and syringe, open the peel-apart sterile packaging around the syringe and needle and assemble the needle and syringe.

Open the sterile packaging and assemble the needle and syringe.

13. If the needle and syringe are packaged separately, open both packages using sterile technique, remove the small plastic cap covering the Luer-Lok on the syringe, and attach the needle by twisting it securely to the Luer-Lok. 14. Do not allow the hub of the needle to touch anything other than the Luer-Lok to avoid contaminating the needle.

CHAP TER 39

Dosage Calculation and Medication Administration

835

PROCEDURE 39-2contd

rubber stopper. Once the needle has penetrated the stopper, use the other hand to hold the vial. Inject the air into the vial. 19. To ll the syringe, invert the vial and syringe so that the tip of the needle is immersed in the medication. Withdraw a little more than the required volume of medication from the vial to ensure that you have enough medication in case of an air bubble within the volume drawn.

Do not allow the needle hub to touch anything other than the Luer-Lok.

15. Remove the cover from the needle. Hold the barrel of the syringe with one hand and carefully remove the cover with the other hand. Place the needle cover on the counter. 16. Closely inspect the needle at eye level and discard if any burrs are present on the tip or the shaft of the needle.
Invert the vial and syringe and withdraw the medication.

Closely inspect the needle at eye level for burrs.

17. Draw air into the syringe. With the needle cover over the needle, draw an amount of air equal to the volume of medication to administer. 18. Insert the needle into the vial. Place the vial on the counter without holding it. This will prevent an accidental needle stick to your hand. Hold the barrel of the syringe with one hand guiding the needle into the

20. If air bubbles have formed in the syringe, invert the syringe and tap the barrel with your nger or ngernail until the air bubble rises to the top of the liquid. Advance the plunger to express the air out of the syringe. When you have expelled the air, measure the exact dose needed by advancing the plunger to the required mark on the barrel. 21. Remove the needle from the vial stopper by pulling your hands away from each other. Be careful not to touch the needle because doing so will contaminate it and put you at risk for a needlestick. 22. If necessary, recap the needle by placing the needle cap on a clean dry surface (such as the countertop), holding the syringe in one hand, and carefully guide the exposed needle into the cap without touching the needle to the cap. When the cap is on the needle, secure it with your hand, touching only the cap, not the needle. 23. If preparing the needle in a different room than the patient, cap and carry the needle on a tray to avoid contamination and accidental needlesticks.

836

UNIT 3

Clinical

Insulin is an example of a subcutaneously injected drug. Because patients or caregivers commonly administer subcutaneous insulin injections daily, they must rotate injection sites to prevent lipodystrophy (atrophy or hypertrophy of fat tissue), bruising, swelling, or infection. Thus, the medical assistant may need to instruct the patient with diabetes about administration of insulin by subcutaneous injection. The patient must be able to inspect and choose administration sites, clean the site, and properly inject herself with insulin. In addition to performing the procedure, the medical assistant must educate the patient about
PROCEDURE 39-3

monitoring her blood glucose level, properly storing her insulin, rotating injection sites, and understanding variations in absorption rates of these sites. The medical assistant should ask the patient to return-demonstrate the self-injection technique and ask her questions to ensure that she has an understanding of her disease and medication. (See Figure 39-5.) The medical assistant should also give the patient written instructions and tell her to call the office if she has any questions. She should always be sure to document such demonstration and instruction in the patients medical record.

Preparing a parenteral medication from an ampule

Task Measure the correct amount of medication from an ampule into a 3-ml hypodermic syringe for injection. Conditions Ampule of medication ordered by physician 70% isopropyl alcohol wipes Appropriate syringe for ordered dose Needle with safety device appropriate for injection site Filter needle (for ampule) 2" 2" sterile gauze pads Sharps container Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure the correct medication dose from an ampule into a syringe for injection. Performance Standards 1. Wash your hands. 2. Assemble the equipment and supplies and verify the order. 3. Check the expiration date of the medication to avoid using expired medication, which may cause injury. 4. Follow the seven rights of medication administration. 5. Check the medication against the physicians order to perform the rst of three checks. 6. Check the patients medical record for allergies or conditions that may contraindicate the medication. 7. Calculate the correct dose to be given (if not already provided). 8. Check the medication against the physicians written order to perform the second of three checks. 9. Clean the ampule with an alcohol wipe and allow it to air dry before withdrawing the medication to avoid contaminating the medication with alcohol.
Clean the ampule with an alcohol wipe.

10. Using an ampule breaker or a piece of gauze wrapped around the top of the ampule, break off the top of the ampule. Be sure to do so in the direction away from your body to prevent injury. Discard the ampule top in the sharps container.

CHAP TER 39

Dosage Calculation and Medication Administration

837

PROCEDURE 39-3contd

Break off the top of the ampule in a direction away from your body.

11. Hold the barrel of the lter needle syringe with one hand and carefully remove the needle cover with the other hand. Place the needle cover on its side on the counter. 12. Inspect the needle and discard if any burrs are present on the tip or the shaft of the needle. 13. Insert the lter needle into the ampule. Placing the ampule on the countertop, hold the barrel of the syringe with one hand and carefully lower the needle into the ampule so that the bevel of the needle is below the surface of the liquid.

14. Do not inject air into the ampule and do not touch the broken edge of the ampule with the needle or your ngers to avoid contamination and injury. 15. Withdraw the entire amount of medication, if ordered, to ensure that you have enough medication in case of an air bubble within the volume drawn. Keep the bevel of the needle under the surface of the liquid as you withdraw the medication to avoid introducing excess air into the syringe. 16. Using sterile technique, exchange the lter needle for an injection needle with a safety device. Inspect the injection needle for defects and discard if found. Do not touch the end of the hub of the needle or the tip of the barrel of the syringe. 17. Remove the cover of the new needle. If air bubbles have formed in the syringe, invert the syringe and tap the barrel with your nger or ngernail until the air bubble rises to the top of the liquid. Advance the plunger to express the air out of the syringe. When any air has been expelled, measure the exact dose needed by advancing the plunger to the required mark on the barrel. 18. Recap the needle if necessary. Place the needle cap on a clean dry surface (such as the countertop) and, holding the syringe in one hand, carefully guide the exposed needle into the cap without touching it. When the cap is on the needle, secure it with your hand, touching only the cap, not the needle. 19. If you are preparing the needle in a different room than the patient, cap and carry the needle on a tray to avoid contamination and accidental needlesticks. 20. Check the medication label to perform the third of three checks and discard the ampule in the sharps container. 21. Wash your hands.

Intradermal The medical assistant administers intradermal injections into the dermis, the layer of skin under the epidermis (surface of the skin). The intradermal route is most common in performing allergy testing or tuberculosis (TB) testing. Common intradermal injection sites are the upper arms for TB screening and the upper back for allergy testing. The quantity of medication given intradermally is small because the medication is not intended to be absorbed beyond the local site but should remain just under the surface for the

patients body to react to the allergen or TB test. The physician then reads the reaction on the surface of the skin. (See Procedure 39-5: Administering an intradermal injection, pages 840 and 841.) Intramuscular When the medical assistant administers an intramuscular (IM) injection, she injects the drug directly into the muscle. Absorption happens quickly in the rich blood supply of the muscle. The muscle can be injected with much more

838

UNIT 3

Clinical

FIG 39-5 Return-demonstration of subcutaneous injection technique.

FIG 39-4 Subcutaneous injection sites.

medication than in the intradermal or subcutaneous methods because the muscle is capable of retaining more liquid. Careful measurement of medications into syringes is necessary to ensure proper dosage. Common IM sites of administration include the ventrogluteal, deltoid, and vastus lateralis muscles. (See Figure 39-6.) The most common injection site for neonates and infants less than age 7 months is the rectus femoris. The dorsogluteal site was one of the most common administration sites in the past; however, it is no longer recommended. Recent studies reveal that the ventrogluteal site is the best choice for adults and children over age 7 months. The ventrogluteal site, located on the lateral hip, is located away from major blood vessels and nerves, limiting the risk of hitting a nerve or blood vessel and causing nerve damage or damaging an artery. This site is also less painful than the dorsogluteal and rectus femoris sites.

The Z-track injection method is a modication of IM injection technique. To use the Z-track method, the medical assistant must pull the skin to one side and hold it while inserting the needle at a 90-degree angle. She should then follow regular procedure for injecting the medication. After administering the medication, she must wait 10 seconds and then withdraw the needle and release the skin. This technique leaves a zigzag needle track from the surface of the skin to the muscular layer, which stops the medication from leaking out into the subcutaneous tissue and onto the skin surface. The preferred sites for the Z-track method are the vastus lateralis and ventrogluteal muscles. This method is used for medications that may discolor or irritate subcutaneous tissues. (See Figure 39-7.) Medications administered IM include antibiotics, vaccines, and drugs to treat a severe allergic reaction. When the medical assistant must administer multiple IM injections, she should use sites on both hips, arms, and legs to avoid excessive soreness in one area. (See Procedure 39-6: Administering an intramuscular injection, pages 843 and 845.) Patients with severe allergies to such foods as peanuts, tree nuts, or shellsh may need to carry an EpiPen, which is a device that delivers an IM injection of a premeasured amount of epinephrine to counteract the effects of a severe allergic reaction. Because the medical assistant cannot ask the patient to actually demonstrate injecting himself with epinephrine, she should ask him to role-play what to do if he accidentally comes in contact with the allergen. The

CHAP TER 39

Dosage Calculation and Medication Administration

839

PROCEDURE 39-4

Administering a subcutaneous injection

Task Select the proper site and properly administer a subcutaneous injection. Conditions Nonsterile disposable gloves Medication ordered by the physician Appropriate syringe for the ordered dose Needle with a safety device 2" 2" sterile gauze pads 70% isopropyl alcohol wipes Sharps container Biohazardous waste container Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully select the proper site and properly administer a subcutaneous injection. Performance Standards 1. Wash your hands to ensure infection control. 2. Assemble the equipment and supplies and verify the order. 3. Check the expiration date of the medication. 4. Follow the seven rights of medication administration. 5. Check the medication against the physicians written order to perform the rst of three checks. 6. Check the patients medical record for allergies or conditions that may contraindicate the medication. 7. Calculate the correct dose to be given, if necessary. 8. Prepare the syringe with the ordered dose to ensure that the patient receives the correct dose. 9. Follow the procedure for drawing medication into the syringe. 10. Greet and identify the patient to ensure that you administer the medication to the right patient. 11. Explain the procedure to the patient to ensure patient understanding and compliance. 12. Select the appropriate injection site and position the patient. 13. Expose the injection site and inspect the site for scars and inammation. If scarring or inammation is present, choose a different site because scarred, broken, or inamed skin will decrease absorption of the drug. Be sure to explain to the patient why you must change the site. 14. Put on gloves. 15. Recheck the medication against the physicians written order to perform the second of three checks. 16. Prepare the injection site by cleaning it with an alcohol wipe, beginning at the center and working in an outward circular motion. Allow the site to air dry. Do not touch the site or allow the patient to touch the site to avoid contaminating the site. 17. Remove the cover from the needle. 18. Recheck the medication against the physicians written orders to perform the third of three checks. 19. Secure the skin at the injection site. Grasp a generous portion of skin around the injection site between the thumb and forenger of your nondominant hand. Hold the syringe at a 45-degree, upward angle. 20. Puncture the skin with the needle in a quick, smooth motion. 21. Check to see if blood aspirates into the syringe. If it does, withdraw the syringe from the site because blood in the syringe is a sign that the needle has pierced a blood vessel. Then begin the procedure again with a new needle. 22. If blood does not aspirate into the syringe, release your grasp of the skin and pull back on the plunger. NOTE: Do not aspirate with heparin or insulin because it may cause tissue damage. 23. If blood does not aspirate into the syringe when pulling the plunger, inject the medication slowly. 24. Place a gauze pad over the injection site and quickly withdraw the needle from the site at the same 45-degree angle. 25. Use a 2" 2" sterile gauze pad to massage the injection site gently but rmly to help distribute the medication into body tissues. NOTE: Do not massage the injection site of heparin or insulin because it may cause tissue damage. 26. Discard the syringe and needle in the sharps container, remove your gloves and discard them in the biohazardous waste container, and wash your hands to ensure infection control. 27. Check on the patient. Ask the patient how she feels and observe her for any signs of immediate emergency reaction, such as dizziness, lightheadedness, or fainting. 28. Document the procedure, including the date, time, lot number of the medication, dose given, and injection site used. Chart any reactions you observe.
Date 10/15/08; 4:15 p.m. Egg allergy injection, 0.20 cc, Lot # GY4453, exp date 12/30/2009 subcutaneous right upper arm. Arm check 15 minutes after injection - no reaction noted. Patient in no distress; verbal and written follow-up instructions given. ----------------------------------------------- C. Chapin, CMA

840

UNIT 3

Clinical

PROCEDURE 39-5

Administering an intradermal injection

Task Select the proper site and properly administer an intradermal injection. Conditions Nonsterile disposable gloves Medication ordered by the physician Appropriate syringe for ordered dose (tuberculin syringe) Needle with safety device (26G or 27G, 38" to 12") 2" 2" sterile gauze pads 70% isopropyl alcohol wipes Written patient instructions for post-testing Sharps container Biohazardous waste container Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully select the proper site and properly administer an intradermal injection. Performance Standards 1. Wash your hands to ensure infection control. 2. Assemble the equipment and supplies and verify the order. 3. Check the expiration date of the medication. 4. Follow the seven rights of medication administration. 5. Check the medication against the physicians written order to perform the rst of three checks. 6. Check the patients medical record for allergies or conditions that may contraindicate the medication. 7. Calculate the correct dose to be given, if necessary. 8. Prepare the syringe with the correct dose to ensure the patient receives the correct dose. 9. Follow the procedure for drawing medication into the syringe. 10. Greet and identify the patient to ensure that you administer the medication to the right patient. 11. Explain the procedure to the patient to ensure patient understanding and compliance. 12. Select the appropriate injection site and position the patient. 13. Recheck the medication against the physicians written orders to perform the second of three checks. 14. Expose the injection site and inspect the site for scars and inammation. If scarring or inammation is present, choose a different site because scarred, broken, or inamed skin will prevent an accurate reading of the injection site. Be sure to explain to the patient why you must change the site. Put on gloves. Prepare the injection site by cleaning it with an alcohol wipe, beginning at the center and working in an outward circular motion. Allow the site to air dry. Do not touch the site or allow the patient to touch the site to avoid contaminating the site. Recheck the medication against the physicians written orders to perform the third of three checks. Remove the cover without touching the needle. Visually inspect the injection site to be sure that the alcohol has dried before you inject to avoid contaminating the drug with alcohol. Secure the skin at the injection site. Pull the skin at the injection site taut with the thumb and forenger of the nondominant hand. Position the needle almost parallel to the skin at an angle of 10 to 15 degrees. Insert the needle until the bevel barely penetrates the skin. Be sure that the entire bevel is below the surface of the skin so that you inject the liquid under the skin layer and not on top of the skin. Release your grasp on the forearm skin and use your nondominant hand to inject the medication slowly. Keep a slow, steady pressure on the plunger until all of the liquid is injected and a wheal forms. The wheal should be 6 to 10 mm in diameter.

15. 16.

17. 18.

19.

20.

21.

Observe the formation of a wheal as you inject.

CHAP TER 39

Dosage Calculation and Medication Administration

841

PROCEDURE 39-5contd

22. If no wheal forms, notify the physician immediately because the injection was too deep and the reaction to the medication will not be visible at the skins surface. 23. Withdraw the needle from the injection site at the same angle (10 to 15 degrees) and activate the safety device to cover the needle. 24. Dab the area with a gauze pad. Do not apply pressure to the wheal because doing so could push the liquid away from the injection site. 25. Discard the needle in the sharps container and wash your hands to ensure infection control. 26. Ask the patient how he feels and observe him for any signs of an immediate emergency reaction, such as dizziness, lightheadedness, or fainting. 27. Discuss the monitoring of test results with the patient. Based on the type of test and the ofce policy, you may be required to: a. Read the test result in the ofce. Using inspection (looking) and palpation (feeling) at the site of the injection, determine the presence of a reaction and the amount of induration.

b. Inform the patient of a date and time to return to the ofce to have the physician read the results of the injection. c. Instruct the patient on reading and interpreting the injection site at home. Give him a card with various levels of induration for comparison. Instruct the patient to call the ofce with the test results. d. Be sure to explain the importance of reading the site at the correct date and time. Checking the site too soon or too late could result in a false-negative result and delay treatment. 28. Document the procedure in the patients chart.
Date 10/15/08; 2:20 p.m. Mantoux tuberculin test, 0.10 ml, intradermal, Lot #XB4432, exp date 12/30/2009, right anterior forearm. Gave patient verbal and written instructions on inspecting the site and to return on 10/18/2008 to have results read. ------------------------------------------------------------------------------- C. Chapin, CMA

patient can show the medical assistant how he would take the cap off of the EpiPen and inject himself. She should also provide written instructions to the patient. In the case of children, the medical assistant should show the parents or caregivers how to administer the medication and how to look for signs of severe allergy. Intravenous Intravenous medication administration is the fastest route of absorption because the medication is injected into a vein and, thus, enters the bloodstream directly. Although a medical assistant cannot legally administer IV medications, she must have an understanding of IV medication administration and uid replacement therapy. Patients receive IV solutions to:

isotonic solutions used to replace cellular uids lost through blood loss or vomiting (The salt, or sodium chloride, concentration of an isotonic solution is the same as that in the patients body.) maintenance solutions, including isotonic solutions and others, used to replace electrolytes in the case of severe diarrhea and vomiting (Minerals and, sometimes, vitamins in the solution replace what is lost.) hypertonic solutions used to treat overhydration.

Topical
The medical assistant can administer medication by placing it on top of the skin, enabling absorption into the bloodstream via the skin. Examples of topical medications include creams and ointments. Cleaning the skin with soap and water enhances absorption of topical creams and ointments. Another method of topical medication administration is the transdermal method, which involves placing a patch made of a semipermeable membrane that releases the medication into the skin. (See Procedure 39-7: Administering a transdermal patch, pages 845 and 846.) Transdermal medication is absorbed more slowly, over a period of 12 to 24 hours. Examples of transdermal medications include nicotine smoking cessation patches, nitroglycerine patches for angina, and patches for contraception.

replace lost uids and electrolytes correct an acid-base imbalance administer medications quickly maintain ready access to venous circulation administer essential nutrients administer blood products or replacement products.

The most common IV solutions are combinations of salt, glucose, sterile water, and other electrolytes to rebalance uid loss. The four basic types are:

Vaginal
The medical assistant may administer medications vaginally by inserting them into the vaginal cavity in the form of a

hypotonic solutions used to rehydrate the body or to prevent dehydration

842

UNIT 3

Clinical

C
Iliac crest Gluteus medius

Anterior superior iliac spine Injection site (between the knuckle of the index and middle finger)

Greater trochanter of femur

Vastus lateralis Greater trochanter Injection site (middle third of vastus lateralis)

Ventrogluteal

B
Acromial process Lateral femoral condyle

Injection site

Deltoid muscle Scapula

Vastus lateralis

Humerus Deep brachial artery Radial nerve

Deltoid

FIG 39-6 Intramuscular injection sites.

CHAP TER 39

Dosage Calculation and Medication Administration

843

cream, foam, or suppository. Patients may need specic instructions on inserting the medication. Administration of foams and creams involves insertion with an applicator. The medical assistant should be sure to give the patient the written instructions that accompany the medication. Insertion of suppositories, which are hard, is similar to that of a tampon. The patients warm body temperature melts the suppository so that the medication can be absorbed through the mucosa. The patient may need to lie in a recumbent position after inserting the medication to ensure absorption. Thus, physicians commonly order vaginal medication administration at bedtime. Examples of vaginal medications are antifungal creams and estrogen replacement therapy.

Rectal
The medical assistant may administer medications rectally by inserting them into the rectum for localized or systemic action. Rectal medications are in suppository form, which melt from the patients body heat. Rectal administration is common for medications to treat nausea and vomiting, when the patient cannot tolerate anything taken orally. Pain relievers and fever reducers are also available in suppository form. If the patient or caregiver must administer the suppository at home, the medical assistant should instruct the patient on proper insertion. She should explain that the patient should remove the foil wrapper and apply a small amount of water soluble lubricant to the suppository. She should instruct the patient or caregiver to insert the suppository past the internal anal sphincter to enable absorption and avoid expulsion of the drug from the body. Rectal drug action takes 15 to 30 minutes after insertion, so the patient should lie quietly for this time period. The medical assistant should always provide written instructions to the patient and

Skin Subcutaneous tissue

Muscle

Medication FIG 39-7 Z-track injection method.

PROCEDURE 39-6

Administering an intramuscular injection

Task Select the proper site and properly administer an intramuscular injection. Conditions Nonsterile disposable gloves Medication ordered by the physician Appropriate syringe for ordered dose Needle with safety device 2" 2" sterile gauze pads 70% isopropyl alcohol wipes Sharps container

Biohazardous waste container Patients medical record

Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully select the proper site and properly administer an intramuscular injection. Performance Standards 1. Wash your hands to ensure infection control. 2. Assemble the equipment and supplies and verify the order.
Continued

844

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PROCEDURE 39-6contd

3. Check the expiration date of the medication. 4. Follow the seven rights of medication administration. 5. Check the medication against the physicians written order to perform the rst of three checks. 6. Check the patients medical record for allergies or conditions that may contraindicate the medication. 7. Calculate the correct dose to be given, if necessary. 8. Prepare the syringe with the ordered dose of the medication to ensure that the patient receives the correct dose. 9. Follow the procedure for drawing medication into the syringe. 10. Greet and identify the patient to ensure that you administer the medication to the right patient. 11. Explain the procedure to the patient to ensure patient understanding and compliance. 12. Select the appropriate injection site and position the patient. 13. Recheck the medication against the physicians written orders to perform the second of three checks. 14. Expose the injection site and inspect the site for scars and inammation. If scarring or inammation is present, choose a different site because scarred, broken, or inamed skin will decrease absorption of the drug. Be sure to explain to the patient why you must change the site. 15. Put on gloves. 16. If the patient is a child, you may need to ask the parent or caregiver to help restrain the child to avoid injury to you or the patient. If the parent or guardian is unable to assist you, obtain assistance from a second health care professional. Restrain the patient only when necessary. You should not restrain a child who is willing to cooperate. 17. Prepare the injection site by cleaning it with an alcohol wipe, beginning at the center and working in an outward circular motion. Allow the site to air dry. Do not touch the site or allow the patient to touch the site to avoid contaminating the site. 18. Recheck the medication against the physicians written orders to perform the third of three checks. 19. Remove the cover without touching the needle. Visually inspect the injection site to be sure that the alcohol has dried before you inject. 20. Secure the skin at the injection site by spreading the skin around the injection site taut with the thumb and forenger of your nondominant hand to ensure that the muscle tissue is injected and not the subcutaneous layer. 21. Puncture the skin quickly at a 90-degree angle and insert the entire needle up to the hub.

Spread the skin taut and puncture it at a 90-degree angle.

22. Check to see if blood aspirates into the syringe by releasing your grasp of the tissues and pulling back on the plunger a little with your nondominant hand. If blood does aspirate, withdraw the needle from the site because blood in the syringe is a sign that the needle has pierced a blood vessel. Then begin the procedure again with a new needle. 23. If blood does not aspirate into the syringe, push the plunger of the syringe slowly and steadily into the intramuscular tissue. Be careful to hold the needle still while administering the medication to avoid bruising the skin. 24. Place a gauze pad over the injection site and withdraw the needle from the site at the same 90-degree angle. 25. Use a 2" 2" sterile gauze pad to massage the injection site gently but rmly to help distribute the medication into body tissues. NOTE: Do not massage the injection site of heparin or insulin because it may cause tissue damage. 25. Discard the syringe and needle in the sharps container, remove your gloves and discard them in the biohazardous waste container, and wash your hands to ensure infection control. 26. Check on the patient. Ask the patient how she feels and observe her for any signs of immediate emergency reaction, such as dizziness, lightheadedness, or fainting.

CHAP TER 39

Dosage Calculation and Medication Administration

845

PROCEDURE 39-6contd

27. Document the procedure, including the date, time, lot number of the medication, dose given, and injection site used. Chart any reactions you observe.

Date 10/20/08; 10:45 a.m. Hep B, first series, Lot #44776, exp date 12/30/2009, IM left deltoid. Pt. instructed to return in 1 month for second shot in series. Injection well tolerated, no adverse effects noted. ------------------------------------------------------------- C. Chapin, CMA

PROCEDURE 39-7

Administering a transdermal patch

Task Apply a transdermal patch to the appropriate site. Conditions Medicated transdermal patch Nonsterile disposable gloves Patient education-instruction sheet Patients medical record Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully apply a transdermal patch to the appropriate site. Performance Standards 1. Wash your hands to ensure infection control. 2. Assemble the equipment and supplies and verify the order. 3. Check the expiration date of the medication. 4. Follow the seven rights of medication administration. 5. Check the medication against the physicians written order to perform the rst of three checks. 6. Check the patients medical record for allergies or conditions that may contraindicate the medication. 7. Calculate the correct dose to be given, if necessary. 8. Check the medication against the written order again to perform the second of three checks. 9. Greet and identify the patient to ensure that you a dminister the medication to the right patient. 10. Explain the procedure to the patient and discuss any possible adverse effects, contraindications, and reactions listed on the package. Give the patient an educationinstruction sheet. Conrm that the patient understands the instructions by asking him to repeat the directions to you. 11. Expose the patients skin in an area that is relatively free from hair, such as the chest, upper back, or upper arm. 12. Clean the skin if needed with mild soap and water to ensure that the area is clean and free from lotions or oils. If you must remove hair, clip it close to the skin, rather than shaving it because shaving may cause nicks in the skin that cause the medication to be absorbed incorrectly. 13. Instruct the patient to rotate subsequent patches to different sites for each application to prevent skin irritation. Discuss the need for hair removal and skin cleaning. 14. Put on gloves and open the patch packaging. Peel away the protective cover from one side of the patch and stick the patch to the patients skin. Smooth the edges of the patch for full skin contact.

Apply the patch and smooth the edges. Continued

846

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PROCEDURE 39-7contd

15. Provide further patient education, including: a. information on removal of the patch and proper disposal b. emphasis on removing the patch himself, if possible, and instructing anyone else who removes the patch to wear gloves to avoid transdermal effects of the medication being absorbed into the skin c. information on application of a patch and remembering to rotate application sites d. reminder to wash and dry his hands after applying the patch and that the medication may get onto his hands and so transmission to others is possible

e. written instruction-direction sheet f. encouragement for the patient to share any questions he has 16. Dispose of waste materials. 17. Remove your gloves and wash your hands. 18. Document the application of the patch in the patients medical record as well as patient education conducted.
Date 10/22/08; 3:10 p..m.
Nicoderm 0.5 mg/patch applied to upper left arm. Patient given instructions on removal and application of daily patch and site rotation. Pt. given verbal and written instructions. Pt. understood and repeated instructions. ---------------------------------------------------------------------------------------- C. Chapin, CMA

instruct the patient to call the ofce if further questions arise. In addition, she should advise the patient to store the medication in a cool, dry place to avoid melting before administration. (See Teaching about self-administration.)

Patient Education

Teaching About Self-Administration

The medical assistant plays a vital role in educating patients in the proper self-administration of their medications. Because a patient may take many prescription medications on a daily basis, he must self-medicate. The medical assistant should ensure that the patient is aware of signs of allergy to his medication and what medications or foods he should avoid consuming with his medication. One of the most powerful forms of educating patients about their medications is the medication insert. These inserts include information for prescription and over-thecounter medications that can help patients understand their medications. The intended effects, adverse effects, contraindications, and dosage information are all listed on the medication insert, sometimes called a package insert. The medical assistant should remind patients to read the inserts, ask the pharmacist, or call the ofce if they have questions.

Patient name Name of medication Dosage

Prescribers name

CHAP TER 39

Dosage Calculation and Medication Administration

847

Team Work Exercises Chapter Summary

The medical assistant must calculate the proper dosage of medications to be administered to her patient based on the amount ordered and what she has available (on hand). The medical assistant can calculate dosages for children using the BSA method and a nomogram. The medical assistant must administer medication to patients carefully and properly, following the seven rights of medication administration. There are several routes of administration. The major routes are oral and parenteral. The oral route is the most common route of medication administration. Parenteral routes of administration include inhalation, injection, topical, vaginal, and rectal routes. Routes of administration are based on how quickly the drug reaches the bloodstream and the ease of administration. When administering medications, the medical assistant must check the medication against the order three times to prevent errors. The medical assistant can use three types of injections to administer medications: subcutaneous, intradermal, and intramuscular. A subcutaneous injection is administered into the fatty layer beneath the dermis. An intradermal injection is administered by injecting the medication into the dermis. An intramuscular injection is administered into the muscle. Administering medications intravenously is the fastest absorbing route since the medication enters the bloodstream directly. Although a medical assistant cannot legally administer IV medications, she must have an understanding of IV medication administration and uid replacement therapy. Patients can inhale medications through the respiratory tract for immediate absorption. Bronchodilators are an example of an inhaled medication that has an immediate action. Medication placed on top of the skin and absorbed into the bloodstream via the skin is called transdermal. The medication absorbs more slowly, over a period of 12 to 24 hours. Rectal administration of medications may be indicated if a patient is unable to tolerate medications orally. Vaginal administration of medications treat local infection or administer hormone therapy. The medical assistant must educate patients in administering medications orally, by use of an inhaler, injection, vaginally, and rectally. Her effective communication with the patient is vital.

1. Divide into groups of three to ve students. Each group must research a drug classication and create a poster or computer presentation that describes the therapeutic effects of the drugs in the classication. How does the drug work in the body? What disorders does it treat? What patients or concurrent conditions would contraindicate use of the medication? Each group should provide three examples of medications in the classication. Based on the work of each group, the class should determine if one of the meds is a better choice. If so, why? Consider issues of price, safety, adverse effects, and concurrent conditions. 2. Divide into groups of two to three students. Each group must create a practice examination with 10 dosage calculation questions for classmates to complete. Be sure to include a pediatric patient in one of the examples. Correct each others examinations and give feedback on performance.

Case Studies
1. Logan Shaw is a newly diagnosed diabetic. He is 60 years old and depressed about his weight and diabetes. The medical assistant is instructing him on the use of the glucometer and injecting insulin. He seems distracted and uninterested in learning to inject himself. How should the medical assistant engage him in recording his blood glucose and injecting his insulin? 2. Mrs. Czarnecki comes to the ofce with her granddaughter. She is 78 years old and taking several medications. Her blood pressure pill, lipid-lowering medication, arthritis medication, and calcium tablets look very similar. She tells the medical assistant that she is afraid she will get confused and forget to take medications or take too much. How can the medical assistant work with Mrs. Czarnecki and her granddaughter to form a strategy for ensuring that she takes her medications properly each day?

Resources

Body surface area calculator: www.halls.md/body-surface-area /bsa.htm Injection sites for insulin administration: www.dlife.com /dLife/do/ShowContent/type1_information/treatment /insulin.page1 Intramuscular and subcutaneous injection sites and technique guides: www.drugguide.com/intraInjectNew.asp and www.healthinfotranslations.com/pdfDocs/Subcutaneous -Injection-Sites.pdf Joint Commissions Do-Not-Use Abbreviation List: www.jointcommission.org/PatientSafety/DoNotUseList/ Review of dosage calculations: www.classes.kumc.edu/son /nurs420/clinical/basic_review.htm and www.nursesaregreat .com/articles/drugcal.htm

CHAPTER

Introduction to the Clinical Laboratory

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary describe the functions of the clinical laboratory explain the purposes of performing laboratory tests identify the different departments within the clinical laboratory identify various tests performed in each laboratory department demonstrate an understanding of the physicians ofce laboratory and its relationship with the clinical laboratory explain the purpose of CLIA 88 and identify the various categories of testing within the CLIA 88 regulations explain the concepts of quality control and quality assurance as they relate to the clinical laboratory discuss the purpose and importance of the laboratory requisition discuss the importance of proper patient preparation and education as it relates to specimen collection explain proper procedures for collecting, handling, and transporting specimens list and describe various types of laboratory equipment and properly use the equipment perform proper maintenance on various types of laboratory equipment.

40
Laboratory Profession CLIA 1988
Laboratory Testing Categories Waived tests Moderate-complexity tests High-complexity tests Provider-performed microscopy procedures

CAAHEP Competencies
Clinical Competencies Fundamental Principles
Dispose of biohazardous materials Practice standard precautions

Specimen Collection
Obtain specimens for microbiological testing

Diagnostic Testing
CLIA-waived tests Perform urinalysis Perform hematology testing Perform chemistry testing Perform immunology testing Perform microbiology testing

Quality Control Physicians Ofce Laboratory

Laboratory Requisitions and Reports Laboratory requisition slip Laboratory report

Patient Preparation
Fasting Medication Restrictions

Patient Care
Screen and follow up test results

General Competencies Legal Concepts

Document appropriately

Specimen Collection, Handling, and Transport

Guidelines for Specimen Collection

Laboratory Equipment
Proper Equipment Maintenance

Operational Functions
Perform routine maintenance of administrative and clinical equipment Use methods of quality control

Chapter Summary Team Work Exercises Case Studies Resources

ABHES Competencies
Clinical Duties
Use quality control Collect and process specimens Perform selected CLIA-waived tests that assist with diagnosis and treatment Screen and follow up patient test results

Chapter Outline
Purpose of the Clinical Laboratory Laboratory Tests
Panel Manual or Automated Purpose of Laboratory Tests Quantitative or Qualitative Results

849

Key Terms
analyzer

Purpose of the Clinical Laboratory

Health care providers request laboratory tests for many reasons. These tests can be used to diagnose a disease or condition, to monitor or manage a patients condition, or to assess a patients health status. A patients test results in conjunction with his overall physical assessment are important factors in maintaining proper health. The clinical laboratory is an integral part of the health care system. Most hospitals, medical centers, and HMOs contain full-service laboratories. Reference laboratories, such as Quest Diagnostics, are independent clinical laboratories that offer various services to medical ofces and other health care facilities. Physicians ofces request laboratory analysis on specimens, which are small portions of a patients blood, body uids (including secretions, such as urine and lower respiratory uid), or tissue (such as skin scrapings and tumors). The medical assistant may collect these specimens and then process them to be sent to the laboratory for analysis.

Automated instrument used to test blood and other body uids for various substances
anatomical laboratory

Section of the laboratory that includes histology and cytology

automated method

Laboratory test performed on an automated instrument or machine

biopsy

Removal and microscopic observation of a small piece of living tissue

clinical diagnosis

Diagnosis based on actual observations, diagnostic results, and symptoms

manual method

Test method in which the steps of testing are done by hand instead of by an automated instrument
normal range

Range of values in which a test result should fall for most healthy individuals
panel

Group of blood tests that evaluate the function of a particular body system; also called prole
physicians ofce laboratory (POL)

Laboratory Tests
When a patient comes to the ofce with a chief complaint of fever and sore throat, the physician will conduct a physical examination and may then ask the medical assistant to obtain a throat culture to be sent to the clinical laboratory. A throat culture is one of many laboratory tests that can be ordered for a patient. (See Abbreviations for common laboratory tests.) In other cases, the diagnosis may not be so straightforward and the physician may need to order a series of laboratory tests to assess the patients current condition. The medical assistants responsibility in both of these situations would consist of understanding the process, beginning with the physicians order and ending with the laboratory report received by the office. (See Life cycle of a laboratory test.)

Laboratory within the medical ofce

prociency testing

Tests on unknown specimens provided by an external monitoring agency, such as the state health department and the College of American Pathologists, to meet quality control requirements
qualitative result

Laboratory result that is descriptive, rather than providing a numerical value

quality control

Methods used to monitor the accuracy of laboratory results

quantitative result

Laboratory result that includes a numerical value

reagent

Substance used in a chemical reaction

reference laboratory

Panel
A physician can order a single laboratory test, such as a blood glucose level or a cholesterol level. The physician may also order a group of laboratory tests, called a panel or, sometimes, a prole. All the tests included in the panel relate to the specic organ of the body or a particular disease state. For example, a hepatic panel is used to assess liver function and assist in diagnosis or evaluation of a pathogenic condition that affects the liver. The medical assistant should know the names of common panels listed on the laboratory requisition slip and the tests generally contained in each.

Independent laboratory used by POLs and hospital laboratories to perform specialized testing
requisition slip

Form used to order laboratory tests

routine test

Laboratory test ordered as part of a regular ofce visit

specimen

Blood, other body uid, or body tissue submitted for laboratory analysis

CHAP TER 40

Introduction to the Clinical Laboratory

851

Abbreviations for common laboratory tests

A physician may order any of thousands of laboratory tests. Many of these tests are known mainly by their abbreviation. The following table lists some common laboratory tests known by their abbreviation, along with the normal values for those tests.

Manual or Automated
Laboratory tests can also be classied as manual or automated. Manual methods of laboratory testing involve performing the series of testing steps by hand rather than using an automated system of instruments. Performing a rapid Strep test, for example, is done manually using the proper testing kit. Automated methods involve, for example, testing a blood specimen on a complex analyzer (an automated instrument used to test blood and other body uids for various substances) or on a smaller testing instrument such as a glucose meter. Automated methods take less time and have greater accuracy than manual methods if all the necessary quality controls and instrument maintenance practices have been established.

Abbreviation
ALT AST BUN C&S CBC ESR FBS H&H Lytes PTT TSH

Laboratory Test
alanine aminotransferase aspartate aminotransferase blood urea nitrogen culture and sensitivity complete blood count erythrocyte sedimentation rate; also known as sed rate fasting blood sugar hemoglobin and hematocrit electrolytes partial thromboplastin time thyroid stimulating hormone

Purpose of Laboratory Tests

There are many reasons why a physician may order a laboratory test, including:

health assessmentfor example, evaluation of electrolytes, such as sodium (Na ), chloride (Cl), potassium (K ), and carbon dioxide (CO2) to assess a persons electrolyte balance disease detectionfor example, test for prostate specic antigen (PSA) to screen for prostate cancer

Life cycle of a laboratory test

The following illustration shows the typical life cycle of a laboratory test, from the physicians order through the laboratory report that is led in the patients chart.

Medical assistant shows report to physician.

Physician or medical assistant calls patient with results.

Patient sees physician. Physician evaluates patient.

Physician orders laboratory tests on patient based on physical findings.

Medical assistant receives patients laboratory report.

Medical Office

Medical assistant completes laboratory requisition for tests ordered.

Patients laboratory report is sent to physicians office.

Laboratory

Patient goes to laboratory. Requisition slip is processed.

Results are generated into a laboratory report.

Tests are performed on blood.

Blood is sent to proper department for testing.

Patient has blood drawn.

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diagnosisfor example, a rapid Strep test to diagnose a streptococcal throat infection monitor treatment or disease progressionfor example, measuring levels of thyroid stimulating hormone to monitor treatment for hypothyroidism disease preventionfor example, a Papanicolaou (Pap) smear to detect certain viral infections and other cancercausing conditions.

Quantitative or Qualitative Results

Results obtained from laboratory tests can be classied as quantitative or qualitative. A quantitative result is a numerical value, such as 87 mg/dl for a glucose level. A qualitative result is a result that describes a condition, rather than providing a numerical value as in a quantitative result. An example of a qualitative result would be throat culture: positive for Beta Strep Group A.

Laboratory Profession
The clinical laboratory employs many health care professionals in many departments. (See Laboratory departments.) The director of the laboratory is usually the pathologist. A pathologist is a medical doctor who oversees all diagnostic operations of the laboratory. If there is an anatomical laboratory section (which consists of a histology department, cytology department, or both), the pathologist is also responsible for reading all histological specimens, including those obtained by biopsy (removal and microscopic examination of a small piece of living tissue), and many of the cytological specimens, as well as performing autopsies. The

laboratory manager, who is typically a medical technologist and holds a bachelors and masters degree, is responsible for such daily operations as scheduling, purchasing, and budgets. Each department usually has a department supervisor, also called a section head, who is a medical technologist and may have an advanced degree or certication. The department supervisor oversees the daily tasks of her assigned department and supervises the technologists and technicians within that department. Each department has technologists and technicians who perform the tests within that department. (See MTs and MLTs, page 854.) Many medical technologists and technicians may be generalists, which means they are able to perform testing throughout two or more departments instead of specializing in just one department. The laboratory may also employ various support staff. A phlebotomist collects blood and other body specimens and may also carry out specimen processing duties. He collects specimens from the inpatient floors, the emergency room, and the outpatient laboratory. Some phlebotomists collect specimens from homebound and nursing home patients. The laboratory may also employ a medical secretary. Her duties include reception, receiving specimens, filing, transcribing pathology reports, and sending laboratory reports.

CLIA 1988
In the 1980s, the quality of laboratory testing drew national attention in part because of an increase in patient complaints and lawsuits regarding misdiagnosed conditions. The most notable situation involved misreading of Pap smears, which

Laboratory departments
The physicians office may have different laboratory departments that perform routine testing procedures. Some departments perform their laboratory tests by the automated method. The following table lists common laboratory departments, along with a description of each and routine tests performed in each department.

Department
Blood bank

Description
Section of the laboratory where blood is collected, stored, and prepared for transfusion

Routine Tests
Blood typing Type and screen Basic metabolic panel Blood urea nitrogen (BUN) Calcium (Ca) Cholesterol Creatine kinase (CK) Creatine kinase-MB (CK-MB) Creatinine

Chemistry

Most automated area of the laboratory, where instruments are computerized and designed to perform single and multiple tests from a small specimen

CHAP TER 40

Introduction to the Clinical Laboratory

853

Laboratory departmentscontd
Department Description Routine Tests
Electrolytes Glucose (blood sugar) Liver function panel Thyroid stimulating hormone (TSH) Troponin Coagulation Usually a subsection of the Hematology Department that evaluates the overall process of hemostasis Bleeding time (BT) Partial thromboplastin time (PTT) Platelet count Prothrombin time with INR Cytology Anatomic section of laboratory that deals with the study of cells. Papanicolaou (Pap) smear Urine cytology Sputum cytology Hematology Study of the formed (cellular) elements of the blood Complete blood count (CBC) Erythrocyte sedimentation rate (ESR) Hematocrit Hemoglobin Histology Some physicians perform biopsies or routine excisions in the ofce and submit the specimen to a histology laboratory or reference laboratory for processing Microbiology Responsible for identication of pathogenic microorganisms and hospital infection control Rapid Streptococcus A test Throat culture Urine culture Wound culture Mycology Parasitology Responsible for the collection and isolation of fungi Responsible for microscopic examination of stool specimens for the presence of parasites, ova, or larvae Serology Responsible for evaluating the bodys immune responses Infectious mononucleosis test Rheumatic factor test Syphilis tests, such as rapid plasma reagin (RPR) or uorescent treponemal antibody (FTA-ABS) Urinalysis Possibly a separate section or part of the hematology or chemistry section where routine screening procedures are performed to detect disorders and infections of the kidney Complete urinalysis Urine pregnancy test Fungal culture Ova and parasite test (O&P) Biopsy

resulted in the death of patients in some cases. In 1988, Congress passed the Clinical Laboratory Improvement Amendment (CLIA 1988) to improve the quality of laboratory testing in the United States. CLIA 1988, which became effective in 1992, mandates that all laboratories must be regulated using the same standards, regardless of

their location, type, or size. This law requires every clinical laboratory facility in the country to obtain a certicate from the federal government to help reassure customers that the laboratory testing performed at the facility is reliable and accurate. CLIA regulations cover testing categories, qualications of personnel performing the testing, and standards

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MTs and MLTs

Medical technologists (MTs) and medical laboratory technicians (MLTs) work together in a clinical laboratory. However, they have different education and certification requirements, credentials, duties, and salary ranges, as outlined here.

MT
Education Bachelor of Science degree in medical technology, clinical laboratory science, or biotechnology (4- to 5-year program) Certication Examination taken through the American Association of Clinical Pathologists (ASCP) Credentials Duties MT (ASCP) Laboratory manager, department supervisor, specialist, or generalist technologist Annual salary $41,000 to $52,000

MLT
Associate of Science degree for a medical laboratory technician (2- to 3-year program)

Examination taken through the ASCP

MLT (ASCP) Generalist technician in all laboratory departments $31,000 to $41,000

of testing, as well as quality control and prociency testing protocols.

Laboratory Testing Categories

The CLIA testing category for an individual laboratory is determined by the complexity of testing done at the facility. The four categories of laboratory testing established by CLIA regulations include waived tests, moderate-complexity tests, high-complexity tests, and provider-performed microscopy procedures.

hemoglobin determinations using a CLIA-waived analyzer such as the HemoCue blood glucose determination using an FDA-approved blood glucose analyzer such as One Touch glucometer rapid Streptococcus testing such as BD Strep Link Group A Rapid test.

Moderate-Complexity Tests
Tests in the moderate-complexity category are more difcult to perform than waived tests and require documentation of the technologist or technicians training in testing principles, instrument calibration, quality control, and prociency testing. Prociency testing consists of testing unknown specimens provided by an external monitoring agency, such as the state health department and the College of American Pathologists, to meet quality control requirements. Examples of moderate-complexity tests performed in the medical ofce include hematology and blood chemistry tests performed on automated blood analyzers that are not CLIAwaived.

Waived Tests
Waived tests are simple procedures and include many the patient can perform at home. The majority of testing performed in a physicians ofce will be of this type. Many of the more stringent CLIA requirements do not apply to waived tests. In order to be exempt from the CLIA requirements for moderate- or high-complexity tests, a laboratory that performs only waived tests must apply for and be granted a certicate of waiver from the Health Care Financing Administration (HCFA). (See Figure 40-1.) It is important to note that if a laboratory performs only one test and it is a waived test (for example, a rapid Strep test), the laboratory must still apply for and be granted a waiver or be held to the more stringent requirements. Here are some examples of waived tests:

High-Complexity Tests
High-complexity tests require sophisticated instrumentation and a high degree of interpretation by the testing personnel. Personnel performing within this category must have a formal education with a degree in laboratory medicine. High-complexity tests also require documentation of the technologists training in testing principles, instrument calibration, quality control, and prociency testing. Examples of high-complexity tests are performed in microbiology,

dipstick reagent urinalysis fecal occult blood testing urine pregnancy tests

CHAP TER 40

Introduction to the Clinical Laboratory

855

FIG 40-1 CLIA-waived test kits and analyzers.

immunology, immunohematology, and cytology departments and include cultures, type and screens, and Pap smears.

Provider-Performed Microscopy Procedures

Provider-performed microscopy (PPM) procedures are tests classied as moderate complexity. These tests involve direct visual examination of specimens using a microscope. Persons authorized to conduct these tests include physicians, midlevel practitioners such as physicians assistants, and dentists. A physicians ofce that performs PPM must apply for a Certicate of Provider-Performed Microscopy and follow the same requirements as listed in the moderate-complexity category. Examples of PPM procedures include direct wet mounts for the presence of bacteria, fungus, parasites, and human elements; potassium hydroxide (KOH) preparations; pinworm examinations; urine sediment examinations; and nasal smears for eosinophils.

using control reagents designed to obtain high, normal, or low results. Many commercial testing kits, such as the rapid Streptococcus test or mono test, contain an internal control with each patient test cassette or strip as well as a positive and negative external control reagent. (See Figure 40-2.) The manufacturer of the control samples provides a range of values that each control must fall within in order to ensure the accuracy of the method being used. If a control result falls outside the acceptable range, corrective action must be taken. Under no circumstances should the patient sample be tested until all control sample results are within acceptable ranges. If results dont fall within acceptable ranges, corrective steps include:

Quality Control
Understanding and following quality control (QC) procedures is an essential component of laboratory testing. QC consists of methods and procedures that are used to monitor the accuracy and reliability of laboratory results. QC testing includes testing samples of known values (controls) to ensure the proper function of the machine and the technical process, as well as any reagents (substances used in a chemical reaction) that may be used in the procedure. Prior to testing patient samples, control samples must be tested and the results must be documented. For most laboratory analyzers, testing control samples might include

repeating the control (If the repeated test results fall within the acceptable range, the technician may proceed with patient testing.) checking the control samples expiration date (The technician should never use control samples that have expired.) checking the expiration date of all testing reagents (The technician should discard the reagent if its outdated.) checking to make sure the instrument is calibrated correctly and functioning properly.

The process of quality control also includes proper documentation of the procedures performed. As with most medical procedures, the statement not documented, not done applies to the laboratory. The medical ofce puts policies and procedures in place, as required by CLIA or other laboratory accreditation agencies, to include documentation. (See Figure 40-3.) Examples of documentation include recording:

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FIG 40-2 Quality control results from a mono test kit.

all control sample results and corrective action that may have been taken daily temperatures of laboratory refrigerators, incubators, freezers, and instruments as well as room temperature preventive maintenance performed on an analyzer or instrument instrument calibrations that may have been performed.

Physicians Ofce Laboratory

Because the patient will nd it more convenient to undergo testing at the physicians ofce, a routine test, which is a laboratory test ordered as part of a regular office visit, may be performed in the physicians ofce laboratory (POL). Examples of routine tests that are commonly performed include fasting blood sugar and urinalysis. The medical assistant is most commonly the person in charge of the POL or the one who performs most of the

patient testing. The medical assistant must familiarize herself with the types of tests that are performed in the office. For the most part, the most common type of test performed in the POL is the CLIA-waived test. As mentioned, the medical assistant should follow testing, quality control, and reporting guidelines when performing any patient testing. Tests that are considered time-consuming, highly sophisticated, expensive, or complex are referred to an outside laboratory, such as a hospital laboratory or privately owned commercial laboratory. The outside laboratory provides the POL with a laboratory directory that serves as a valuable reference guide for the proper collection, handling, and transport of clinical specimens. Although directories vary among organizations, they generally include:

comprehensive list of test procedures in alphabetical order method used for each test current procedural terminology (CPT) code patient preparation necessary for each test

CHOLESTECH QUALITY CONTROL LOG SHEET Date Optics check results QC range QC results Initials/comments

02/06/07 02/07/07 02/08/07

94 96 95 98 94 96 95 98 94 96 95 98

130-210 130-210 130-210

183 186 181

OK cg OK cg OK cg

FIG 40-3 Proper documentation of a QC log sheet.

CHAP TER 40

Introduction to the Clinical Laboratory

857

amount and type of specimen required proper storage and handling for the specimen transport instructions for the specimen.

The medical assistant should familiarize herself with the individual laboratory directory as well as the services offered by each outside laboratory used. If she is unable to nd in the directory the answer to a specimen collection question, she should call the reference laboratory prior to collecting the specimen.

Laboratory Requisitions and Reports

In the life cycle of a laboratory test, the requisition (order) for the test is the first step. The medical assistant must familiarize herself with each requisition slip she may complete. Some laboratories will have a separate requisition slip for clinical laboratory tests, Pap smear specimens, and histological specimens. The medical assistant or other office staff should be sure to stock each examination room, the POL area, and the front office area with sufficient quantities of each type of laboratory requisition slip for easy access. In addition, a POL may use the services of a hospital laboratory as well as a reference or private laboratory, so the staff may be dealing with more than one type of laboratory requisition form. Upon testing the patients specimen, the laboratory will generate a formal report of the patients test results. The laboratory report will include much of the patients demographic information found on the requisition slip, as well as the results to the tests ordered.

Laboratory Requisition Slip

A laboratory requisition slip is a printed form that contains a list of the most frequently ordered laboratory tests, some of which are grouped into panels. The medical assistant should know about each of the tests listed on the requisition slip. (See Figure 40-4.) Specic information required on the laboratory requisition slip includes:

name of the hospital or laboratory where the form was issued, which usually appears on the top portion of the requisition form with the laboratorys complete address, telephone number, and fax number type of test, such as STAT, fasting, nonfasting, and routine, with a clear indication from the physician (by checking the appropriate box) about how the specimen should be handled and the test conducted (For example, the laboratory technician performs tests that are marked STAT as soon as possible, telephones the results to the physician, documents the results, and then faxes the results to the physician.) priority, which tells the laboratory exactly how soon the physician needs the results (For example, if routine is checked, the test will be performed with the daily work. If

the physician needs the results immediately, STAT will be checked and the laboratory will perform the test immediately and call the results directly to the physician. If ASAP, or as soon as possible, is checked, the laboratory will give the test a higher priority than a routine order, but not as immediate as a STAT order.) patients name and address, listing the patients last name rst, followed by the rst name and middle initial (required by most hospitals), and including the city, state, and zip code in the address for billing purposes physicians name and address to facilitate the reporting of tests results patients age and gender because these factors may determine whether results fall in the normal range, which is a range of values in which a test result should fall for most healthy individuals (For example, the normal range for a hemoglobin determination for a female is 12 to 16 g/dl, while the normal hemoglobin range for a male is 14 to 18 g/dl.) date of the specimen collection to indicate to the laboratory the freshness of the specimen, and the time of collection, which is critical because the signicance of some test results depend on whether the specimen is collected in the morning versus the afternoon or evening laboratory tests requested, usually indicated by checking boxes next to those tests on the list microbiological specimen type (such as sputum sample) and, possibly, location from which the specimen was taken (such as infected abdominal incision or discharge from right eye) to aid the laboratory in identifying the presence of possible pathogens physicians clinical diagnosis (also known as a tentative diagnosis), established by evaluating the patients health history and the physical examination without conducting laboratory or diagnostic tests (The clinical diagnosis conrms the laboratory test results, alerts laboratory personnel to potentially dangerous pathogens, and is required for insurance billing information.) medications, some of which may interfere with the accuracy and validity of test results. (The medical assistant should note on the requisition slip all medications the patient is taking, regardless of their ability to interfere with results.)

Laboratory Report
A laboratory report, which is usually a computer printout, is used to communicate test results to the physician. A laboratory report includes:

name, address, telephone, and fax number of the laboratory physicians name and address patients name, age, and gender patients accession number, which is assigned to each specimen received by the laboratory (Most laboratories

858

UNIT 3

Clinical

HARTELL MEMORIAL HOSPITAL LABORATORY

LAB REQUISITION
NAME: ADDRESS: PHONE: DX:

STAT CALL RESULTS

X FASTING

NON FASTING

X ROUTINE 12/30/65 D.O.B.: 7/17/08; 7:00 a.m.

Other

Jacqueline Garrett 25 Hilltop Drive, Presley, CT (860) 555-2345 Annual physical

Medicare

DR.

Greer
SYMPTOM: Medex

DATE & TIME DRAWN:

n/a
BCBS Patient

BILL TO: (CIRCLE ONE) Policy #:

RS765OM20
CC R/G SS SS SS SS R SS R SS SS R R U SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS SS R R R R SS SS SS SS L R R R R ANA ASO CMV IgG CMV IgGM CRP RH. PYLORI ab Mono RA/RF RPR RUBELLA OTHER STOOL ANALYSIS OCCULT BLOOD FECAL FAT (Quant) FECAL WBC C. DIFFICILE OVA & PARASITES URINALYSIS S S S S PK CHEMISTRY MAGNESIUM PHENOBARB PSA RUBELLA SALICYLATE T3 UPTAKE T4 F4 FREE TSH VALPROIC ACID VITAMIN B12 COAGULATION PRO TIME-INR PRO TIME PTT FIBRINOGEN BLEEDING TIME HEMATOLOGY B B B B B L L L L L L L L L L R R SS SS R R R R SS SS SEROLOGY CC SS R R R SS SS SS R R LG R

Subscribers name: FLUIDS SOURCE FLUID CELL CT FLUID DIFF FLUID GLUCOSE FLUID PROTEIN FLUID LDH FLUID CHLORINE FLUID CULTURE FLUID CRYSTALS FLUID PH POST VAS SPERM MICROBIOLOGY AFB STAIN AFB CULTURE

Jacqueline Garrett
CC F F F F F F F F F F AFP CA 125 CLOZARIL CORTISOL AM CORTISOL PM CYCLOSPORINE ESTROGEN FSH LH HEP BE Ag HEP BE Ab HEP Bs Ag HEP Bs Ab HEP C LEAD RUBEOLA ADDITIONAL TESTS BLOOD BANK ABO/RH BLOOD TYPE DIRECT COOMBS TYPE & SCREEN TYPE & CROSS 1U TYPE & CROSS 2U TYPE & CROSS 3U TYPE & CROSS 4U OTHER TESTS CC R L R R R R R CC SS SS R SS SS L SS SS SS SS SS SS SS

CHEMISTRY PANELS ELECTROLYTES BASIC METABOLIC COMP METABOLIC RENAL HEPATIC ACUTE HEPATITIS

LIPID OBSTETRICAL CARDIAC * THYROID SCREEN THYR CASCADE * S DRUGS ABUSE U DRUGS ABUSE CHEMISTRY ALB ALK PHOS ALT (SGPT) ALT (SGOT) AMYLASE T BILI D BILI BUN CALCIUM CHOL CREAT CK

ANAEROBIC CULTURE BLOOD CULTURE CHLAMYDIA/GC PROBE EAR CULTURE R L FLUID CULTURE SOURCE FUNGAL CULTURE GC CULTURE GRAM STAIN SOURCE KOH PREP NOSE CULTURE RAPID STREP RAPID UREASE SPUTUM CULTURE STOOL CULTURE THROAT CULTURE URINE CULTURE VAGINAL CULTURE VIRAL CULTURE SOURCE WOUND CULTURE SOURCE VAGINAL VP3

CBC w DIFF. PLTS CBC wo DIFF HCT HGB HCT/HGB PLATELET COUNT RETIC CT SED RATE WBC WBC/DIFF

SS HIV 1.2 MASTERTUBE SS L SS

GLUC GLUC TOLERANCE GLUC 1 HR HDL LDH LDL (Quant) PHOS NA K CHLORIDE CO2 T PROTEIN TRIG URIC ACID ACETAMINOPHEN ALCOHOL B-HCG (Quant) B-HCG TUMOR CARBAMAZEPINE CEA DIGOXIN DILANTIN GENTA TROUGH GENTA PEAK GLYCOHEM FERRITIN FOLIC ACID IRON IBC

COLLECTION CODES B Blue Red Green Lavender Stool U SS F Urine SST Fluid R G L S

URINALYSIS 24 HR. URINE HCG-SERUM HCG-URINE MICROALBUMIN

U U R U U

PHYSICIAN ACKNOWLEDGMENT The undersigned physician certifies for the laboratory: 1) the tests ordered on this requisition are medically necessary for the diagnosis and treatment of the patient; the physician is treating the patient in connection with the diagnosis or symptoms listed on this requisition; and the medical necessity of each test ordered on the requisition is appropriately documented in the patients medical record. 2) tests ordered using customized panels may result in denial of payment by Medicare and, 3) the physician believes the tests ordered are appropriate for patient care, and payment may be denied by Medicare for reasons explained to the patient, who has agreed to pay for the tests personally by signing an Advanced Beneficiary Notice (ABN).

Robert Greer
SIGNATURE

7/15/08
DATE

FIG 40-4 Example of a completed laboratory requisition slip.

CHAP TER 40

Introduction to the Clinical Laboratory

859

have computerized systems that assign a specic bar code for the automated instrument to identify when it is processing the specimen.) date the specimen was received by the laboratory date the results were reported by the laboratory names of the tests performed or panels requested results of the tests performed normal range for each test performed because the normal range, or reference range, of each test varies slightly among laboratories, depending on the test method, equipment, and reagents used to perform the test (See Figure 40-5.)

Whenever the physician orders laboratory tests that are to be performed in a laboratory other than the POL, the medical assistant must complete the laboratory requisition slip completely and legibly. Even if blood or other specimens are collected in the office but sent to an outside laboratory for testing, the laboratory requisition slip must accompany the specimen. If a laboratory receives a patient specimen without a laboratory requisition slip, it will not accept the specimen and the patient may have to come back for a repeat collection, which may delay diagnosis and treatment. When the medical assistant has completed the slip, she must stamp it with the physicians signature and then document the order (and specimen collection if any) in the patients chart. In addition to documenting the order, some medical office procedures require the medical assistant to put a copy of the completed laboratory slip in the patients chart. Completed reports are hand-delivered, faxed, sent electronically to the physicians ofce computer, or mailed to the medical ofce by the laboratory. Abnormal results that are critical and indicate a threat to the patients health or reports on requisitions that are marked STAT are telephoned immediately, documented in the computer system, and then faxed to the medical ofce. A hard copy of the report will also be generated and sent to the ofce via mail or computer network printer. The medical assistant should review each laboratory report, compare the patients results to the normal ranges, and then immediately notify the physician of an abnormal result. When the physician has reviewed and initialed the laboratory report, the medical assistant may be responsible for calling the patient with the results, scheduling a follow-up visit with the patient, and ling the patients results.

time of day could affect or invalidate certain laboratory results. A patient who is not instructed properly may have to come back to the laboratory for a repeat test. The medical assistant must explain the reasons for the advanced preparation so that the patient will be more likely to comply with the instructions. After she has explained the instructions, the medical assistant should determine if the patient completely understands the instructions and answer any questions the patient has. The medical assistant should also provide the patient with written instructions to serve as a reference if the patient forgets some of the information after leaving the office. The medical assistant should go slowly when providing instructions and always reinforce those instructions by repeating the procedure and have the patient repeat the instructions back to her. She should always remember that the quality of laboratory rest results can only be as good as the quality of the specimen collected.

Fasting
Certain laboratory tests require the patient to fast prior to collection. Fasting is sometimes necessary because the composition of blood and, thus, the laboratory test may be altered by the consumption of food. Examples of tests affected by fasting include blood glucose and triglycerides. Fasting requires that the patient abstain from eating and drinking (except water) for a specic amount of time before the specimen is collected. The most common fasting time is 12 to 14 hours.

Medication Restrictions
The physician determines whether a patient should abstain from her medication prior to laboratory testing. The medical assistant is responsible for ensuring that the patient understands medication restriction instructions and recording her medications, including the dosage, on the laboratory request form. If the physician determines that the patient cannot stop taking her medication, the medical assistant should also document this information on the laboratory request form.

Specimen Collection, Handling, and Transport

Proper specimen collection, handling, and transport are critical to the accuracy of test results. Such circumstances as a delay in transport or unsterile specimen collection could seriously affect a laboratory result and lead to improper treatment of the patient. (See Specimen collection tips, page 861.)

Patient Preparation
It is the responsibility of the medical assistant to instruct the patient about preparation for testing because such factors as food consumption, medications, activity, and the

860

UNIT 3

Clinical

PATIENT LABORATORY REPORT HARTELL MEMORIAL HOSPITAL LABORATORY Name: Seth Banas Sex: M M/R#: 032608 D.O.B.: 05/02/63 Age: 45 Physician: Greer, R. Location: Outpatient HEMATOLOGY <<<<<<<<<<COMPLETE BLOOD COUNT>>>>>>>>>> ELECTROLYTES WBC RBC Hemoglobin Hematocrit MCV MCH MCHC RDW PLT CT MPV Neutrophils Lymphocytes Monocytes Eosinophils Basophils ABS NEU CT Manual diff RBC morph CHEMISTRY <<<<<<<<<<BASIC METABOLIC PANEL>>>>>>>>>> REFERENCE Glucose Sodium Potassium Chloride CO2 Anion gap BUN Creatinine BUN/creat Calcium 94 141 4.7 105 27 9 19.0 H 1.3 15 9.1 8.510.10 mg/dl 718 0.601.30 mg/dl mg/dl 70110 136145 3.505.10 98107 2229 UNITS mg/dl mmol/L mmol/L mmol/L mmol/L RESULT 6.0 5.0 14.4 42.3 85 29 34.0 11 237 10 61 28 8 2 1 4 Not indicated Not indicated REFERENCE 3.8010.80 4.706.10 1418 4252 77104 2734 3137 1116 150400 614 4480 1444 412 05 02 UNITS 10^3 10^6 g/dl % FL PG g/dl % 10^3 FL % % % % % Date ordered: 08/30/2008 Date collected: 08/30/2008 Time collected: 0 Date tested: 08/30/2008 Time tester: 21:41 Accession Number: 0007413225

FIG 40-5 Example of a typical patient laboratory report.

CHAP TER 40

Introduction to the Clinical Laboratory

861

Specimen collection tips

When collecting a specimen for a laboratory test, remember these tips: 1. Collect specimens before antibiotic therapy whenever possible. 2. Collect material from where the suspected organism will most likely be found. 3. Observe asepsis in collection of all specimens. 4. Consider the stage of disease. 5. Instruct the patient clearly, giving him written instructions whenever possible. 6. Use proper containers and transport media. 7. Deliver specimens promptly. 8. Provide sufcient information to the laboratory.

Guidelines for Specimen Collection

Specic guidelines should be followed for the collection, handling, and transport of specimens:

Always follow OSHA guidelines on standard precautions during specimen collection. Follow requirements of collection and handling for the specic specimenfor example, the correct type of blood tube for plasma versus serum, the proper amount of specimen, if the specimen should be delivered on ice or protected from light. (See Figure 40-6.) Use proper equipment and supplies. Use only the appropriate specimen containers or equipment for specimen

collection as specied by the laboratory or medical ofce. Specimens submitted in an inappropriate container can affect the test results. Microbiological specimens should be submitted in a sterile container or sterile swab. The medical assistant should check each container or swab before use for cracked, chipped, or otherwise damaged equipment. Properly identify the patient and provide clear instructions. The medical assistant must properly identify the patient before specimen collection. An explanation of the procedure helps relax and reassure the patient and gains his condence and cooperation. The medical assistant should determine whether the patient complied with precollection instructions. For example, if the patient did not fast for a fasting blood glucose (FBG) and lipid panel and the tests were performed, the results could be falsely elevated. If the patient has not prepared properly, notify the physician prior to collection. The physician may want the patient to return or she may tell the medical assistant to proceed with collection but to document on the laboratory requisition slip and laboratory report that the patient was not fasting at the time of collection. (See Specimen collection, page 862.) Collect the specimen using the proper techniques. Specimen collection involves a combination of medical and surgical aseptic techniques. When collecting specimens for microbiological studies, the medical assistant must ensure that the culture medium used is protected from contamination. She must also be sure to collect the proper type of specimen for each test ordered. For example, the collection of a random urine specimen when a clean-catch midstream (CCMS) specimen is required

FIG 40-6 Various specimen collection containers.

862

UNIT 3

Clinical

Patient Education

Date 01/2/08 2:10 p.m. Collected sputum specimen for C&S. Sent to Lewis Laboratory Services for processing. --------- C. Chapin, CMA

Specimen Collection
As a medical assistant, you may instruct patients about how to properly collect specimens. When providing patient instructions, it is important to remember the following: Speak slowly and clearly. Ask the patient to repeat the instructions back to you. Provide written instructions whenever possible, especially if the patient is to collect the specimen at home. Provide written instructions in other languages native to the community. Emphasize the importance of following these instructions fully, to avoid requiring the patient to repeat the procedure. Repeating procedures is not only costly but also delays the diagnosis and treatment.

FIG 40-7 Sample of charting for specimen collection.

Specimen collection manual

All hospital and reference laboratories follow specic specimen collection and handling protocols. These written protocols make up a specimen collection procedure manual. A typical specimen collection procedure manual includes: required supplies, such as a sterile specimen container or specimen collection swab patient preparation instructions, if any step-by-step instructions for collection storage requirements (room temperature, refrigeration, freezer) transportation requirements

will affect the accuracy of results. The medical assistant must know the correct amount to collect for a given test, depending on the specimen type and the number of laboratory tests ordered. If she fails to collect the specied amount, the laboratory may not be able to perform the test and the laboratory report will be marked as quantity not sufcient (QNS). Such a result would require the patient to come back for another specimen collection. After the medical assistant has collected the specimen, she should document the following information in the patients chart: a. date and time of collection b. laboratory test ordered c. type of specimen collected d. special instructions for correct transport of the specimen (such as refrigerated, room temperature, or frozen) e. medical assistants initials. (See Figure 40-7.)

time restrictions, such as specimen must be processed within 1 hour of collection reasons for specimen rejection, such as quantity not sufcient (QNS), an unsterile container, and so forth miscellaneous instructions or special considerations. If the medical assistant has any questions about the proper procedure when collecting a specimen, she should call the laboratory prior to collecting the specimen. The laboratory will fax the instructions for collection or explain them over the phone. Most physician ofce laboratories have their own specimen collection manual for commonly collected procedures, such as urinalysis, urine culture, throat culture, sputum culture, wound culture, and Papanicolaou smear. Such a procedure manual is a useful tool and reference for newly hired medical assistants.

Conduct proper specimen handling and storage. Whenever possible, laboratory tests are best performed with fresh specimens because they yield the most reliable test results. When transporting a specimen to an outside laboratory, the medical assistant must follow the guidelines set by the outside laboratory regarding storing and packaging the specimen until it is picked up by the courier service. (See Specimen collection manual.)

Laboratory Equipment
The physicians ofce laboratory should have the most up-to-date equipment needed for proper specimen processing and testing. (See Figure 40-8.) Most ofces performing laboratory tests will have the following equipment:

microscope (See Parts of a microscope, page 864.) centrifuge

CHAP TER 40

Introduction to the Clinical Laboratory

863

microcentrifuge 37C incubator laboratory refrigerator various automated analyzers HemoCue Cholestech One Step glucometer automated urine dipstick reader.

purchase of laboratory equipment, the manufacturers specic instructions for assembly and operation as well as recommendations for proper maintenance and troubleshooting should be followed. The operation manual should be stored in an area that is accessible to anyone who needs to operate the equipment. Daily, monthly, and yearly maintenance should be documented as well as any troubleshooting procedures that may be required. (See Common equipment maintenance procedures, page 865.)

Proper Equipment Maintenance

The medical assistant may be responsible for the setup, operation, and maintenance of all laboratory equipment. Upon

FIG 40-8 Various equipment used in a medical ofce. (A) Microscope. (B) Centrifuge. (C) Microhematocrit centrifuge.

864

UNIT 3

Clinical

Parts of a microscope
The microscope shown here is one of the most commonly used pieces of laboratory equipment in the physicians ofce. Understanding the function and use of each part of a
Oculars (eyepieces)

microscope will help the medical assistant use this equipment properly.

Binocular observation tube

Arm

Objectives

Stage Course focus adjustment Stage clips Diaphragm In-base illumination (light source) Stage adjustment knobs

Fine focus adjustment

Base
67 45 12 3 10 89

CHAP TER 40

Introduction to the Clinical Laboratory

865

Common equipment maintenance procedures

The following table lists common laboratory equipment along with maintenance procedures for each.

Equipment
Microscope

Maintenance
Clean eyepieces and objectives daily with approved cleaner. Ensure that a yearly professional cleaning is conducted. (The ofce may have a service contract with the manufacturer or another company.)

Centrifuge/microcentrifuge

Clean the inside of the centrifuge using a 10% bleach solution as needed. Change brushes as needed. Check rotation speed with a tachometer yearly. (The ofce may have a service contract with the manufacturer or another company.)

Incubator Refrigerator

Check temperature daily. Check temperature daily.

Chapter Summary

The clinical laboratory is an integral part of the health care team. Members of the laboratory team are responsible for proper specimen collection and testing to ensure that all patient results are reported in a timely and accurate manner. The medical assistant must be knowledgeable about the different areas of the clinical laboratory and the various tests performed in each department. The medical assistant may be responsible for the overall direction and operation of the physicians ofce laboratory. The medical assistant must know CLIA regulations as well as the proper documentation required for CLIA. Quality control procedures are essential for reliable and accurate patient results. The physicians ofce laboratory may perform many laboratory tests. The medical assistant may also need to know how to properly use and maintain the equipment in the laboratory.

2. The list of waived tests is continually updated by the federal government. Log onto the CLIA website (http://www .cms.hhs.gov/clia/) and, in groups of two to three people, select a topic from the following list (or your instructor will assign each group a topic) to research. Give a report to the class on what you found in your research. a. applying for a certicate of waiver b. categorization of tests c. prociency testing d. CLIA regulations and federal registry documents e. interpretive guidelines for laboratories

Case Studies
1. Mr. McGregor comes to the medical ofce for a complete physical examination. Dr. Manuel orders a fasting glucose and a lipid panel. Jack Brown, CMA, explains to Mr. McGregor what patient preparation is necessary for the test. Mr. McGregor returns the next morning to have the blood tests. At that time, Jack notices that Mr. McGregor is chewing gum. What type of questions should Jack ask prior to collecting Mr. McGregors blood sample? 2. Jennifer performs a rapid group A Streptococcus test in the ofce laboratory. What are the proper steps Jennifer will take when collecting the specimen? What are some of the various test kits that are on the market for the rapid diagnosis of Strep throat?

Team Work Exercises

1. Gather in groups of two or three people. Obtain a microscope. Your instructor will supply you with various types of prepared slides (blood smears, bacteria smears, or tissue slides). First, take turns identifying the parts of the microscope. Then, put a slide on the stage and try to get the slide in focus. Each student should take turns getting a slide into focus.

866

UNIT 3

Clinical

Resources
Brassington, C., and Goretti, C.: MA Notes: Medical Assistants Pocket Guide. Philadelphia: F.A. Davis, 2006. Sacher, R.A.: Widmanns Clinical Interpretation of Laboratory Tests, 11th ed. Philadelphia: F.A. Davis, 2000. Strasinger, S.K., and DiLorenzo, M.S.: The Phlebotomy Workbook, 2nd ed. Philadelphia: F.A. Davis, 2003.

American Society for Clinical Pathology: www.ascp.org Clinical Laboratory Improvement Amendments at the U.S. Department of Health and Human Services: www.cms.hhs.gov/clia Lab Tests Online: www.labtestsonline.org Laboratory Corporation of America: www.labcorp.com

CHAPTER

Phlebotomy
Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary describe the composition and function of blood identify and explain various equipment and supplies used in phlebotomy explain the evacuated tube system identify the proper tube selection according to the tests being ordered discuss proper patient preparation procedures prior to performing phlebotomy discuss various patient considerations when performing phlebotomy perform venipuncture procedures accurately perform capillary puncture procedures accurately explain the proper standard precautions when performing phlebotomy describe patient education regarding phlebotomy.

41
Clinical Duties
Apply principles of aseptic techniques and infection control Use quality control Collect and process specimens Screen and follow up patient test results Perform sterilization techniques Practice standard precautions Perform venipuncture Perform capillary puncture Perform hematology Proper Site Selection for Capillary Puncture Patient Preparation for Capillary Puncture Capillary Puncture Procedure

ABHES Competencies

Special Phlebotomy Considerations

Fainting Failing to Obtain Blood Dealing with Problem Specimens

Communication
Recognize and respond to verbal and nonverbal communication

Chapter Summary Team Work Exercises Case Studies Resources

Procedures
Performing a venipuncture Performing a venipuncture using a winged infusion set Performing a capillary puncture

Chapter Outline
Types of Phlebotomy Procedures Venipuncture
Composition of Blood Venipuncture Equipment Tubes Plastic adapters Needles Syringes Winged infusion sets Tourniquet Gloves Proper Site Selection for Venipuncture Patient Preparation for Venipuncture Venipuncture Procedure

CAAHEP Competencies
Clinical Competencies Fundamental Principles
Dispose of biohazardous materials Practice standard precautions

Specimen Collection
Perform venipuncture Perform capillary puncture

Capillary Puncture
Composition of Capillary Blood Capillary Puncture Equipment Capillary puncture devices Capillary puncture collection containers

General Competencies Legal Concepts

Document appropriately

867

Key Terms
additive

Types of Phlebotomy Procedures

Although the term phlebotomy refers specically to inserting a needle into a vein for the purpose of obtaining a blood sample for analysis, it is used in the health care eld to refer to venipuncture, the process of puncturing a vein with a needle to obtain blood, or capillary puncture, the process of performing a skin puncture to obtain blood. Blood is composed of various components that, when tested, can tell a physician a lot about what is going on with a patient. Phlebotomy is an extremely important skill for a medical assistant to possess. The medical assistant will employ venipuncture or capillary puncture when obtaining blood from patients. The medical assistant who can understand and perform venipuncture and capillary puncture properly and efciently will help win her patients condence.

Substance, such as an anticoagulant or preservative, that may be added to an evacuated blood collection tube
antecubital space

Space inside the arm at the bend of the elbow that is the best site for routine venipuncture
anticoagulant

Substance that inhibits blood clotting

buffy coat

Middle layer of a whole blood tube that has been allowed to settle or has been centrifuged and contains leukocytes and platelets
capillary puncture

Process of performing a skin puncture to obtain blood

erythrocyte

Red blood cell responsible for carrying oxygen to all cells and tissues in the body
evacuated tube

Plastic tube that contains a vacuum, which draws blood from the vein into the tube through a dual needle system
hematoma

Venipuncture
Venipuncture is dened as the process of piercing a vein with a needle to withdraw blood. However, the actual process involves more than the denition describes. In addition to piercing a vein, the venipuncture procedure consists of proper patient preparation, an understanding of the blood tests being ordered, and proper selection of supplies. The rst step in properly performing this technical process is understanding the composition of blood.

Discoloration of the area around a puncture site caused by an accumulation of blood around the site; also called bruise
hemoconcentration

Accumulation of blood caused by leaving the tourniquet on the venipuncture arm longer than 1 minute, causing an increase in red blood cells and a decrease in plasma volume
hemolysis

Destruction of red blood cells, causing a red tinge in serum

lancet

Composition of Blood
Whole blood is composed of formed elements, or blood cells, and plasma. (See Figure 41-1.) The formed elements consist of:

Capillary puncture device that usually contains a retractable blade

leukocytes

White blood cells responsible for ghting off infection and producing antibodies
phlebotomy

Process of collecting blood for analysis

plasma

Liquid portion of blood that contains clotting factors

serum

Liquid portion of blood without the cells and clotting factors

thrombocytes

Platelets responsible for clot formation

tourniquet

erythrocytes (red blood cells), which are responsible for transporting oxygen to all cells in the body and removing carbon dioxide, the waste product of cellular activity, to the lungs for elimination via the respiratory system leukocytes (white blood cells), which are an important part of the immune system because they protect against infection and disease thrombocytes (platelets which are fragments of larger cells and are responsible for clot formation. (For more information on blood cells and their function, see Chapter 42, Hematology and Coagulation Procedures, page 889.)

Device used to aid vein protrusion

venipuncture

Process of puncturing a vein with a needle to obtain blood

whole blood

Blood composed of formed elements (cells) and plasma

The formed elements are suspended in plasma, the liquid portion of blood. (See Figure 41-2.) Plasma makes up about 55% of blood volume and is approximately 90% water. Plasma also contains clotting factors (such as brinogen), gases, carbohydrates, electrolytes, and various other substances. (See Substances found in plasma.) If a tube of

CHAP TER 41

Phlebotomy

869

Eosinophil Neutrophil

Erythrocytes

Basophil

Plasma (yellow layer)

Buffy coat (white layer - consists of white blood cells and platelets)

Monocyte Lymphocyte Thrombocytes FIG 41-1 Various types of blood cells found in whole blood. Packed red blood cells (red layer)

uncoagulated whole blood is allowed to stand straight up for a period of time, the tube will develop three layers:

plasma, which is the top layer and appears as a cloudy yellowish color buffy coat, which sits atop the layer of red blood cells and consists of the white blood cells and the platelets red blood cells, which will separate out and settle to the bottom of the tube.

FIG 41-2 Buffy coat (layers of uncoagulated blood that form when a blood tube is left standing or centrifuged).

Serum is the liquid portion of blood that does not contain brinogen or blood cells. Serum contains all of the same substances found in plasma. If a tube of clotted blood were spun in a centrifuge, it would separate into serum and clotted cells. (See Figure 41-3.) Serum is the most common portion of blood that is analyzed for medical testing. A medical assistant selects the type of tube based on whether serum or plasma is required for the test.

Substances found in plasma

Plasma contains many substances that can be measured by a blood test: glucose hormones, such as thyroid stimulating hormone (TSH), follicle-stimulating hormone (FSH), growth hormone (GH), and human chorionic gonadotropin (HCG) cholesterol medications drugs of abuse protein albumin calcium carbon dioxide clotting factors.

Venipuncture Equipment
When performing phlebotomy, the medical assistant must be sure to select the proper equipment for the procedure. She must decide on the proper tube for the tests being ordered and the size and type of needle to use, as well as proper site-cleaning solution.

Tubes
The blood collection tubes used in venipucture use the evacuated system. Evacuated tubes are plastic tubes that contain a vacuum, which draws blood from the vein and collects the

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blood directly into the tube through a dual needle system. These tubes come in glass and plastic versions, but plastic tubes are more commonly used because they are safer. Tubes are available in different sizes by volume, depending on how much blood is needed or how fragile a vein is. Tube volume size can vary from 2 to 15 ml. Each tube has a different color-coded stopper, or tube top. Many collection tubes contain an additive, which is a substance that will act upon the specimen in a certain way. For example, a preservative is an additive that will protect the integrity of the specimen. Because glucose is easily broken down in a blood specimen, the preservative in the gray-stoppered tube will preserve any glucose that may be in the specimen, protecting it from breaking down, which would cause erroneous test results. Each color-coded stopper correlates with the type of additive that is inside the tube. Other tubes have an additive that, rather than preserving a specimen, acts on it to yield a whole blood or serum specimen. For instance, a tube with a lavender stopper contains ethylenediaminetetraacetic acid (EDTA), an anticoagulant, which is a substance that does not allow the blood to clot. Blood collected in this type of tube remains in the whole blood state. In contrast, blood drawn in a red-topped tube containing a clot activator will coagulate and yield serum upon centrifugation. (See What tube colors mean.) To select the proper tube size for venipuncture, the medical assistant must consider:

FIG 41-3 The rst lavender top tube shows whole blood before centrifugation. The second lavender top tube shows plasma sitting on top of a layer of blood cells after centrifugation. The SST (gold top) tube shows serum sitting on top of clotted blood cells.

amount of blood needed for the tests orderedIf the tube selected is too small, it may not yield enough blood for the tests being ordered. The patient may be called to return to the laboratory or ofce to have the sample redrawn.

What tube colors mean

This table provides a complete listing of tube colors, along with the additive contained in the tube, the specimen type it yields, and common tests drawn using the tube.

Tube Color
Yellow

Additive
Sodium polyanethol sulfonate (SPS)

Specimen
Whole blood

Common Tests
Blood cultures

CHAP TER 41

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871

What tube colors meancontd

Tube Color
Light blue

Additive
Sodium citrate

Specimen
Whole blood or plasma

Common Tests
Prothrombin time (PT-INR) Partial thromboplastin time (PTT)

Serum-separator tube (SST)

Thixotropic separator gel

Serum

Fasting blood glucose (FBG) Blood urea nitrogen (BUN) Creatinine Electrolytes Thyroid stimulating hormone (TSH) Lipid panel Cardiac panel

Plain red

No additive

Serum

ABO/RH Type and screen Most serological tests

Green

Sodium heparin

Whole blood or plasma

Ammonia Electrolytes (STAT orders)

Continued

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What tube colors meancontd

Tube Color
Lavender

Additive
Ethylenediaminetetraacetic acid (EDTA)

Specimen
Whole blood or plasma

Common Tests
Complete blood count (CBC) Hemoglobin and hematocrit (H&H) Platelet count White blood cell count Red blood cell count Erythrocyte sedimentation rate (ESR)

Gray

Sodium uoride with Na2 EDTA Sodium uoride Potassium oxalate and sodium uoride

Whole blood or plasma

FBG Glucose tolerance test (GTT)

needle sizeIf a needle that has a small opening is used with a large-volume tube, then the force of the blood coming through that opening may destroy the red blood cells in the specimen, a process called hemolysis. Hemolysis of a specimen is indicated by a red tinge to the serum. type of veinIf a large tube, which has a more forceful vacuum, is used on a small or fragile vein, the vein could collapse and the medical assistant may have to redraw the sample, causing additional discomfort to the patient.

Plastic Adapters
A venipuncture adapter is made of clear, rigid plastic that holds the needle and the collection tube. The needle is screwed into one end and the blood tube is inserted into the barrel of the holder. The Occupational Safety and Health Administration (OSHA) requires all personnel to discard the adapter with the used needle. The medical assistant should refer to her facilitys procedure manual for the needle-adapter disposal protocol. (See Figure 41-4.)

Needles
Needles used in evacuated tube venipuncture are doublepointed and consist of an anterior needle and a posterior
FIG 41-4 Blood tube adapters. (A) Adult. (B) Pediatric.

CHAP TER 41

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needle. The anterior needle is longer (1" to 1 12" long) with a beveled point for easy entry into the skin and the vein. The posterior needle is shorter and covered by a rubber sheath. The needle screws into the top of the tube adaptor and the posterior end of the needle enters the inside of the adaptor. When the tube is inserted into the adaptor, it goes into the back of the needle. At the same time, the tube pushes the sheath back. When the medical assistant removes the tube from the adaptor, the sheath rolls forward into place to prevent blood from leaking out. The size of the needle opening is called the gauge. Needles come in various gauge sizes ranging from 16G to 25G. Needles with a larger opening have a smaller gauge number. A medical assistant may use a 16G needle on a patient donating blood because a large amount of blood is required in a shorter period of time; the typical gauge for an adult venipuncture is 20G to 21G. A medical assistant would use a smaller-gauge needle, such as 23G, on the elderly and children, who typically have fragile or smaller veins. (See Figure 41-5.) Regardless of the size, all phlebotomy needles are for one use only. After using a needle, the medical assistant should dispose of it in the proper puncture-resistant biohazard container. (See Figure 41-6.)

Safety Needles
To increase needle safety and prevent needlestick injuries, the Needlestick Prevention and Safety Act mandates the use of safety needle devices. (See Accidental needlestick: What to do, page 874.) Devices such as the Punctur-Guard needle and the Vacutainer Eclipse blood collection needle are just a

FIG 41-5 Needles used during venipuncture. (A) A 21-gauge needle. (B) A 22-gauge needle.

FIG 41-6 Different types of puncture-proof needle-disposal containers.

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few of the many types of safety needles available. In addition, some devices are adaptors in which the safety feature is attached to the adaptor and, when engaged, covers the needle to prevent an accidental needlestick. (See Figure 41-7.)

Syringes
Syringes are sometimes used when collecting blood for analysis. Some situations in which a medical assistant might

select a syringe for venipuncture include patients with fragile or small veins or when drawing from a hand vein. Syringes are preferred in these instances because the medical assistant is able to control the suction pressure in the vein to prevent the veins from collapsing. (See Figure 41-8.) If the medical assistant draws blood in a syringe, she should immediately transfer the blood to the appropriate evacuated tubes to prevent clot formation.

Winged Infusion Sets

A winged infusion set, commonly called a buttery needle, consists of a needle that is attached to plastic tubing. The winged infusion set is used when encountering a small or fragile vein, which is common in children and elderly patients. (See Figure 41-9.) Using a winged infusion set puts less pressure on the vein when the vacuum tube is attached to the tubing. It is preferred over a syringe because the risks of specimen contamination and accidental needlestick are lower than with a syringe. A winged infusion set used for phlebotomy is usually 21G, 23G, or 25G with lengths of

FIG 41-7 Safety needles and safety adapters.

Accidental needlestick: What to do

Medical assistants should strictly adhere to standard precautions and proper safety procedures when performing phlebotomy. However, regardless of these procedures, accidental needlesticks do happen. In the event of an accidental needlestick, the medical assistant should: 1. remove her gloves immediately and wash the puncture site with soap and water (If she has punctured her nger, she should press on the nger to help the site bleed out slightly, while still washing the site.) 2. dry the punctured area and bandage it 3. notify the supervisor of the incident 4. have the patient stay until the supervisor arrives and determines a course of action 5. follow the procedure outlined by the supervisor and the formal needlestick exposure protocol for obtaining immediate medical attention 6. document the incident.
FIG 41-8 Venipuncture procedure using the syringe method.

CHAP TER 41

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875

FIG 41-9 Venipuncture procedure using a winged infusion set. (A) Insertion of a winged infusion set. (B) Insertion of the tubes into the adapter.

'' to 34''. The medical assistant should learn the proper technique for activating the safety feature of the winged infusion set to avoid accidental needlesticks.

1 2

Tourniquet
A tourniquet is a at, soft elastic band approximately 1" wide and 18" long. It is used to locate patient veins by impeding venous but not arterial blood ow. Tourniquets are inexpensive and can be disposed of if they become contaminated or soiled. Nonlatex tourniquets are available for phlebotomists and patients who are allergic to latex. Tourniquet placement is a key step in successful venipuncture. The medical assistant should place the tourniquet approximately 3" to 4" above the bend of the patients elbow. She should take care to avoid tying the tourniquet too tightly or keeping it on too long. Otherwise, hemoconcentration in the area can occur. Hemoconcentration is the accumulation of blood with increased levels of red blood cells and decreased plasma volume. It can cause the breakdown of red blood cells (hemolysis) in the specimen.

Hemoconcentration or hemolysis could cause inaccurate results or specimen rejection, which would require another venipuncture and more patient discomfort. Additionally, if a tourniquet is kept on the arm longer than 1 minute, it may cause a hematoma, which is a discoloration of the area around a puncture site caused by an accumulation of blood. Not only can a hematoma be painful to the patient, it can also cause the vein to be rendered useless for subsequent venipuctures because the blood from the old hematoma may seep into the needle and contaminate the venous blood.

Gloves
Latex allergy is increasing among health care workers. As mandated by OSHA, gloves must be worn when performing venipuncture and must be changed after each patient. Gloves are available in powdered or powder-free latex and nonlatex (vinyl or nitrile). The medical assistant should ask the patient if he has a latex allergy and, if so, be sure to use nonlatex gloves when performing the venipuncture. (See Additional venipuncture supplies, page 876.)

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Additional venipuncture supplies

In addition to tubes, needles, adaptors, syringes, winged infusion sets, tourniquets, and gloves, a medical assistant will need additional supplies in order to perform a proper venipuncture. These supplies include: alcohol cleansing pads (70% isopropyl alcohol) sterile 2 2 gauze pads station. The medical assistant should make sure that venipuncture supplies are readily available and within reach. In some POLs, the medical assistant will draw blood in an examination room. In that case, the medical assistant will bring a phlebotomy tray to the examination room in order to draw the patients blood. Regardless of where she draws the blood, the medical assistant should routinely keep the blood drawing station and phlebotomy tray stocked, preferably on a daily basis.

adhesive bandage or surgical tape ammonia inhalant puncture-proof biohazard disposal container. Most physicians ofce laboratories (POLs) will have a separate area for blood drawing called a blood drawing

Typical set-up for a phlebotomy tray

Proper Site Selection for Venipuncture

After proper identication of the patient, the rst thing the medical assistant must do is select the proper site for venipuncture. The antecubital space, which is located at the surface of the arm anterior to the elbow, is the preferred site for routine venipuncture. (See Figure 41-10.) The three major veins located in this area are the median cubital, cephalic, and basilic veins. For a routine venipuncture, the median cubital vein should be the medical assistants vein of choice because it is close to the skins surface and, thus, is not as likely to move or roll to the side when a needle is inserted. The cephalic or basilic veins should be the second choice because they tend to be smaller and may move during puncturing. Regardless of the vein used, the medical assistant must properly anchor the vein prior to puncture so

the vein does not move or roll. Movement of a vein during venipuncture can cause the needle to enter through the vein or miss the vein altogether, requiring a repeat puncture and additional patient discomfort. (See Sites to avoid in venipuncture.)

Sites to avoid in venipuncture

Avoid these sites when performing a venipuncture: scarred, bruised, or edematous areas sites above an IV arm side of a mastectomy sites containing stulas or vascular grafts.

CHAP TER 41

Phlebotomy

877

Front ofceBack ofce connection

Blood Test Desk Check

Cephalic vein

Median cubital vein

Basilic vein

Basilic vein Median vein

The front ofce medical assistant may be responsible for asking a patient coming to the ofce for blood work if he has conformed to pretesting requirements. When was the last time you ate or drank anything? or Did you take your medication today? are important questions to ask the patient when he is checking in at the front desk. The medical assistant should document in the patients chart any information that may be helpful to the clinical medical assistant before the patients blood is drawn.

Order of the draw

When drawing blood, the medical assistant must follow the proper order of the draw, because some tube anticoagulants may contaminate other tubes being drawn or sterile specimens may become contaminated. Here is the proper order of the draw: yellow-top tube or culture bottles
FIG 41-10 Antecubital area of arm showing proper veins for venipuncture.

light blue plain red SST green

Patient Preparation for Venipuncture

The medical assistant should demonstrate condence in her ability to perform phlebotomy. Upon greeting the patient with a smile and professional tone, the medical assistant should seat the patient comfortably and put him at ease. She should briey explain the procedure to the patient, verify that he followed pretesting preparation, such as fasting, and ask him if he is allergic to latex. In addition, the medical assistant should ask the patient if he has ever had a problem with venipuncture. She can be better prepared to assist the patient if she knows that he may experience faintness or other problems.(See Blood test desk check.) Next, the medical assistant should review the laboratory requisition slip to see which tests have been ordered. Knowing which tests are ordered will determine the proper tube color to select. (See Order of the draw.)

lavender gray.

direction, depth, and size of the vein. Determining these vein characteristics will allow the medical assistant to select the proper size needle and collection tube. In addition, the medical assistant should visually inspect both arms and notice scars or moles, which are areas she should stay away from because they may interfere with the venipuncture procedure. (See Procedure 41-1: Performing a venipuncture, page 878, and Procedure 41-2: Performing a venipuncture using a winged infusion set, page 883.)

Venipuncture Procedure
The medical assistant should be familiar with the proper procedure for selecting a vein. Palpation enables her to feel around for the vein rather than simply looking at the vein. The medical assistant should use the index nger of her nondominant hand to palpate the area and determine the

Capillary Puncture
While venipuncture is the most commonly performed phlebotomy procedure, there are certain circumstances in which a medical assistant may be required to perform a capillary puncture, also called a dermal puncture. Such circumstances include drawing blood from an infant, a burned or scarred

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PROCEDURE 41-1

Performing a venipuncture
Task Perform a venipuncture. Conditions Requisition slip Blood tubes Needles Gauze Alcohol cleansing pad Tourniquet Adaptor Adhesive bandage or surgical tape Biohazard sharps container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform a venipuncture. Performance Standards 1. Examine the requisition slip to identify the tests ordered and, therefore, to select the proper tubes to use for collection. 2. Greet the patient and ask him to state his full name and date of birth. Check pretesting requirements, such as fasting, nonfasting, and medication restrictions to avoid rendering the sample unacceptable due to misidentication of the patient or failure to adhere to pretesting specications. 3. Reassure the patient and explain the procedure. 4. Select the correct equipment and tubes for the procedure. Have extra tubes handy in case the rst tube does not work. 5. Wash your hands and put on gloves. 6. Position the patients arm. The arm with the vein selected for venipuncture should be extended and in a straight line from the shoulder to the wrist with the antecubital veins facing anteriorly. You may need a towel to support the arm if the armrest is too low.

Correct positioning of patients arm

Completed requisition slip showing correct tubes selected for tests ordered

CHAP TER 41

Phlebotomy

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PROCEDURE 41-1contd

7. Apply a tourniquet 3" to 4" above the antecubital area of the patients arm and ask the patient to clench his st.

Palpating a vein for venipuncture

Tourniquet properly applied 3" to 4" above the antecubital area

8. Identify the vein of choice by palpation.

9. Release the tourniquet to avoid patient discomfort and altered test results, which can occur if the tourniquet is left on for more than 1 minute. 10. Clean the site and allow it to air dry. Cleaning should be done in a circular motion starting from the inside and moving away from the puncture site to allow the site to dry because a wet injection site can cause a stinging sensation and contaminate the sample, leading to inaccurate test results. 11. Assemble the equipment. Screw the needle into the adaptor and select the rst tube to be drawn. Position within reach all items to be used during the procedure. Rest the tube in the back of the adaptor without pushing it into the back of the needle to avoid having to reach for the tube, which may cause the needle to move in the patients arm. 12. Reapply the tourniquet, positioning it 3" to 4" above the antecubital space and making it snug but not tight.
Continued

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PROCEDURE 41-1contd

13. Do not touch the puncture site to avoid contaminating the area after cleaning the site. 14. Anchor the vein below the puncture site. Then grasp the patients arm with your nondominant hand, placing your thumb 1" to 2" below the puncture site. Using your thumb, draw the skin over the vein in the direction of the patients hand.

Inserting the needle at a 20-degree angle and blood owing into the tube

Nondominant hand anchoring the vein and dominant hand holding the venipuncture equipment

15. When the vein is securely anchored, align the needle with the vein and insert the needle, bevel up, at an angle of 15 to 30 degrees, depending on the depth of the vein. 16. Once you are in the vein, push the tube into the back of the needle; blood should start owing into the tube.

17. Do not move the needle when changing tubes. The hand used to hold the needle assembly should remain braced on the patients arm when tubes are inserted or removed from the adaptor to avoid movement that could cause patient discomfort and the needle to come out of the vein, thus losing the vacuum in the tube. 18. Use tubes in the correct order to follow the correct order of draw and prevent cross-contamination. 19. Make certain to mix tubes gently and promptly. Rotate the tube eight to ten times to mix it with the anticoagulant to avoid a delay that may allow the specimen time to clot, which will make it unacceptable for testing. 20. Make certain that each evacuated tube is lled to the level appropriate for that tube. Tubes that are not lled to the correct level may be rejected for testing.

CHAP TER 41

Phlebotomy

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PROCEDURE 41-1contd

21. Release the tourniquet after inserting the last tube to avoid patient discomfort and altered test results, which can occur if the tourniquet is left on for more than 1 minute. 22. Be sure to remove the last tube from the adaptor to prevent blood from dripping out of the tip of the needle. 23. Place a sterile gauze pad over the needle and quickly withdraw the needle. Do not apply pressure to the puncture site until the needle is completely removed to avoid patient discomfort and scratching the patients skin.

24. Activate the safety needle.

Safety needle activation

25. Apply pressure with the gauze pad for 1 to 2 minutes or longer for a patient on anticoagulation therapy. 26. Dispose of the needle and holder in a biohazard sharps container.

Removing the needle from the arm and placing gauze over the puncture site Continued

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PROCEDURE 41-1contd

27. Label the tubes containing the samples.

Applying a bandage to the venipuncture site Labeling a blood tube

28. Examine the puncture site for bleeding. 29. Apply a bandage over the puncture site.

30. Dispose of all used supplies in appropriate containers. 31. Remove your gloves and wash your hands. 32. Document the procedure in the patients chart.
Date 07/17/08; 7:09 a.m. Labs drawn for CBC and FBG, tubes sent to hospital laboratory. ------------------------------------------- C. Chapin, CMA

patient, a patient with fragile or inaccessible veins, and a patient who only requires point-of-care testing (such as a glucose or hemoglobin determination).

Composition of Capillary Blood

Blood collected by capillary puncture contains a mixture of blood from arterioles, venules, capillaries, and interstitial (tissue) uid. The medical assistant must warm the puncture

site to increase blood ow to the area. She should also avoid squeezing the puncture site, because doing so may cause more tissue uid to mix with the blood, thus interfering with the test results. The medical assistant must understand the difference between blood obtained by venipuncture and blood obtained by capillary puncture. For example, glucose levels in blood obtained from a capillary puncture may be higher than

CHAP TER 41

Phlebotomy

883

PROCEDURE 41-2

Performing a venipuncture using a winged infusion set

Task Properly perform a venipuncture using a winged infusion set or buttery system. Conditions Winged infusion set with push-button needle activation Requisition form Blood tubes Alcohol wipe Gauze Tourniquet Adaptor Adhesive bandage or surgical tape Biohazard disposable container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform a venipuncture using a winged infusion set. Performance Standards 1. Examine the requisition slip to identify the tests ordered and, therefore, to select the proper tubes for collection. 2. Greet the patient and ask him to state his full name and date of birth to avoid drawing blood from the wrong patient. Check pretesting requirements, such as fasting, nonfasting, and medication restrictions, to avoid rendering the sample unacceptable because of failure to adhere to pretesting specications. 3. Reassure the patient and explain the procedure. 4. Select the correct equipment and tubes for the procedure. 5. Wash your hands and put on gloves. 6. Position the patients arm. The arm with the vein selected for venipuncture should be extended and in a straight line from the shoulder to the wrist with the antecubital veins facing anteriorly. The arm should also be supported on the armrest by a towel. 7. Apply a tourniquet and identify the vein of choice by palpation. 8. Release the tourniquet to avoid patient discomfort and altered test results, which can occur if the tourniquet is left on for more than 1 minute. 9. Clean the site and allow it to air dry. Cleaning should be done in a circular motion starting from the inside and moving away from the puncture site to allow the site to dry. A wet injection site can cause a stinging sensation and contaminate the sample, leading to inaccurate test results. 10. Assemble the winged infusion set. Peel back the packaging at the arrows so that the back of the winged infusion set is exposed. Grasp the rear barrel of the set and remove it from the package. If the winged infusion set has a button, be careful not to activate the button when removing the set from the package. If the button is pushed, the needle will retract into the winged infusion set, rendering it useless. 11. Attach the adaptor to the multiple sample Luer adaptor at the end of the tubing. 12. Assemble additional supplies and position all of the items to be used during the procedure within reach. 13. Reapply the tourniquet 3" to 4" (7.5 to 10 cm) above the antecubital space, making it snug but not tight. 14. Do not touch the puncture site to avoid contaminating the area after cleaning the site. 15. Anchor the vein below the puncture site. Then grasp the patients arm with your nondominant hand, placing your thumb 1" to 2" (2.5 to 5 cm) below the puncture site. Using your thumb, draw the skin over the vein in the direction of the patients hand. 16. When the vein is securely anchored, grasp the wings together with your thumb and index nger and insert the needle into the vein at a 15- to 20-degree angle. (You can also hold the body of the device instead of the wings during insertion if you prefer.) Inserting the needle to deep or too shallow may cause it to miss the vein. 17. You should see a ash of blood enter the tubing, which indicates successful entrance into the vein. 18. Attach the proper blood collection tube to the adaptor and watch as blood enters the tube. 19. Make certain to mix tubes with anticoagulant promptly because a delay in mixing may allow the specimen to clot, which will make it unacceptable for testing. 20. Make certain that each evacuated tube is completely full because tubes that are not completely full may be rejected for testing. 21. After inserting the last tube, release the tourniquet to avoid patient discomfort and altered test results, which can occur if the tourniquet is left on for more than 1 minute. Remove the last tube from the adaptor before removing the needle. 22. After blood collection is complete, place a gauze pad over the venipuncture site and, while the needle is still in the vein, grasp the body of the infusion set with your thumb and middle nger and activate the button, if available, with the tip of your index nger to retract the needle into the winged infusion system, decreasing the chance of an accidental needlestick.
Continued

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PROCEDURE 41-2contd

23. Remove the needle from the patients arm and apply pressure to the venipuncture site with gauze. 24. Dispose of the winged infusion set in a biohazard sharps container. 25. Label the tubes containing samples. 26. Examine the puncture site for bleeding. Patients on anticoagulant therapy may bleed for a longer time than other patients. 27. Apply a bandage over the puncture site and dismiss the patient.

28. Dispose of all used supplies in the appropriate containers. 29. Remove your gloves and wash your hands. 30. Document the procedure in the patients chart.
Date 05/26/08; 9:45 a.m. CBC and glucose drawn using winged infusion set. ---------------------------------------------------------------- S. Gonzales, CMA

levels in blood obtained from a venipuncture. Therefore, the medical assistant must document in the patients chart (on the laboratory report) if the sample was obtained from a capillary puncture.

Capillary Puncture Collection Containers

The types of collection containers used to collect blood from a capillary puncture include:

Capillary Puncture Equipment

When performing capillary puncture, the medical assistant must be sure to select the proper capillary puncture device and puncture site as well as the proper microcollection container to collect the sample.

capillary tubesavailable as plain or coated with heparin and typically used for microhematocrit determinations microcollection tubesplastic tubes, available with or without additives, that are preferred when larger amounts of blood are needed. (See Figure 41-12.)

Capillary Puncture Devices

Most capillary puncture devices are manual or semiautomatic lancets. A lancet is a device with a sterile, sharppointed blade used to puncture the skin to obtain blood. Many disposable lancets are available in various depths and widths. But, regardless of the device, the puncture must not penetrate deeper than 3.0 mm on adults and 2.0 mm on infants and children. (See Figure 41-11.)

Proper Site Selection for Capillary Puncture

The medical assistant must take care when selecting a site for capillary puncture. (See Figure 41-13.) Acceptable sites include:

plantar surface of the heelpreferred site for infants from birth to 1 year plantar surface of the big toeacceptable for infants

FIG 41-11 Different types of capillary puncture devices available.

CHAP TER 41

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885

warming the site. As mentioned earlier, it is always a good idea to warm the puncture site prior to performing the procedure in order to increase the blood ow to the area. Commercial heel warmers are available; however, the same effect can be obtained by running a towel under warm water and then placing it on the heel or ngertip for a few seconds. In addition, the medical assistant must remember to document on the requisition slip when a sample is collected by capillary puncture. (See Capillary puncture.)

Capillary Puncture Procedure

When performing capillary puncture, the medical assistant must identify the patient, following the same procedures as for venipuncture (patient requisition slip and verbal identication or identication band). The medical assistant must remember to let the alcohol dry on the site or the blood will be runny, a rounded drop of blood will not form, and the drop of blood may contain alcohol, interfering with the test results. After puncturing, the medical assistant must wipe away the rst drop of blood using a sterile pad, because the rst drop could be contaminated with interstitial uid. She must also be careful not to squeeze the site, or the sample will also become contaminated with interstitial uid or may be hemolyzed, rendering the sample inadequate. (See Procedure 41-3: Performing a capillary puncture, page 886.) In addition to obtaining the proper type of blood specimen, the medical assistant should be sure to collect the appropriate amount of blood in order to maintain the proper ratio of blood to anticoagulant.

FIG 41-12 Various types of microcollection containers that can be used during a capillary puncture.

A
YES NO (white area) NO

B
HEEL PUNCTURE SITES

Calcaneous (heel bone) Puncture zone

FIG 41-13 The ring and middle ngers as well as the plantar surface of a heel or big toe are acceptable sites for a capillary puncture. . (from Brassington/Goretti: MA Notes. FA Davis, Philadelphia, 2005, p 90, with permission)

Patient Education

Capillary Puncture

lateral eshy area of third or fourth ngerpreferred site for adults and children over 1 year of age. Sites to avoid include:

bruised, scarred, calloused, or previously punctured areas toes other than the big toe thumb, index, or pinky ngers back area of heeltoo close to calcaneus bone arch of the foot.

When performing a capillary puncture on a patient, the medical assistant should understand that this procedure may be new to the patient and the patient may ask how this differs from a typical venipuncture. The main differences include: use of a lancet to make the puncture instead of a needle various sites used, including the ring or middle nger and the plantar surface of the heel preparation of the site, which may include warming the site prior to puncture to increase the blood ow to the area. It is important for the medical assistant to provide proper patient education prior to performing the procedure.

Patient Preparation for Capillary Puncture

The patient preparation procedure for a capillary puncture is similar to that used for a venipuncture, with the exception of

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PROCEDURE 41-3

Performing a capillary puncture

Task Perform a capillary puncture. Conditions Gauze Alcohol cleansing pad Adhesive bandage or surgical tape Lancets Microcollection tubes or capillary tubes Biohazard sharps container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform a capillary puncture. Performance Standards 1. Examine the requisition slip to identify the tests ordered and, therefore, to select the proper tubes to use. 2. Greet the patient and ask him to state his full name and date of birth to avoid rendering the sample unacceptable due to patient misidentication. Check pretest requirements, such as fasting, nonfasting, and medication restrictions to avoid rendering the sample unacceptable because of failure to adhere to pretesting specications. 3. Reassure the patient and explain the procedure. 4. Select the correct equipment and tubes for the procedure. 5. Wash your hands and put on gloves. 6. Select the puncture site. 7. Warm the puncture site if necessary to increase blood ow to the area and promote bleeding from the puncture site. 8. Clean the site and allow it to air dry. Cleaning should be done in a circular motion starting from the inside and moving away from the puncture site to allow the site to dry, because a wet injection site can cause a stinging sensation and contaminate the sample, leading to inaccurate test results. 9. Assemble the equipment. Position within reach all items that will be used during the procedure. 10. Perform the puncture using the proper lancet. 11. Wipe away the rst drop of blood to avoid contaminating the sample, because the rst drop of blood is diluted with tissue uid and, possibly, alcohol, both of which could interfere with testing. 12. Collect the sample using the proper collection tubes. 13. Mix the sample if necessary. 14. If you must do point-of-care testing, perform the test according to the manufacturers specications. 15. Apply pressure to the site. Examine the site for bleeding and bandage it according to your facilitys policy, because some health care facilities do not allow adhesive bandages to be applied to babies or children. 16. Dispose of the puncture device in a biohazard sharps container. 17. Label the sample. 18. Remove your gloves and dispose of them properly. 19. Wash your hands. 20. Document the procedure in the patients chart.
Date 10/04/08; 9:45 a.m. Hemoglobin determination performed via capillary puncture. ---------------------------------------- S. Gonzales, CMA

Special Phlebotomy Considerations

The medical assistant may encounter difcult situations while performing a venipuncture or a capillary puncture. She must be aware of such situations in order to prevent them or handle them properly as they happen. Such situations may include fainting and failing to obtain blood. In addition, the medical assistant may have to eld calls from outside laboratories regarding problems with a specimen that her ofce submitted to the laboratory for analysis.

Fainting
When performing venipuncture or capillary puncture, the medical assistant may encounter a patient who faints. A

patient may faint at the sight of the needle or blood or after the blood collection procedure. Symptoms a person may exhibit prior to fainting include becoming pale, sweating, and feeling dizzy or lightheaded. As part of the initial patient questioning, the medical assistant should ask the patient if he has ever had adverse affects to needles or his blood being drawn. If he has, the medical assistant should request that the patient lie down on an examination table while she is drawing his blood. If the patient faints while the blood is being drawn, the medical assistant should pull the needle out immediately and help the patient lie down. Applying a cold compress to his forehead or the back of his neck may help him. She should keep smelling salts handy to help awaken the patient. She should never allow the patient to leave the ofce if she feels he is in danger of fainting again.

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887

Failing to Obtain Blood

Another challenging situation when performing venipuncture is the failure to obtain blood. There are many reasons why blood may not be obtainable, including:

Chapter Summary

missing the vein with the needle vein rolling away from the needle vein collapsing needle going through the vein.

Whatever the reason, the medical assistant should try again. However, if the second attempt is unsuccessful, she should ask another member of the health care team for assistance. In any event, the patient always has the right to refuse to have blood drawn again. If the patient does refuse, tell the physician immediately and document the occurrence in the patients chart.

Major components of blood include formed elements, such as erythrocytes, leukocytes, and platelets. Substances found in plasma include hormones, glucose, cholesterol, calcium, electrolytes, and brinogen. Selection of the proper site and equipment is essential when performing a venipuncture or capillary puncture. Tube selection is based on the tests ordered and the type of sample required for testing. Needle selection is based on the size and depth of the patients vein. Pretesting criteria must be met by the patient before blood can be drawn.

Dealing with Problem Specimens

A hospital or reference laboratory may contact a physicians ofce regarding problems with a specimen. (See Taking phone calls from an outside laboratory.) They may even reject the specimen outright. The major reasons for specimen rejection include:

Team Work Exercises

1. Divide into teams of two to three persons. Each group should select a type of safety needle currently in use (or your instructor will assign each group a type). Research the assigned type. Discuss the advantages and disadvantages of your type and present the information to the class. 2. Divide into teams of two to three persons. Practice applying a tourniquet to each others arm. The person who is having the tourniquet applied should tell the student if it is too tight, too loose, or not positioned correctly. After the tourniquet is applied, take turns palpating the veins, pointing out the median cephalic, basilic, and cephalic veins.

unlabeled or mislabeled sample inadequate volume collection in the wrong tube grossly hemolyzed sample clotted blood in an anticoagulant tube improper handling during transport, such as not chilling the sample and not protecting it from light samples without a requisition slip contaminated specimen containers.

Case Studies
1. Tim is a medical assistant working as a phlebotomist in a hospital laboratory. He is sent to the emergency room to collect an EDTA sample for a STAT hemoglobin and hematocrit (H&H). He properly identies the patient and is in the process of lling the lavender-top tube when an ER nurse tells him that the ER physician wants to add coagulation studies to the test order. He nishes lling the lavender top tube and grabs a light blue-top tube. After completing the draw, he takes the sample to the laboratory for immediate processing. a. Which one of the samples collected is compromised and why? b. How could this situation be avoided? 2. Rachel, a medical assistant working in a family medicine practice, is asked to collect a complete blood count (CBC) on a 2-year-old patient. Neither arm has a palpable vein, so Rachel decides to perform a skin puncture on the middle nger of the childs right hand. She has not performed many skin punctures. Although the child is uncooperative, Rachel is able to puncture the site. However, the blood did not form a rounded drop. Instead, the

Front ofceBack ofce connection

Taking Phone Calls from an Outside Laboratory

The front ofce medical assistant may eld calls from the outside laboratory the ofce uses for patients blood specimens. The laboratory may call the medical ofce because incorrect blood tubes were drawn. Because the laboratory cannot process the tubes that were drawn, the front ofce medical assistant must notify the physician of the delay in results, let the clinical medical assistant know of the error, and call the patient to return to the ofce or medical laboratory to get his blood tests redrawn.

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blood runs down the childs nger. The child keeps pulling away and Rachel has to grab and squeeze the nger forcefully. Rachel is able to ll the container to the minimum level. When the sample is tested, the platelet count is low. What factors may have contributed to this result and why?

Resources

American Society of Phlebotomy Technicians (ASPT): www.aspt.org Becton, Dickinson and Company: www.bd.com National Phlebotomy Association (NPA): www .nationalphlebotomy.org Strasinger, S.K., and Di Lorenzo, M.S.: The Phlebotomy Workbook, 2nd ed. Philadelphia: F.A. Davis Company, 2003.

American Society for Clinical Laboratory Science (ASCLS): www.ascls.org American Society for Clinical Pathology (ASCP): www.ascp.org

CHAPTER

Hematology and Coagulation Procedures

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary list the components and functions of blood list the tests included in a complete blood count describe the different cellular elements and their roles describe the components of hemoglobin and hematocrit and their functions describe the different leukocytes and their functions state the normal range for the different hematological tests state the importance of a differential cell count list the tests associated with a coagulation determination describe the importance of knowing the patients International Normalized Ratio in relation to prothrombin time.

42
Whole Blood, Plasma, and Serum
Whole Blood Plasma Serum

CAAHEP Competencies
Clinical Competencies Diagnostic Testing
CLIA-waived tests Perform hematology testing

Blood Cells and Their Functions

RBCs WBCs Granulocytes Agranulocytes Platelets

General Competencies Operational Functions

Use methods of quality control

ABHES Competencies
Clinical Duties
Use quality control Collect and process specimens Perform hematology testing

Tests and Procedures Associated with Hematology

Hemoglobin and Hematocrit Complete Blood Count CLIA-Waived Hematological Tests Other Hematology Department Tests Diseases Associated with Hematology Tests

Procedures
Measuring hemoglobin using the hemoCue analyzer Measuring hematocrit using a microhematocrit centrifuge Measuring prothrombin time using a CLIA-waived analyzer

Tests and Procedures Associated with Coagulation

Other Coagulation Department Tests Diseases Associated with Coagulation

Chapter Outline
Hematology and Coagulation Overview

Chapter Summary Team Work Exercises Case Studies Resources

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Key Terms
anemia

Condition marked by a decrease in the number of red blood cells or the amount of hemoglobin
coagulation

Hematology and Coagulation Overview

Hematology is the study of the formed or cellular elements of the blood. Hematology testing includes the morphologic appearance and function of blood cells as well as diseases associated with blood and blood-forming tissues. Through the interpretation of various hematological results, a physician is able to diagnose such disorders as anemia and infection. Coagulation is usually a subsection of the hematology department that evaluates the overall process of hemostasis, which is the blood clotting process. Medical assistants should have an understanding of the many tests performed in the hematology and coagulation departments of the clinical laboratory because they may be required to review patient results and refer them to the appropriate health care professional.

Subsection of the hematology department within the clinical laboratory

brinolysis

Breakdown of a brin clot

hematology

Study of blood and blood-forming tissues

hemoglobin

Iron-containing protein found in red blood cells that is responsible for transporting oxygen to cells and carbon dioxide to the lungs
hematocrit

Volume of packed red blood cells

hematopoiesis

Process of blood formation

hemostasis

Blood clotting process

leukocytosis

Whole Blood, Plasma, and Serum

Blood is responsible for transporting nutrients, gases, medications, wastes, and other substances throughout the entire body. The average adult body contains approximately 5 to 6 L of blood. Depending on the collection method, a blood sample can be in the form of:

Abnormal increase in circulatory white blood cells

leukemia

Marked increase in the number of abnormal or immature white blood cells in bone marrow and circulating blood
leukopenia

Abnormal decrease in circulatory white blood cells

macrophage

Type of white blood cell that destroys cellular debris and foreign invaders within tissues and organs
phagocytosis

whole blood plasma serum.

Process in which specialized white blood cells (phagocytes) engulf and destroy microorganisms, foreign antigens, and cellular debris
plasma

Whole Blood
Whole blood is a mixture of blood cells and plasma. Whole blood is obtained by using a collection tube with an anticoagulant to prevent blood clotting. Most tests performed in the hematology section of the laboratory require whole blood.

Liquid portion of blood that contains clotting factors

polycythemia

Abnormal increase in the amount of red blood cells

prothrombin time

Plasma
The liquid portion of blood is called plasma. Plasma is obtained when a tube of whole blood undergoes centrifugation. Upon centrifugation, the blood in the tube will separate into three layers; plasma is the first layer. Similarly, if a tube of whole blood is left to stand in a test tube rack, the contents of the tube will settle into different layers. (For more information on these layers, see Chapter 41, Phlebotomy, page 867.) Plasma is clear and straw-yellow in color. It consists of 90% water and 10% solutes and makes up approximately 55% of the bodys total blood volume. Substances found in plasma include hormones, nutrients, and plasma proteins. Plasma also contains the bloods clotting factors.

Blood test that determines how long it takes for blood to clot and that monitors warfarin (Coumadin) therapy
serum

Liquid portion of blood that does not contain clotting factors

thrombocytopenia

Abnormal decrease in platelets

whole blood

Mixture of blood cells and plasma

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Serum
Blood that is allowed to clot and then centrifuged is called serum. Serum, a clear yellow uid that results from centrifuging clotted blood, is the most commonly used specimen in the clinical chemistry department. Serum contains such substances as nutrients, hormones, and antibodies but does not contain clotting factors. (See Figure 42-1.)

nutrients, blood assists in regulating body temperature, acidbase balance, uid and electrolyte balance, and hemostasis. Blood cells, or formed elements, constitute 45% of the total volume of blood. These cells include:

red blood cells (RBCs), or erythrocytes, which make up 99% of total blood volume white blood cells (WBCs), or leukocytes platelets, or thrombocytes, which, combined with WBCs, constitute the other 1% of blood volume. (See Figure 42-2.)

Blood Cells and Their Functions

Blood is the bodys main uid. It functions to transport gases (such as oxygen from the lungs to the tissues and carbon dioxide from the tissues to the lungs), antibodies and white blood cells (for defense against pathogenic microorganisms), nutrients (such as glucose and vitamins), and waste products (such as urea). In addition to transporting

Hematopoiesis, or the process of blood formation, occurs in bone marrow. In the bone marrow, all blood cells go A

FIG 42-1 The lavender top tube shows plasma and the SST (gold top) tube shows serum.

FIG 42-2 Blood cell types. (A) Red blood cells. (B) White blood cells. (C) Platelets.

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through a maturation process before being released into the bloodstream. Normally, the bone marrow releases only mature, functional blood cells into the circulating bloodstream. Thus, release of immature blood cells into the bloodstream could indicate a hematological disorder or a reaction to a severe infection or hemorrhage.

particularly bacteria. Their granules are purple in color and they contain a segmented nucleus. They are also known as segmenters or polymorphonuclearcytes because of their segmented nucleus. An increase in neutrophils is commonly seen in bacterial infections. The normal range for neutrophils is 40% to 60%.

RBCs
Red blood cells (RBCs) contain the protein hemoglobin, an iron-containing protein. Hemoglobin is responsible for transporting oxygen and carbon dioxide. Oxygen molecules attach to the hemoglobin on the RBC and are transported throughout the body. RBCs are formed in the bone marrow and, once mature, are released into the bloodstream. The normal life span for an RBC is 120 days. Old RBCs are destroyed by macrophages, which are known as tissue cells because they are a type of WBC that leaves the bloodstream and resides in the bodys organs and tissues. Macrophages that reside in the spleen and liver are responsible for destroying cellular debris such as old red blood cells. Low levels of RBCs in a patient could indicate a loss of blood, which may be due to trauma or a chronic condition. RBCs also contain the blood group antigens. These antigens are located on the surface of the cell and determine a persons blood type. (See Chapter 43, Clinical Chemistry and Serological Procedures, page 903, for more information on blood typing.)

Eosinophils
Eosinophils assists with the inammatory response by releasing histamine and they are also phagocytic. The number of these cells increases during allergic reactions, skin infections, and parasitic infections. Their granules are bright orange-pink in color. Eosinophils are rarely seen in a patients blood; thus, their normal range is 0% to 4%.

Basophils
Basophils are the least common of all types of WBC. They assist with the inammatory response by releasing histamines and are also phagocytic. They also release heparin to prevent abnormal blood clotting. Their granules are very dark blue-purple in color. Like eosinophils, basophils are rarely seen in a patients blood and have a normal range of 0% to 1%.

Agranulocytes
There are two types of agranulocytes:

lymphocytes monocytes.

WBCs
White blood cells (WBCs) are responsible for ghting off infection. They do so by producing antibodies or through a process in which specialized white blood cells (phagocytes) engulf and destroy microorganisms, foreign antigens, and cellular debris or other foreign substances. Produced in the bone marrow, the life span of a WBC ranges from 1 day to 1 year, depending on the type. An increase or decrease in the WBC count can indicate a wide range of diseases and conditions. WBCs are classied as granulocytes or agranulocytes. Granulocytes contain granules in their cytoplasm; agranulocytes do not. In addition, granulocytes contain smaller, segmented nuclei, and agranulocytes contain very large nuclei. Within these two classications, there are ve types of leukocytes.

Lymphocytes
Lymphocytes are the second most numerous type of WBC and are responsible for producing antibodies. Lymphocyte levels increase during viral infections such as infectious mononucleosis. Lymphocytes can be further differentiated into B-cell lymphocytes (which produce antibodies) and T-cell lymphocytes (which aid the immune system.) Lymphocytes have a large, round, bluish-purple nucleus that tends to take up the entire cell. The normal range for lymphocytes in the blood is 20% to 40%.

Monocytes
Monocytes are the largest circulating WBC. They are responsible for phagocytosis and are effective against chronic infection such as tuberculosis (TB). A monocyte is a large cell that contains vacuoles, or holes, in its cytoplasm and has a large, blue, slightly indented nucleus. The monocyte quickly leaves the bloodstream and travels to tissues (where it becomes a macrophage) to aid in phagocytosis within the tissues. The normal range for monocytes is 3% to 8%. (See Figure 42-3.)

Granulocytes
There are three types of granulocytes:

neutrophils eosinophils basophils

Neutrophils
Neutrophils are the most numerous of the types of WBC and are responsible for phagocytosis of pathogens,

Platelets
Platelets are small, irregularly shaped disks that are fragments of a larger cell called a megakaryocyte, which is formed

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893

Common hematology and coagulation tests

The following table lists common hematology and coagulation tests along with their normal values.

Test
Red blood cells (RBCs) Male Female

Normal Range
4.7 to 6.1 microliter 4.2 to 5.4 microliter 106 cells/ 106 cells/

FIG 42-3 White blood cells. (A) Neutrophils. (B) Eosinophils. (C) Basophils. (D) Lymphocytes. (E) Monocytes.

Hemoglobin (Hgb) Male Female 14.0 to 18.0 g/dl 12 to 16 g/dl

in the bone marrow. A platelets life span is 9 to 12 days. Platelets are responsible for blood clotting and are important in all stages of the coagulation process. An increase in platelet count can cause a person to suffer from a blood clot; a decrease could hinder the ability to stop bleeding from a minor cut.

Hematocrit (HCT) Male Female WBC (total) Differential Neutrophils Lymphocytes Monocytes 40% to 60% 20% to 40% 3% to 8% 0% to 4% 0% to 1% 130,000 to 400,000/microliter 42% to 52% 37% to 47% 4.8 to 10.8 103

Tests and Procedures Associated with Hematology

Tests and procedures associated with hematology include a hemoglobin and hematocrit test (H&H), complete blood count (CBC), erythrocyte sedimentation rate, and reticulocyte count.

Eosinophils Basophils Platelets Erythrocyte sedimentation rate (ESR) Male Female Prothrombin time (PT)

15 mm/hr 20 mm/hr

11.0 to 14.5 seconds 24 to 36 seconds

Hemoglobin and Hematocrit

Hemoglobin (Hgb) and hematocrit (HCT) values, also known as H&H, are important indicators of the RBCs ability to carry oxygen. Hematocrit is the percentage of the volume occupied by RBCs compared to the volume of whole blood. (See Common hematology and coagulation tests.) The H&H and RBC count tests are commonly performed together and the physician evaluates them to determine if a patient is anemic or is suffering from a severe loss of blood. Patient results that the analyzer flags as critical values must receive immediate attention from the medical assistant, who should notify the physician without delay. (See Reporting critical values, page 894.)

Partial thromboplastin time (PTT) International Normalized Ratio (INR) Bleeding time

2.0 to 3.0

Up to 10 minutes

Complete Blood Count

The most commonly ordered hematological test is the complete blood count (CBC). A CBC can be considered a

panel because it is composed of numerous individual blood counts, calculations, and microscopic evaluations of blood cells. However, other than an H&H, a physician would rarely order one test within the CBC, because the hematological instruments used to perform a CBC will not test just one component. When the instrument tests the blood specimen, it will perform a test for and report on all of the components within the CBC. In the case where an H&H is ordered, the technologist will make sure to report only

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Front ofceBack ofce connection

Blood cell indices

Blood cell indices are calculations used to determine the average size of red blood cells as well as the amount of hemoglobin present in the average red blood cell. The RBC count and H&H determine total amounts of cells and hemoglobin present in the blood, but the blood indices provide a better picture of such characteristics as the volume and weight of RBCs. These results help the physician understand the potential causes of a patients anemia and, thus, better assess his condition and prescribe treatment. Blood cell indices include: mean corpuscular hemoglobin (MCH), which measures the average amount of hemoglobin within RBCs mean corpuscular hemoglobin concentration (MCHC), which measures the concentration of hemoglobin in an average red blood cell and compares it with the size of the cell. mean corpuscular volume (MCV), which measures the size of RBCs red cell distribution width (RDW), which measures the variations in size of RBCs.

Reporting Critical Values

The administrative medical assistant working in the front ofce may frequently receive laboratory results for a patient. A critical value, one that is out of the normal range, may indicate a threat to a patients health. Thus, it is important for the administrative medical assistant as much as the clinical medical assistant to know the normal ranges for values. For example, if an administrative medical assistant receives results of a patients complete blood count (CBC) that reveal a white blood cell (WBC) count below 4.0 or higher than 13.0, she must know that such a result may indicate a critical condition for the patient. Hemoglobin levels below 11 g/dl or hematocrit above 35% may indicate blood loss and possibly the need for a blood transfusion. Any of these results would require immediate attention from the physician. The administrative medical assistant should be able to recognize these abnormal results and respond appropriately based on the procedure set by the ofce.

the H&H results from the CBC. Components of a CBC include:

WBC count, which measures the number of circulating WBCs RBC count, which measures the number of circulating RBCs hemoglobin (Hgb), which measures the oxygen-carrying capacity of RBCs hematocrit (HCT), which measures the volume of packed RBCs blood cell indices, which provide additional information on RBCs (See Blood cell indices.) platelet count, which measures the number of platelets in the circulating blood differential count, which measures the percentage of different types of WBCs (neutrophils, eosinophils, basophils, lymphocytes, and monocytes) and evaluates the size, shape, and appearance of WBCs, RBCs, and platelets. (See CBC with differential.)

CLIA-Waived Hematological Tests

Although a clinical laboratory will use an automated hematology analyzer to perform a CBC, a POL may use less sophisticated technology to obtain some hematological results. A medical assistant may perform CLIA-waived hematological tests in the physicians ofce. Tests such as hemoglobin and hematocrit measurements are quick, easy procedures to perform and are convenient for the patient. Many ofces use the

HemoCue B-Hemoglobin Test System to test a patients hemoglobin. The test system consists of the B-Hemoglobin Analyzer and disposable microcuvettes. (See Figure 42-4.) Results are measured in 1 minute and require a drop of blood from a dermal puncture. (See Procedure 42-1: Measuring hemoglobin using the HemoCue analyzer, page 896.) The hematocrit test is another test commonly performed in the POL and is used to evaluate anemia, blood loss, hemolytic anemia, and polycythemia. This test requires a special microhematocrit centrifuge and heparinized capillary collection tubes. (See Figure 42-5.) The medical assistant must prepare the patient for a capillary puncture and blood collection and ll as required two heparinized capillary tubes. Upon sealing each tube, she processes the tubes in the microhematocrit centrifuge and then determines the percentage of packed RBCs that are contained in the centrifuge tubes. The hematocrit result is expressed as a percentage. (See Procedure 42-2: Measuring hematocrit using a microhematocrit centrifuge, pages 897 and 898.) Although the medical assistant can perform a hemoglobin and hematocrit test in a POL, in ofces that do not perform these tests, the medical assistant may be required to draw blood from a patient and send the specimen to a hospital or reference laboratory for testing. The medical assistant should know not only which tube to draw for the specimen (lavender) but should also be familiar with the testing abbreviations used on the various laboratory requisitions forms. (See Understanding hematological abbreviations, page 898.)

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Hematology and Coagulation Procedures

895

CBC with differential

On some laboratory requisition slips, the complete blood count (CBC) order may say CBC w/Diff (differential), rather than just CBC. This phrasing is a holdover from the past, before more advanced hematology analyzers were available. Back then, the differential was always a manually performed part of the complete blood count and some laboratories considered the differential to be a separate procedure. In the past, when a CBC was ordered the technologist would put the blood tube through the hematology analyzer for the cell counts. The hematology technologist would then take a drop of blood and smear it onto a microscope slide, let it dry, and then stain the slide with Wrights stain. Then the technologist would look at the smear under the microscope and count the rst 100 white blood cells observed. As she counted, she would identify, or differentiate, each type. For example, if she identified 34 neutrophils, 61 lymphocytes, 3 monocytes, and 2 eosinophils out of the rst 100 white blood cells seen, she would report out 34% neutrophils, 61% lymphocytes, 3% monocytes, 2% eosinophils. She would then inspect the red blood cells and platelets for their size, shape, and appearance and report her visual ndings. The completed CBC report would include the automated cell counts as well as the manual differential results. Hematology analyzers today are capable of performing the differential. Thus, unless the analyzer ags a result that requires a subsequent manual differential, the entire CBC testing is done automatically.

PATIENT LABORATORY REPORT HARTELL MEMORIAL HOSPITAL LABORATORY Name: Seth Banas M/R#: 032608 D.O.B.: 05/02/63 45 Physician: Greer, R. Location: Outpatient Sex: M Date ordered: 08/30/2008 Date collected: 08/30/2008 Time collected: 0 Date tested: 08/30/2008 Time tester: 21:41 Accession Number: 0007413225

HEMATOLOGY Electrolytes WBC RBC Hemoglobin Hemotocrit MCV MCH MCHC RDW PLT CT MPV Differential Neutrophils Lymphocytes Monocytes Eosinophils Basophils ABS NEU CT Manual diff RBC morph

<<<<<<<<<<COMPLETE BLOOD COUNT>>>>>>>>>> Result 6.0 5.0 14.4 42.3 85 29 34.0 11 237 10 61 28 8 2 1 4 Not indicated Not indicated Reference 3.80-10.80 4.70-6.10 14-18 42-52 77-104 27-34 31-37 11-16 150-400 6-14 44-80 14-44 4-12 0-5 0-2 Units 10^3 10^6 g/dl % FL PG g/dl % 10^3 FL % % % % %

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FIG 42-4 HemoCue test system.

PROCEDURE 42-1

Measuring hemoglobin using the HemoCue analyzer

Task Measure hemoglobin using the HemoCue analyzer. Conditions HemoCue analyzer Calibrator cuvette Quality control sample Testing cuvettes Lancet Alcohol preparation Gauze Gloves Manufacturers manual Biohazard waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure hemoglobin using a HemoCue analyzer. Performance Standards 1. Wash or sanitize your hands and put on gloves and other personal protective equipment (PPE) as designated by your facility. 2. Assemble the supplies. 3. To ensure proper functioning, calibrate the analyzer by putting the calibrator cuvette into the machine. 4. Perform the necessary quality control procedures and record the results. You must run quality control to ensure accurate results and achieve results within the normal range prior to patient testing. 5. Greet and identify your patient and introduce yourself. Explain the procedure. 6. Perform a capillary puncture on the patient using the proper procedure. 7. Using a testing cuvette, collect the appropriate specimen from the capillary puncture. 8. Wipe off the end of the cuvette in the proper manner to avoid erroneous results. 9. Placed the cuvette in the machine. 10. Read the results. 11. Record the results in the patients chart.
Date 05/26/08; 9:45 a.m. Hgb: 13.4 g/dl. --------------------------------- S. Gonzales, CMA

12. Dispose of the cuvette in the biohazard waste container. 13. Disinfect the equipment if indicated to avoid erroneous results from a dirty or contaminated machine. 14. Dispose of the gloves and wash or sanitize your hands.

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Reading guide

Microhematocrit centrifuge

Heparinized collection tubes FIG 42-5 Microhematocrit centrifuge, heparinized collection tubes, and reading guide.

PROCEDURE 42-2

Measuring hematocrit using a microhematocrit centrifuge

Task Measuring hematocrit using a microhematocrit centrifuge. Conditions Microhematocrit centrifuge Heparinized capillary tubes Lancet Gloves Hematocrit reader grid Sealing clay Alcohol preparation Gauze Biohazard sharps container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure hematocrit. Performance Standards 1. Wash or sanitize your hands and put on gloves and other personal protective equipment (PPE) as designated by your facility. 2. Assemble the supplies. 3. Greet and identify your patient and introduce yourself. Explain the procedure. 4. Perform a capillary puncture on the patient using the proper procedure. 5. Collect the appropriate specimen from the capillary puncture using the heparinized capillary tubes. Using nonheparinized capillary tubes will cause the specimen to clot and render the test inaccurate. 6. Fill both tubes as required. Two tubes are required to balance the centrifuge correctly and to ensure a sufcient sample if one tube breaks during the procedure. 8. Seal both tubes by gently pushing the end of one tube into the clay two to three times. Unsealed tubes will cause the blood to leak out of the tube and render the specimen unacceptable. 9. Place both tubes in the microhematocrit centrifuge, making sure the tubes are placed directly across from each other (also called balanced). Unbalanced tubes will cause the tubes to break upon centrifugation, rendering the test unacceptable.

Continued

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PROCEDURE 42-2contd

10. Secure the cover to the centrifuge to avoid tube breakage and start the centrifuge timer for the desired time as indicated by the manufacturers or your instructors specications. 11. Listen for the timer to go off. Allow the centrifuge to come to a complete stop before opening it. 12. Inspect the tubes, making sure they are intact and not broken. 13. Read the results. Depending on the type of microhematocrit centrifuge, the cover may have the reading grid on it or you may have to use a handheld hematocrit reader grid. 14. Dispose of both capillary tubes in a biohazard waste container.

15. Record the results in the patients chart.

Date 10/26/08; 2:32 p.m. Performed microhematocrit: 43% ------- S. Gonzales, CMA

16. Disinfect the centrifuge if indicated. A dirty or contaminated centrifuge can cause unnecessary exposure to biohazardous material. 17. Dispose of the gloves and wash or sanitize your hands.

Front ofceBack ofce connection

CBC and H&H, two other tests related to hematology include:

Understanding Hematological Abbreviations

There are many times when someone from the clinical laboratory will call the ofce to give a CBC result. Some of the terminology used when giving that report may be different or abbreviated from what is actually written on a report form. Although the clinical medical assistant may be more familiar with such terminology because she is using it every day in the POL, it is also important for the administrative medical assistant to recognize standard hematological abbreviations so that she can understand certain tests or test results. Here are some common hematology abbreviations used in the POL: basobasophil diffdifferential count eoseosinophil lymphlymphocyte monomonocyte pltplatelet seg or polyneutrophil

erythrocyte sedimentation rate (ESR), which determines the rate of red blood cell sedimentation and is usually ordered as a screening test to determine nonspecic inammation reticulocyte count (also called retic count), which evaluates the ability of the bone marrow to produce and release red blood cells into the bloodstream and, if abnormally increased, could indicate such conditions as hemolytic anemia or a problem with the bone marrow.

Diseases Associated with Hematology Tests

The medical assistant will see patients with many different diseases and conditions. Understanding these conditions will allow the medical assistant to better relate the tests used to diagnose and treat such conditions. Here are some common diseases diagnosed using hematology tests:

Other Hematology Department Tests

For hematology tests that may not be performed in a POL, the medical assistant may be involved in processing blood specimens for such testing or reading the nal laboratory results received by the ofce. The medical assistant should familiarize herself with the most common hematology tests in order to facilitate better patient care. In addition to the

anemia, which is characterized by a decrease in the number of red blood cells or in the amount of hemoglobin in the circulating blood and includes sickle cell anemia and iron deciency anemia leukemia, which is a marked increase in the number of abnormal or immature white blood cells in the bone marrow and the circulating blood and can be classied by the type of white blood cell affected, such as chronic lymphocytic leukemia (CLL), which affects the patients lymphocytes, and chronic myelogenous leukemia (CML), which affects the monocyte blood cell (See Managing a patients treatment.) polycythemia, which is a rare disorder of unknown cause that involves an excess of red blood cells in the circulating blood and causes the blood to have a viscous consistency

CHAP TER 42

Hematology and Coagulation Procedures

899

leukocytosis, which is an abnormal increase in white blood cells and is usually caused by a bacterial infection or dehydration leukopenia, which is an abnormal decrease in the number of white blood cells and can be caused by some medications, failure of the bone marrow to produce enough white blood cells, or chemotherapy thrombocytopenia, which is an abnormal decrease in the amount of circulating platelets characterized by bruising or frequent nosebleeds and can be caused by a decrease in platelet production by the bone marrow or increased platelet destruction from unknown factors.

vessel. The nal stage in the process is brinolysis, when the brin clot eventually breaks down after the blood vessel has healed. Many offices have begun using recently developed CLIA-waived prothrombin instruments in their POLs. (See Figure 42-6.) Patients on warfarin (Coumadin) therapy must undergo frequent blood tests to ensure that the anticoagulation therapy is effective. Now that the medical assistant can perform these tests in the POL, the physician can receive patient results immediately and thus make decisions regarding the effectiveness of the patients therapy without delay. (See Procedure 42-3: Measuring prothrombin time using a CLIA-waived analyzer, page 900.)

Tests and Procedures Associated with Coagulation

The coagulation laboratory is usually a section of the hematology department, but in larger laboratories, coagulation may be a separate department. The coagulation section evaluates the overall process of hemostasis (the process of forming a blood clot), including the function of platelets, blood vessels, coagulation factors, and anticoagulant therapy, such as heparin and warfarin (Coumadin). The process of hemostasis involves several steps. First, collagen released by an injured blood vessel causes circulating platelets to bind with the collagen and then adhere to the site of injury. The platelets form what is known as a platelet plug. Also circulating in the blood are substances known as plasma proteins. These plasma proteins are coagulation factors that become activated upon injury to a blood vessel. The coagulation factors go through a complex series of reactions called pathways. One of the last steps in these pathways consists of a brin clot that combines with the platelet plug to stabilize and strengthen the injured blood

Other Coagulation Department Tests

Even though some additional coagulation tests may not be performed in a POL, a medical assistant may be involved with processing blood specimens for such testing or reading the nal laboratory results received by the ofce. The medical assistant should familiarize herself with the most

Front ofceBack ofce connection

Managing a Patients Treatment

A patient diagnosed with leukemia may need to undergo various procedures, treatments, and laboratory tests. The administrative medical assistant may have to coordinate such appointments for the patient. The medical assistant should keep handy a list of the various facilities to which the patient may be referred. In addition, she should familiarize herself with what these procedures, treatments, and tests may entail so she can answer questions the patient may have regarding the amount of time a certain procedure may take or any specialized patient preparation.
FIG 42-6 CLIA-waived prothrombin time analyzer.

900

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Clinical

PROCEDURE 42-3

Measuring prothrombin time using a CLIA-waived analyzer

Task Measure prothrombin time using a CLIA-waived analyzer. Conditions Prothrombin time analyzer Test strips Lancet Alcohol preparation Gauze Biohazard waste container Gloves Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully measure prothrombin time using a CLIA-waived analyzer. Performance Standards 1. Wash or sanitize your hands and put on gloves and any other personal protective equipment (PPE) as designated by your facility. 2. Assemble the supplies. 3. Greet and identify your patient and introduce yourself. Explain the procedure. 4. Turn the meter on. 5. Insert the test strip into the meter and check the code. The test strip code must match the meter code to ensure accurate results. 6. Perform a capillary puncture on the patient. 7. Apply a large hanging drop of blood to the test strip when prompted by the meter. A sample that is too small will cause erroneous results. 8. Wait for results to appear on the display. 9. Read the results. 10. Record the results correctly in the patients chart.
Date 05/26/08; 9:45 a.m. INR 1.00. ----------------------------------------- S. Gonzales, CMA

11. Dispose of the cuvette in the biohazard waste container. 12. Disinfect the equipment if indicated. A dirty or contaminated machine may cause erroneous results. 13. Dispose of the gloves and wash or sanitize your hands.

common coagulation tests in order to facilitate better patient care. Here are some commonly ordered coagulation tests:

prothrombin time (PT), which determines how long it takes for blood to clot and is used to screen for bleeding abnormalities, evaluate the entire coagulation process, and monitor warfarin (Coumadin) therapy. (See Therapeutic ranges for oral anticoagulant therapy.) International Normalized Ratio (INR), which provides uniform prothrombin time results for physicians in all parts of the country, as recommended by the World Health Organization activated partial thromboplastin time (APTT or PTT), which evaluates the intrinsic system of the coagulation cascades, monitors heparin therapy, and, if prolonged, may indicate disseminated intravascular coagulation (DIC), hemophilia, or cirrhosis bleeding time (BT), which evaluates the function of platelets and, if increased, may indicate decreased level of platelets or decreased platelet function thrombin time (TT), which determines if adequate brinogen is present for normal coagulation and, if prolonged, may indicate the presence of brin degradation products (FDPs) or an increased level of heparin

brin degradation product (FDP), which measure the bodys clot dissolving system and, if increased, may indicate disseminated intravascular coagulation (DIC), primary brinolysis, or pulmonary embolus. D-dimer, which measures abnormal clotting and brinolysis and, if increased, may indicate deep vein thrombosis, pulmonary embolism, DIC, or myocardial infarction brinogen, which determines the amount of brinogen in plasma and indicates the bodys clotting ability and clotting activity in the body.

Diseases Associated with Coagulation

Diseases associated with coagulation include:

disseminated intravascular coagulation (DIC), a severe blood disorder caused by certain cancers, septicemia, blood transfusion reaction, and such complications of pregnancy as eclampsia and abruptio placenta and in which a persons blood coagulates throughout the body, possibly resulting in blood clots, severe bleeding, or death thrombophilic disorder, an inherited disease in which a person is at risk of developing or has developed thrombosis or blood clots that can occur in veins and arteries and cause strokes and heart attacks

CHAP TER 42

Hematology and Coagulation Procedures

901

Therapeutic ranges for oral anticoagulant therapy

The following table shows normal International Normalized Ratio (INR) ranges according to various conditions.

Condition
Treatment of venous thrombosis Treatment of pulmonary embolism Prevention of thrombosis in patients with: atrial brillation myocardial infarction mechanical prosthetic heart valve recurrent systemic embolism

INR
2.0 to 3.0 2.0 to 3.0

c. normal range for the cell type d. diseases or conditions associated with an increase and a decrease of this cell type. 2. The coagulation process is complicated and follows what is known as a cascade or pathway. Your instructor will divide the class into two groups. One group will research the intrinsic pathway of coagulation and the other group will research the extrinsic pathway. After each group has done its research, it will develop a visual representation of its cascade and present it to the class. Discussion of how the two pathways relate to the entire coagulation process should take place as a full class discussion.

2.0 to 3.0 2.0 to 3.0 2.5 to 3.5 2.5 to 3.5

Case Studies
1. Mr. Bomba is on warfarin therapy because of atrial brillation and he goes to your POL for his regular prothrombin time with INR test. Blood was drawn and submitted for processing, and the result came back with prothrombin time of 9.5 and INR of 0.8. What is the interpretation of these results? After alerting Dr. Mahoney of Mr. Bombas results, he asks you to interview the patient. What question(s) are you going to ask of Mr. Bomba? 2. Edna Lorenkiewicz has just been diagnosed with polycythemia vera and, as she leaves the ofce, she seems distraught. Although you have heard of the disease, you do not know much about it but want to educate yourself for the next time Edna comes to the ofce. What type of information will you nd on this disease?

hemophilia, a rare hereditary blood disease usually affecting males more than females in which blood does not clot normally and is characterized by excessive bleeding due to the decrease or lack of a certain blood substance that is responsible for the clotting of blood, known as a clotting factor. (Hemophilia is differentiated into two types based on the deciency of a specic factor. Type A is known as classic hemophilia; type B is known as Christmas disease.)

Resources

Chapter Summary

Hematology is the study of formed elements in the blood. Hematological tests a medical assistant may perform include: CBC, Hgb, HCT, and ESR. Coagulation is the study of the clotting process. Coagulation tests a medical assistant may perform include the CLIA-waived PT test. Diseases associated with hematology include: anemia, leukemia, polycythemia, leukocytosis, leucopenia, and thrombocytopenia Diseases associated with coagulation include: disseminated intravascular coagulation and hemophilia.

American Society for Clinical Pathology: www.ascp.org/ American Society of Hematology: www.hematology.org/ Hematology atlas: www.hematologyatlas.com/principalpage .htm Public resource for clinical laboratory testing: www .labtestsonline.org/ Sacher, R.A., and McPherson, R.A.: Widmanns Clinical Interpretation of Laboratory Tests, 11th ed. Philadelphia: F.A. Davis, 2000. Strasinger, S.K., and Di Lorenzo, M.S.: The Phlebotomy Workbook, 2nd ed. Philadelphia: F.A. Davis, 2003.

Team Work Exercises

1. Divide into groups of two to three students. Your instructor will assign each group a different type of white blood cell. Each group should provide the following information on their assigned cell: a. colored drawing or image (approximately 8" 10" or bigger) of the cell with its correct anatomy b. function of the cell type

CHAPTER

Clinical Chemistry and Serological Procedures

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary explain the basic principles of a blood chemistry test state the proper collection, handling, and processing of specimens state the proper instruction for patient preparation for a fasting blood glucose specimen state the process of quality control and maintenance of a basic chemistry analyzer state the restrictions that must be followed by the patient undergoing a glucose tolerance test understand and explain the desirable ranges for some chemistry panels perform blood chemistry tests using an automated chemistry analyzer explain the antigenantibodies reaction in relation to blood typing explain the principles of ABO and Rh typing understand the basic principles of serological methodologies perform basic serological procedures and accurately interpret results.

43
2-hour postprandial Glucose tolerance test Glucose monitors Lipids Cholesterol Other Chemistry Department Tests Diseases Associated with Chemistry Tests

CAAHEP Competencies
Diagnostic Testing CLIA-Waived Tests
Perform chemistry testing Perform immunology testing

Operational Functions Use Methods of Quality Control

Serology
AntibodyAntigen Reactions Agglutination ELISA Blood Groups and Typing

ABHES Competencies
Clinical Duties
Use quality control Collect and process specimens Perform chemistry testing Perform immunology testing

Common POL Serological Tests

Mononucleosis Testing Rheumatoid Factor HIV Testing Syphilis Testing

Procedures
Performing a blood glucose test and patient education for a glucose monitoring system Performing cholesterol or lipid panel testing Performing a CLIA-waived mono test

Chapter Summary Team Work Exercises Case Studies Resources

Chapter Outline
Testing in the POL Clinical Chemistry
Chemistry Analyzers Specimen Types

Common POL Chemistry Tests

Blood Glucose Testing Fasting blood glucose

903

Key Terms
agglutination

Testing in the POL

Advances in automated chemistry analyzers, the utilization of microsample testing, and the development of specic, rapid, antibody testing have made it possible to perform some basic chemistry and serology tests in the physicians ofce laboratory (POL). Medical assistants should know how to properly handle, maintain, and operate the instruments in the POL as well as perform quality control testing on these instruments. In addition, medical assistants should be aware of the normal ranges for various chemistry analytes and serological results in order to alert the physician to an abnormal or critical laboratory result. (See Know the format.)

Type of antibodyantigen reaction in which a solid antigen clumps with a soluble antibody
analyte

Measurable chemical substance

antibody

Protein produced by B lymphocytes in response to the presence of an antigen

antigen

Substance that, when introduced into the body, elicits an immune response
atherosclerosis

Thickening and hardening of the walls of the arteries; also called arteriosclerosis
methodology

System of principles and procedures used in scientic testing

microsample

Clinical Chemistry
Clinical chemistry is the most automated area of the clinical laboratory. Testing involves the quantitative measurement of a chemical substance, or analyte, in the circulating blood and other body uids. Common measurable blood constituents include glucose, hormones, drugs, and antibodies. The instruments are designed to perform single or multiple tests from a microsample (very small amount) of serum or plasma. The menu of tests available in the POL may not be as varied as in a hospital or reference laboratory. Even so, the medical assistant must have an understanding of all types of chemistry tests that might be ordered for a patient. This knowledge will help the medical assistant better assist the patient and the physician. (See Common blood chemistry tests.)

Very small amount of a specimen

panel

Group of blood tests that evaluates the function of a particular body system; also called prole
photometric reectance

Measurement of the amount of light reected by a specimen

Chemistry Analyzers
The types of chemistry analyzers used in the clinical laboratory have been adapted for the POL. However, they share

Front ofceBack ofce connection

Know the Format

Many hospital and reference laboratories provide the physicians ofce with direct access to laboratory reports via faxes, printers, and, most recently, secure electronic transfer. The administrative medical assistant may be responsible for collecting and reviewing the reports prior to alerting the physician. The administrative medical assistant should familiarize herself with each laboratorys report format, knowing how results are arranged and identifying when a report has a critical or out-of-range (abnormal) value so that she can notify the physician immediately and facilitate proper patient care.

CHAP TER 43

Clinical Chemistry and Serological Procedures

905

Common blood chemistry tests

The following table provides a list of common blood chemistry tests and their normal ranges.

Test
General Chemistry albumin alkaline phosphatase alanine aminotransferase (ALT)* aspartate aminotransferase (AST) ammonia amylase bilirubin, total blood urea nitrogen (BUN) calcium (Ca) cholesterol cortisol creatinine creatine kinase (CK) male Female CK-MB gamma-glutamyl transferase (GGT) glucose (FBS) glycosylated hemoglobin (Hgb A1C) iron (Fe) lactate dehydrogenase (LD) lipase lithium

Normal Range
3.5 to 5.0 g/dl 31 to 97 units/L 10 to 40 units/L 10 to 37 units/L 10 to 65 micromoles/L 25 to 125 units/L 0.1 to 1.0 mg/dl 6 to 19 mg/dl 8.4 to 10.2 mg/dl < 200 mg/dl

Test
General Chemistry magnesium phosphorus prostate-specic antigen (PSA) total protein troponin I uric acid Electrolytes carbon dioxide (CO2) chloride (Cl) potassium (K ) sodium (Na ) Thyroid Panel thyroglobulin thyroid stimulating hormone (TSH) thyroxine (T4) triiodothyronine (T3) uptake

Normal Range
1.6 to 2.6 mg/dl 2.7 to 4.5 mg/dl 0 to 4.0 ng/ml 6.0 to 8.3 g/dl < 1.0 ng/ml 2.6 to 7.2 mg/dl

22.0 to 30.0 mmol/L 101 to 110 mmol/L 3.5 to 5.0 mmol/L 135 to 145 mmol/L

6 to 23 mcg/dl 0.5 to 1.4 mg/dl 38 to 174 units/L 96 to 140 units/L < 4.0 ng/ml 5 to 85 units/L 70 to 110 mg/dl 3.0% to 6.1% 35 to 150 g/dl 91 to 180 units/L 7 to 58 units/L 0.6 to 1.2 mmol/L

0 to 56 mg/ml 0.34 to 5.6 million International Units/ml 6.1 to 12.2 ug/dl 32% to 48.4%

* Formerly known as serum glutamic-pyruvic transaminase (SGPT). Formerly known as serum glutamic-oxaloacetic transaminase (SGOT). Formerly known as LDH. Cholesterol results vary with age, gender, and testing facility.

the same methodology, or system of principles and procedures, used in scientic testing. Blood chemistry analyzers use photometric reectance (measurement of the amount of light reected by a specimen) or photometric absorbance (measurement of the amount of light absorbed by a specimen) for quantitative measurements of analytes in the blood. Many of these analyzers are waived by the Clinical Laboratory Improvement Amendment (CLIA). The medical assistant should familiarize herself with all laboratory equipment and instruments before using them, including the chemistry analyzer. Before operating an analyzer, the medical assistant should read the instruments operating manual provided by the manufacturer completely. Information found in the operating manual includes specimen collection and type, step-by-step operating instructions, quality control measures, troubleshooting information, and preventive maintenance measures. Some manufacturers provide customer support or a maintenance agreement if the

analyzer malfunctions. The medical assistant may be able to call customer support and a technician may be able to run through a series of steps over the phone to x the problem with the instrument.

Specimen Types
Depending on the chemistry analyzer and the analyte being tested in the medical ofce, proper specimen collection should be strictly followed in order to obtain the most accurate results. Some chemistry analyzers measure serum, plasma, and whole blood samples; others measure only serum or plasma. Occasionally, the POL cannot evaluate a specimen and must refer it to a reference laboratory. Such a referral might be necessary because the result was inconclusive or the specimen could not be tested on a POL instrument. In such cases, the medical assistant should refer to the manual provided to collect, store, and transport the appropriate specimen.

906

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Clinical

Common POL Chemistry Tests

Chemistry tests commonly performed in a POL include blood glucose and lipids testing.

the test will be performed. If the patient is to eat a meal and then report to the laboratory 2 hours later, the medical assistant should instruct the patient to eat at least 100 g of carbohydrates and arrive at the laboratory at the appropriate time. (See 100-gram meal.)

Blood Glucose Testing

When carbohydrates are digested, simple sugars, such as glucose, are generated. The glucose travels from the bloodstream to provide energy to the bodys cells and tissues. The body produces two hormones that aid in the regulation of blood glucose levels: insulin and glucagon. Glucagon converts the stored form of glucose (glycogen) into glucose when blood glucose levels become low. In contrast, the pancreas releases insulin to facilitate the transport of glucose from the bloodstream to the tissues and cells, thus lowering blood glucose levels. Blood glucose is one of the most common tests performed in the chemistry department of the laboratory. It is used to detect abnormalities in carbohydrate metabolism. Several collection procedures are used to measure blood glucose, such as fasting blood glucose , 2-hour postprandial blood glucose (2 pp), and glucose tolerance tests (GTT), including a 3-hour GTT to diagnose diabetes mellitus and a 6-hour GTT to diagnose hypoglycemia.

Glucose Tolerance Test

If a patients 2-hour postprandial results are inconclusive or above normal, the physician may order a 3-hour glucose tolerance test (GTT). The GTT assists in the diagnosis of diabetes mellitus. The test measures the bodys ability to metabolize glucose using insulin in response to a glucose load. Ideally, after 3 hours, the patients blood glucose levels should return to the normal fasting range. A physician may order a 6-hour GTT if he suspects the patient has hypoglycemia. A hypoglycemic patients fasting blood sugar dips below the normal 70 to 110 mg/dl. (Because some institutions may consider a range below 70 mg/dl as normal, the medical assistant should take care to check with the testing facility regarding its range of normal values.) The procedure is the same as the 3-hour GTT except the test lasts

Patient Education

Fasting Blood Glucose

Blood glucose is best measured when the patient has been fasting. The medical assistant should advise the patient undergoing a fasting blood glucose (FBG) test, formerly called fasting blood sugar (FBS )test, to refrain from eating or drinking anything (except water) for 12 hours before the test. Although the normal range for fasting blood glucose is 70 to 110 mg/dl, the range can vary depending on the specimen, methodology, and laboratory. If a patients FBG is elevated and the patient has complied with pretesting instructions, the physician may order additional testing, such as a 2-hour postprandial test or a glucose tolerance test.

100-Gram Meal
Here are some examples of meals with 100 g of carbohydrates.

Breakfast
30 g of cereal 1 banana 200 ml of milk 500 ml of orange juice OR 4 slices of toast 1 piece of fruit 6 to 8 oz of yogurt (that does not contain a sugar substitute)

2-hour Postprandial
The 2-hour postprandial (2 pp) glucose test is used as a screening test for diabetes mellitus. The test measures the amount of blood glucose in the bloodstream 2 hours after a patient has ingested a meal. Ideally, blood glucose levels should return to fasting levels within 2 hours after a meal. The normal range for a 2 pp is less than 140 mg/dl. Results of 140 mg/dl or higher may indicate that the patient has diabetes mellitus. Sometimes a physician will order the 2 pp with the patient ingesting a controlled amount of glucose by drinking 100 g of Glucola. It is the medical assistants responsibility to instruct the patient on the manner in which

Lunch
1 large baked potato 200 ml of fruit juice or milk 400 mg of rice or pasta OR 300 g of homemade fruit salad 6 to 8 oz of yogurt (that does not contain a sugar substitute) 500 ml of fruit juice

CHAP TER 43

Clinical Chemistry and Serological Procedures

907

for 6 hours in order to observe a below-normal fasting blood sugar. Patient preparation is essential for a successful GTT. The medical assistant may be responsible for scheduling the test for the patient and should understand how the test is administered as well as the proper patient preparation in order to instruct the patient correctly. (See Instructions for GTT.) On the day of the test, the medical assistant must gather the equipment necessary to conduct a GTT, including the urine specimen containers, the glucose solution the patient will drink, the proper venipuncture tubes (usually gray-stoppered or SST tubes), a timer, and stickers to indicate specimen one, two, and three. (See Figure 43-1.)

Patient Education

Instructions for GTT

When preparing a patient for a 3-hour glucose tolerance test (GTT), be sure to include these instructions: The test is usually ordered for the early morning, such as 7 a.m. The procedure takes approximately 4 hours. Make sure to arrive on time for the test so that the phlebotomist will have the opportunity to prepare for and begin the test before the laboratory becomes busy. Fast for 12 hours. Consume a high-carbohydrate diet 3 days prior to the examination, as ordered. A fasting blood glucose test and a urine glucose test will be done before you ingest the glucose. You must ingest a measured amount of liquid glucose within 5 minutes. You will need to provide multiple blood and urine samples at specic times during the test. Time intervals include: 30 minutes, 1 hour, 2 hours, and 3 hours. Bring a book to read or something else to keep busy during the examination because you may not be able to leave the laboratory. You cannot eat or drink during the testing (although you may be encouraged to drink some water in order to provide the required urine samples). You may experience minor symptoms, such as lightheadedness, dizziness, and nausea, during the examination. It is important to follow instructions exactly, because the test may have to be repeated if you do not comply.

Glucose Monitors
Medical assistants can provide better patient care if they use glucose monitors in the medical ofce. The benets of testing in the ofce include ease, speed, and convenience for the patient. In addition, the physician is provided with immediate results that will aid in assessment and treatment of the patient. There are many glucose monitoring systems available to patients and the POL. The latest monitors require fewer specimens, provide faster results, and can even generate a computer printout. The patient is able to monitor and document her levels and provide her physician with a history of her blood glucose results. Not only is the monitoring convenient but it also provides the patient with an immediate indication of her blood glucose level, which will allow her to know how much insulin she has to take. Several glucose monitoring systems, such as One Touch Ultra (Lifescan), are CLIA-approved and easy to use. (See Figure 43-2.) In addition to testing the patients blood glucose when she comes to the ofce, the medical assistant may be responsible for providing instructions to the patient on the use and maintenance of her personal glucose machine. (See Procedure 43-1: Performing a blood glucose test and patient education

FIG 43-1 Supplies for glucose tolerance test.

for a glucose monitoring system, page 908.) A patient who is newly diagnosed with diabetes may experience various emotions, including denial and anxiety. By explaining the purpose and process of using a glucose monitoring instrument, the medical assistant can help allay the patients fears and empower the patient to take control of her treatment. (See Glucose monitoring tips, page 909.) The medical assistant may also want to discuss with the patient the implications of failing to follow the physicians advice or not complying with proper glucose monitoring. The medical assistant should stress to the patient that, in addition to the daily glucose monitoring he performs, the physician may still require an FBG or a glycosylated hemoglobin test. Long-term blood glucose regulation, and thus

908

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Clinical

effectiveness of treatment and patient compliance, can be objectively assessed by determining a patients glycosylated hemoglobin (Hgb A1c) levels. If a patient with diabetes mellitus has carefully regulated his blood glucose levels over a period of 5 or 6 weeks, his HgbA1c levels will be normal or just slightly above normal. If the patient has had uncontrolled levels during the same time period, his HgbA1c level will be elevated. For a patient who is not regulating his insulin properly, the physician may suggest an insulin pump. The medical assistant should understand how an insulin pump operates and provide patient teaching on its use. (See Insulin pump, page 910.)

Lipids
Lipids are fats or fatlike substances that are insoluble in water. They include fatty acids, waxes, and sterols. Lipids provide an alternative source of energy and, therefore, are essential to the body. Blood lipids that are responsible for cardiovascular disease are classified as lipoproteins. Lipoproteins are fats that are attached to proteins. Examples of blood lipids include cholesterol and triglycerides. Analysis of these levels in the bloodstream can provide information on a patients risk of atherosclerosis and cardiovascular disease.

FIG 43-2 One Touch Ultra glucose monitoring system.

PROCEDURE 43-1

Performing a blood glucose test and patient education for a glucose monitoring system
Task Properly perform a capillary puncture and glucose test and instruct the patient in the care and use of a glucose monitoring system. Conditions Glucose monitoring system Gloves Alcohol wipe Gauze Lancet Adhesive bandage Test strips Glucose control Biohazard disposable container Standards In the time specified and within the scoring parameters determined by the instructor, the student will successfully perform a capillary puncture and glucose testing and instruct the patient in the care and use of a glucose monitoring system. Performance Standards 1. Wash or sanitize your hands and assemble the supplies. 2. Put on gloves. 3. Identify the patient and explain the procedure. 4. Perform quality control measures, including: a. Turn the meter on. b. Check the code number on the display with the code number on the test strip package, making sure they match or inaccurate results may occur. c. Insert the test strip when prompted. d. When APPLY SAMPLE appears, apply one drop of quality control reagent. e. Read the meter for results. f. Check the results against the proper control range, as set by the manufacturer. Quality control results must be in the proper range before patient testing can occur. g. Repeat the process if necessary using additional control reagents, such as high or low values.

CHAP TER 43

Clinical Chemistry and Serological Procedures

909

PROCEDURE 43-1contd

h. Record the results. If you do not document quality control results, there is no proof that you performed them. Notify the instructor if controls are out of range. If quality control results are out of range, you must take corrective action before conducting patient testing. 5. Instruct the patient on how to operate the glucose monitoring system, Topics should include: a. Turning on the monitor b. Display area c. Proper code reading d. Proper testing strips e. Proper cleaning and care. 6. Perform patient testing, including: a. Press the ONOFF button. b. Insert the test strip. c. Prepare the patient for capillary puncture. d. Perform the puncture and wipe away the rst drop of blood to ensure that the testing drop does not include tissue uid, which may alter the

e. f. g.

h.

i.

results. Then apply one drop of blood to the test strip without touching the test strip or smearing the blood to avoid altering test results. Bandage the patients nger. Read the results after hearing the beep. Correctly record the results in the patients chart because proper documentation is key to patient care. Discuss with the patient the physicians orders and any necessary follow-up visits to ensure patient compliance and follow-up. Remove the test strip and discard all biohazard material in the appropriate container.

Date 05/26/08; 9:45 a..m. Provided patient with proper care and operation of glucose monitoring system. Performed FBG. FBG: 86 mg/dl. ------------------------------------------------------------------ S. Gonzales, CMA

Patient Education

Glucose Monitoring Tips

Here are some tips for the medical assistant to follow when educating patients about glucose monitoring. The medical assistant should: have the patient bring in his own monitor, along with the test strips and operating instructions, if possible read the operating manual before testing if she is unfamiliar with the patients monitor show the patient how to turn on the monitor explain how the test strip code must correlate with the code in the monitor and, if the code is different, show the patient how to change the code explain to the patient the importance of running a high, low, and normal control prior to testing his own blood show the patient how to use the automatic puncture device show the various acceptable puncture sites have the patient perform his own puncture and apply the sample to the test strip have the patient read and record his results tell the patient that, if he is on insulin, he may also need to record the time of his meals, keep a diary of food eaten, the times and dosages of insulin, and any exercise undertaken show the patient how to use the memory function to retrieve past results have the patient read troubleshooting and maintenance procedures as described in the operating manual allow the patient time for questions.

Cholesterol
Cholesterol is the main lipid associated with atherosclerotic vascular disease. Atherosclerosis is the general term used to describe thickening and hardening of the walls of the arteries. It is synthesized in the liver and a normal constituent of bile. Cholesterol is also important in metabolism and responsible for the production of steroid hormones. Cholesterol testing is an important tool in helping to identify patients who are at risk for heart disease and is just one component of the lipid panel. A panel, sometimes called a prole, is a group of blood tests that evaluates the function of

910

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Clinical

Patient Education

Insulin Pump
A patient diagnosed with diabetes may be intimidated by the thought of injecting himself with insulin 2 to 4 times each day. For such a patient, an insulin pump offers an alternative to daily insulin injections. Here is some information about insulin pumps that the medical assistant can provide: An insulin pump delivers insulin 24 hours per day. The insulin is delivered through a catheter that is placed under the skin. The patient programs the pump to deliver various amounts of insulin over the course of the day. The pump has a feature that allows the patient to push a button to deliver a bolus or loading dose of insulin, if needed, to treat a high blood glucose level.

excretion. A high HDL cholesterol level shows a reduced risk of heart disease, whereas a low level of HDL cholesterol (less than 35 mg/dl) is a risk factor for coronary artery disease (CAD). LDL is referred to as the bad cholesterol because, in excessive amounts, it can cause plaque to build up in arterial walls. The ingestion of saturated and trans fats can cause LDL levels to increase. A third type of lipoprotein, called very-low-density lipoprotein (VLDL), is composed mostly of cholesterol with little protein. VLDL is also known as bad cholesterol because, like LDL, it deposits cholesterol on the walls of arteries. Increased levels of VLDL are associated with atherosclerosis and CAD.

Lipid Panel
One of the most commonly performed chemistry tests in the POL is the lipid panel. It is very easy to perform, uses a small amount of blood, and provides the physician with an immediate indication of the patients coronary artery health. The lipid panel includes tests of:

Insulin injected through catheter

total cholesterol (TC) HDL LDL VLDL triglycerides TC-to-HDL ratio. (See Normal ranges for the lipid panel.)

Tubing delivers insulin

Insulin pump

A commonly used chemistry analyzer in the POL is the Cholestech LDX. (See Figure 43-3.) The Cholestech can provide cholesterol results or perform an entire lipid panel. Newer versions of the analyzer can also perform blood glucose testing. In the POL, the medical assistant may be responsible for the proper maintenance, quality control, and operation of the analyzer. (See Procedure 43-2: Performing cholesterol or lipid panel testing.)

Insulin pump

Normal ranges for the lipid panel

The table lists the tests included in a lipid panel and the normal ranges for each.

a particular body system. The lipid panel evaluates the health of a patients arteries.

HDL and LDL Cholesterol

There are two types of lipoproteins that contain cholesterol:

Test
Total cholesterol High-density lipoprotein (HDL) Low-density lipoprotein (LDL) Very low-density lipoprotein (VLDL) Triglycerides

Normal Range
< 200 mg/dl 35 to 60 mg/dl < 130 mg/dl 20 to 40 mg/dl 35 to 160 mg/dl

low-density lipoprotein (LDL) high-density lipoprotein (HDL).

HDL, commonly called the good cholesterol, removes excess cholesterol from cells and carries it to the liver for

CHAP TER 43

Clinical Chemistry and Serological Procedures

911

Interpretation of CAD risk

Several factors affect coronary artery disease (CAD), including hypertension, smoking, diabetes, severe obesity, and premature CAD. However, determining CAD risk is done by comparing the total cholesterol (TC) level to the high-density lipoprotein (HDL) level, or the TC-to-HDL ratio. The table shows the TC-to-HDL ratio for men and women.

Risk
Men Half the average risk Average risk 3.4 5.0 9.6 23.4

Ratio
Women 3.3 4.4 7.1 11.0

FIG 43-3 Cholestech LDX instrument.

Two times the average risk Three times the average risk

Patient Preparation
Some physicians prefer the patient to be in a fasting state for any testing. Although total cholesterol and HDL cholesterol determination are not affected signicantly by food consumption, triglyceride levels are affected. Therefore, if a physician orders a lipid panel, the medical assistant should instruct the patient to fast.

Other Chemistry Department Tests

Although there are many chemistry tests that may not be performed in a POL, a medical assistant may be involved with processing blood specimens for such testing or reading the nal laboratory results received by the ofce. The medical assistant should familiarize herself with the most common chemistry tests and panels in order to facilitate better patient care. Some of these tests include:

Interpretation of Results
Cholesterol values vary with gender, age, and the testing facility. Cholesterol levels under 200 mg/dl for adult and elderly patients are desirable. Levels between 200 mg/dl and 239 mg/dl are considered borderline high, and levels of 240 mg/dl and above are high. HDL levels above 60 mg/dl are considered optimal and levels below 35 mg/dl constitute a risk factor for CAD. (See Interpretation of CAD risk.)
PROCEDURE 43-2

renal panel, which assesses kidney function and includes tests for albumin, calcium, carbon dioxide (CO2), chloride, creatinine, glucose, phosphorous, potassium, sodium, and blood urea nitrogen (BUN) electrolyte panel, which assesses acidbase balance and, possibly, hydration status and includes tests for sodium, potassium, CO2, and chloride

Performing cholesterol or lipid panel testing

Task Perform cholesterol or lipid panel testing using a CLIAwaived instrument. Conditions Cholesterol instrument Gloves Alcohol wipe Gauze Lancet Capillary tubes and other supplies as required by manufacturer

Adhesive bandage Test strips Control reagents Calibration cassette Biohazard disposable container

Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform cholesterol or lipid panel testing.

Continued

912

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Clinical

PROCEDURE 43-2contd

Performance Standards 1. Wash or sanitize your hands and assemble supplies. 2. Put on gloves. 3. Identify the patient to ensure accurate results and explain the procedure. 4. Perform quality control measures, including: a. Turn the instrument on, and watch as it performs a self-test. b. Remove the cassette from the pouch without touching the black bar or magnetic strip because touching the magnetic strip may interfere with test results. Place the cassette on a at surface. c. Apply a quality control reagent to the well of the cassette. Place the cassette in the drawer and press the RUN button. d. Read the results after you hear the beep. e. Check the results against the control range, as set by the manufacturer. Quality control results must be in the proper range before any patient testing can occur. f. Repeat the process if necessary using additional control reagents, such as high or low values. g. Record the results because if quality control results are not documented, there is no proof that they were ever performed. Notify the instructor if a control is out of range. If quality control results are out of range, corrective action must take place prior to any patient testing. 5. Perform patient testing steps, including: a. Prepare the patient for capillary puncture. b. Remove the cassette from the pouch without touching the black bar or magnetic strip. Place the cassette on a at surface.

c. Perform the puncture, wipe away the rst drop of blood, and then collect the blood in the capillary tube. d. Apply the sample to the well of the cassette within 5 minutes of collection because blood may coagulate after 5 minutes, which could cause erroneous test results. e. Place the cassette in the drawer and press the RUN button. f. Bandage the patients nger. g. Read the results after hearing the beep. h. Record the results in the patients chart because proper documentation is key to patient care.
Date 12/20/08; 8:45 a..m. Capillary blood tested via Cholestech. Results: 256 mg/dl. Physician referred patient for further laboratory studies. --------------------------------------------------------- S. Gonzales, CMA

i. Talk to the patient about the physicians orders and follow-up. Communication with the patient is vital to patient compliance and follow-up. j. Remove the test strip and discard all biohazard material appropriately. k. Remove the results and wash your hands.

basic metabolic panel, which assesses electrolytes, glucose, and kidney function and includes tests for calcium, CO2, chloride, creatinine, glucose, potassium, sodium, and BUN comprehensive metabolic panel, which assesses various body systems and organs and includes tests for albumin, total bilirubin, calcium, bicarbonate, chloride, creatinine, glucose, alkaline phosphatase, potassium, total protein, sodium, BUN, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) hepatic panel, which assesses liver function and includes tests for ALT, AST, lactate dehydrogenase (LD), gammaglutamyl transferase (GGT), bilirubin, and alkaline phosphatase

thyroid panel, which assesses thyroid function and includes tests for triiodothyronine (T3), thyroxine (T4), thyroid stimulating hormone (TSH), and thyroglobulin cardiac panel, which aids in the diagnosis of myocardial infarction and includes tests for creatine kinase (CK), CK-MB, and troponin.

Diseases Associated with Chemistry Tests

The medical assistant will see patients with many different diseases and conditions. Understanding these conditions will allow the medical assistant to better relate the tests used to diagnose and treat such conditions. Here are some common diseases that are diagnosed using chemistry tests:

CHAP TER 43

Clinical Chemistry and Serological Procedures

913

diabetes mellitus, which is a chronic disorder of carbohydrate metabolism in which there is an inadequate production or use of insulin and demonstrates such symptoms as excessive thirst, excessive urine production, dizziness, loss of coordination, and sweet-smelling breath hypoglycemia, which is an abnormal decrease in blood glucose levels and demonstrates such symptoms as lightheadedness, dizziness, fatigue, and fainting hyperlipedemia, which is an excessive amount of fat in the blood, giving the serum a milky appearance but otherwise is usually asymptomatic hyperthyroidism, which is characterized by increased triiodothyronine (T3) and thyroxine (T4) levels with a possibly normal, increased, or decreased thryoid stimulating hormone (TSH) level and demonstrates such symptoms as palpitations, heat intolerance, nervousness, insomnia, fatigue, weight loss, and hair loss hypothyroidism, which is characterized by decreased T3 and T4 levels with usually increased TSH levels and demonstrates such symptoms as fatigue, weakness, hair loss, dry skin, constipation, intolerance to cold, and irritability.

Antibody

Antigen Antibody-antigen complex

FIG 43-4 Antibody-antigen reaction.

known antigen coated with latex particles. If the suspected antibody is present in the patients serum, it will react with the antigen-coated latex and, upon mixing, will cause a visual clumping reaction. Conversely, if an antigen is suspected in a patients serum, then the specimen would be tested against a known latex-coated antibody. Certain test kits for mononucleosis and rheumatoid arthritis utilize the agglutination method. The advantages of agglutination tests are that they can be performed quickly, are easy to read, and usually contain a positive and negative control for quality control purposes. (See Figure 43-5.)

Serology
Serology is dened as the study of the serum of the blood. Serology testing deals with the study of antigen and antibody reactions. Antigens are substances that are perceived by the body as foreign and are capable of stimulating the production of antibodies. Antibodies are formed from B lymphocytes as a response to the foreign substance (antigen) invading the body. An antigenantibody reaction is formed when the protective antibody seeks out, attacks, and combines with the antigen to destroy it. The medical assistant needs a basic knowledge of the antibodyantigen reaction to understand the serological methodologies of many tests performed in the POL.

ELISA
Many CLIA-waived test kits incorporate the enzymelinked immunosorbent assay (ELISA) method of antibody

AntibodyAntigen Reactions
An antigenantibody reaction can be simulated in the laboratory and thus aid in the diagnosis of certain diseases and conditions. The various methods used in testing include agglutination and enzyme-linked immunosorbent assay. (See Figure 43-4.)

Agglutination
The agglutination method of testing consists of an antibodyantigen reaction in which a solid antigen clumps with a soluble antibody. The most common type of agglutination testing consists of mixing a patients serum with a

FIG 43-5 Agglutination reaction.

914

UNIT 3

Clinical

or antigen detection. A manufacturer develops a test kit to identify a specic analyte in a patients bloodan antibody or an antigen. For example, a kit that tests for the presence of the Streptococcus antigen in a throat specimen would use a known antibody to the Streptococcus organism. The antibody couples with an enzyme as a result of the manufacturing process or during the course of the test. The enzyme helps accelerate the antibodyantigen reaction. When the antibody, enzyme, and patient specimen containing the Streptococcus antigen combine and react, the reaction that is created causes a color change in the testing well. The HIV test and the rapid Streptococcus test both incorporate the ELISA method. (See Figure 43-6.)

Blood type, antigens, and antibodies

The following chart lists the ABO blood types with their associated antigens on the red blood cells and antibodies circulating in the serum.

Blood Type
A B AB O

Antigen
A B A and B None

Antibody
B A None A and B

Blood Groups and Typing

There are four principal blood types, or groups, that a person can possess: A, B, AB, or O. A persons blood type is based on the antigen that is present on the surface of her red blood cells (RBCs). In addition, that person has a noncorresponding antibody in her serum. (See Blood type, antigens, and antibodie.) Knowing a patients blood type is the rst step when that patient needs a blood transfusion. Administering the wrong type of blood could cause a life-threatening reaction. (See Figure 43-7.) Another antigen, known as Rh factor, may also be present on a persons RBCs. People whose red blood cells contain Rh factor are known as Rh-positive (Rh+). Conversely, if people do not have the Rh factor antigen, they are considered Rh-negative (Rh). Although it is important for a

person to know her ABO type, it is equally important, especially for a woman, to know her Rh type as well. (See Rh incompatibility.) Medical assistants do not typically perform blood typing in the POL. However, it is important for medical assistants to understand the procedure and how it works. A simple blood typing procedure involves a capillary puncture to obtain a few drops of blood. The examiner mixes one drop of blood with a commercially prepared anti-serum A and another drop with anti-serum B. Then the examiner observes both mixtures for agglutination. If a patients blood agglutinates with anti-serum A and not with anti-serum B, the patients blood type is A. Conversely, if the patients blood agglutinates with anti-serum B and not with antiserum A, then her blood type is B. A patient whose blood does not agglutinate with either anti-sera has blood type O. To determine a persons Rh status, a drop of the persons blood is mixed with the known anti-serum D (the name given to the commercially prepared Rh anti-serum). If the patients blood agglutinates with anti-serum D, then the person is considered Rh . For example, if a persons blood agglutinates with the anti-serum A and anti-serum D, that persons blood type is A . While simple blood typing is common in the POL, a hospital laboratory would conduct a more complex procedure. Traditionally, hospital laboratories use serum for blood typing and screening procedures. However, use of plasma has become more common. Medical assistants who may work as hospital phlebotomists should become familiar with the facilitys blood bank specimen collection policies and procedures.

Common POL Serological Tests

FIG 43-6 QuickVue In-Line Strep test using the ELISA serological method. (A) Positive. (B) Negative.

There are a variety of serological tests that can be performed in the POL. Most are CLIA-waived and can be performed by the medical assistant. Some serological tests, such as syphilis

CHAP TER 43

Clinical Chemistry and Serological Procedures

915

Blood type A Only A antigen on RBCs

Blood type B Only B antigen on RBCs

Blood type AB Both A and B antigens on RBCs

Blood type O No antigens on RBCs

FIG 43-7 Red blood cell antigens.

testing, should not be performed in the physicians ofce. However, the medical assistant should understand the test and its results. (See Syphilis testing and reporting, page 916.)

Rh incompatibility
If a pregnant womans blood type is Rh-negative and the baby she is carrying happens to be Rh-positive, then the condition of Rh incompatibility could occur. In Rh incompatibility, when the babys blood mixes with the mothers blood during delivery, the mothers body recognizes the Rh protein as a foreign substance and begins producing antibodies (protein molecules in the immune system that recognize and, later, work to destroy foreign substances) against the Rh proteins introduced into her blood. These antibodies that the mother produces are not harmful to her; however, they may be harmful to her fetus during a subsequent pregnancy. If, during the next pregnancy, the mother is carrying an Rh-positive baby, her Rh antibodies will attack the Rh antigen that is on the babys red blood cells (RBCs). The babys RBCs will undergo lysis (destruction), a disorder called hemolytic disease of the newborn (HDN). A physician can prevent HDN by testing a pregnant womans blood for type and Rh factor. If the woman is Rh-negative, the physician can administer a series of two Rh immune-globulin (RhoGAM) shots to the woman at 28 weeks gestation and then again within 72 hours after giving birth. The RhoGAM prevents the mothers antibodies from attacking the babys RBCs if the baby is Rh-positive. A woman who has experienced a miscarriage, abortion, or blood transfusion may also receive RhoGAM because those events put the woman at risk for having been exposed to the Rh-positive antigens from a fetus or blood transfusion.

Mononucleosis Testing
Mononucleosis (typically referred to as mono) is an acute infectious disease commonly seen in children and young adults. It is caused by the Epstein-Barr virus (EBV) and causes such symptoms as a sore throat, fatigue, lymphadenopathy, and splenomegaly. A physician who suspects that a patient has mononucleosis will order a test for mononucleosis, called a mono test, as well as other clinical tests, including a complete blood count (CBC) and liver enzymes. (See Figure 43-8.) Most mononucleosis tests do not specically look for EBV, but instead test for heterophile antibodies, which are sometimes present when a patient is acutely infected with EBV. (See Procedure 43-3: Performing a CLIA-waived mono test, page 916.)

Rheumatoid Factor
Rheumatoid arthritis (RA) is a chronic inammatory disease that usually affects the connective tissue or joints of the body. Symptoms of rheumatoid arthritis include joint stiffness and pain, swelling, and difculty moving. Patients with RA develop an antibody called rheumatoid factor. Rheumatoid factor can be detected in a patients serum during serological testing. (See Figure 43-9.)

HIV Testing
Human immunodeciency virus (HIV) causes acquired immune deciency syndrome (AIDS). Early HIV detection helps the physician choose the best course of treatment to delay the rate at which HIV weakens the immune system. Some early symptoms of HIV infection include fatigue,

916

UNIT 3

Clinical

Front ofceBack ofce connection

Syphilis Testing and Reporting

Syphilis is a sexually transmitted disease caused by the bacterium Treponema pallidum. Symptoms include headache, fever, fatigue, and a chancre at the site of infection. If detected early enough, the infection can be successfully treated with antibiotics.

Syphilis testing
The Venereal Disease Research Laboratory (VDRL) test and the rapid plasma reagin (RPR) test are the most common serological screening tests for syphilis. If either test is positive, then the microhemagglutinationTreponema pallidum (MHA-TP) test is performed to conrm the diagnosis of syphilis.

Reporting results and condentiality

Regardless of where screening tests are performed, the medical assistant must keep positive results condential. When an ofce receives positive results for certain tests, such as human immunodeciency virus or syphilis, the medical ofce must send a report to the local and state Departments of Public Health. It may be the responsibility of the administrative medical assistant to notice such results and to collaborate with the clinical medical assistant in order to complete and submit the required form to the proper agency. It is a good idea to have the phone numbers for the local and state Department of Public Health at hand for easy reference. Usually, the physician will want to meet with the patient to review the results and gather information on the patients sexual history and other pertinent information in order to complete the required forms. When the medical assistant calls the patient to come in for an appointment, she must make sure not to leave any information regarding the results of the tests on the patients answering machine.
FIG 43-8 QuickVue+ mono test kit.

weight loss, fever, malaise, and lymphadenopathy. The ELISA method is widely used by clinical laboratories for initial testing for HIV infection. If the test indicates HIV antibodies are present in a patients serum, the Western blot assay test conrms those results. HIV tests that actually detect the presence of the virus and not the antibody are becoming more common and provide earlier detection of infection. Although typical POLs do not perform the more advanced tests, CLIA-waived HIV tests are available for use in the POL and test for the presence of HIV antibodies in blood or oral specimens. (See Figure 43-10.)

PROCEDURE 43-3

Performing a CLIA-waived mono test

Task Perform a CLIA-waived mono test. Conditions CLIA-waived mono test kit Gloves Lancet Alcohol wipe Gauze

Adhesive bandage Biohazard waste container

Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform a mono test using a capillary blood specimen.

CHAP TER 43

Clinical Chemistry and Serological Procedures

917

PROCEDURE 43-3contd

Performance Standards 1. Assemble supplies and prepare the testing cassette (commonly referred to as a reaction unit). Refer to the manufacturers test procedure directions to familiarize yourself with the proper procedure. 2. Run quality control (QC) according to the manufacturers specications before testing the patient specimen. Record the results on the proper QC chart. Quality control results must be within limits and properly documented or the patient specimen cannot be tested. 3. Greet and identify your patient. Introduce yourself and explain the procedure to prevent errors and ease patient anxiety. 4. Wash or sanitize your hands and apply gloves to ensure infection control. 5. Collect capillary blood from the patients ring or middle nger using the collection capillary tube supplied by the manufacturer. 6. Dispense the patients blood sample to the ADD well of the testing cassette.

7. According to the manufacturers instructions, add the proper number of drops of developer to the ADD well to avoid adding the incorrect amount and rendering the results invalid. 8. Wait 5 minutes (or the amount of time specied by instructions). Underestimating or overestimating the reaction time can render the patient results invalid. 9. Read the test results in the TEST COMPLETE or RESULTS window. Refer to the manufacturers instructions about reading the results. 10. Properly dispose of all supplies and wash your hands to ensure infection control. 11. Chart the procedure to ensure the accuracy of the medical record.

Date 06/11/08; 9:35 a..m. Mono Test performed, results: negative ----------------------------------------------------------------------------------- S. Gonzales, CMA

FIG 43-9 Typical CLIA-waived test kit for rheumatoid factor.

FIG 43-10 CLIA-waived HIV test kit.

918

UNIT 3

Clinical

Chapter Summary

The clinical chemistry department in a hospital or reference laboratory is highly automated and performs a large inventory of tests. Most chemistry tests require a serum specimen, but some POL testing uses plasma. Medical assistants must be aware of normal ranges for each chemistry test result. The most common chemistry tests performed in a POL include glucose, cholesterol, and lipid panel. Medical assistants often provide patient education and instructions for proper blood glucose monitoring. Increased lipids are a common factor in cardiovascular disease. Panels associated with the chemistry department include: renal panel electrolyte panel basic and comprehensive metabolic panels hepatic panel thyroid panel cardiac panel.

Each team will research its assigned test and provide the following information in report format: a. reason for test b. patient education and preparation c. supplies required for testing d. normal and abnormal test results. The instructor may have each group discuss its results with the rest of the class. 2. This chapter discusses the two most common serological testing methods used in the POL. There are various other testing methods used in the clinical laboratory: a. agglutination b. ELISA c. Western blot d. complement xation e. agar gel immunodiffusion test. Divide into groups of 2 to 3 students and research the serological method assigned to you by your instructor and provide the following information to the class: a. description of the method b. difculty of performance (including length of time, elaborate equipment, and training) c. uses of the method (such as specic condition or disease identied with this method).

Case Studies
1. Stephanie performs a lipid prole on Mr. Dean. As required, the patient fasted for 12 hours. Mr. Deans results are: total cholesterol, 185; triglycerides, 210; LDL, 80; HDL, 60. How would you interpret Mr. Deans results? Are they normal or abnormal? Explain. 2. Dr. Burgess examines Jill Raymond, a 16-year-old high school student. She notes that Jill has swollen glands in her neck and splenomegaly. Which tests would you expect Dr. Burgess to order for Jill?

Some diseases associated with chemistry tests include: diabetes mellitus hypoglycemia hyperlipidemia hyperthyroidism hypothyroidism.

Serology is the study of serum. Antibodies and antigens are key components in serology testing. The two most common testing methodologies in the POL are agglutination and ELISA. Common serological tests performed in the POL include mononucleosis testing, rheumatoid factor testing, syphilis testing, and HIV testing.

Resources

Team Work Exercises

1. Divide into groups of 2 to 3 students. Your instructor will provide each group with one of the following blood glucose tests: a. FBG b. 1-hour postprandial c. 2-hour postprandial d. 3-hour postprandial e. 5-hour postprandial

Brassington, C., and Goretti, C.: MA Notes: Medical Assistants Pocket Guide. Philadelphia: F.A. Davis, 2006. Sacher, R.A., and McPherson, R.A.: Widmanns Clinical Interpretation of Laboratory Tests, 11th ed. Philadelphia: F.A. Davis, 2000. American Society for Clinical Pathology: www.ascp.org Laboratory Corporation of America: www.labcorp.com Overview of CLIA: www.cms.hhs.gov/clia Public resource for clinical laboratory testing: www .labtestsonline.org

CHAPTER

Urinalysis
Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary understand the basic structures of the urinary system describe the importance of urinalysis explain the importance of medical terms related to the urinary system explain the importance of the different methods of urine collection explain and educate the patient in the proper method of urine collection identify the various tests that are included in the physical and chemical examination of urine explain the basis for urine pregnancy testing recognize the various structures or elements that may be found in normal and abnormal urine under the microscope.

44
CAAHEP Competencies
Clinical Competencies Specimen Collection
Instruct patients in the collection of a clean-catch, midstream urine specimen

Collecting a Urine Specimen

Urine Specimen Types Collection Procedure

Preparation for Urinalysis

Reagent Strip Urine Analyzer Quality Control

Diagnostic Testing
CLIA-waived tests Perform urinalysis

Urinalysis Components
Evaluating the Physical Components of Urine Color Clarity Odor Specic gravity Evaluating the Chemical Components of Urine pH Glucose Protein Ketones Bilirubin Urobilinogen Blood Nitrite Leukocytes Evaluating the Microscopic Components of Urine

General Competencies Operational Functions

Use methods of quality control

ABHES Competencies
Clinical Duties
Use quality control Instruct patients in the collection of a clean-catch midstream urine specimen Perform urinalysis Collect and process specimens

Procedures
Instructing the patient on collecting a clean-catch, midstream urine specimen Performing a urinalysis Performing a urine pregnancy test

Chapter Outline
Urinalysis in the POL Urinary System Overview Characteristics of Urine

Urine Pregnancy Testing Chapter Summary Team Work Exercises Case Studies Resources

919

Key Terms
anuria

Urinalysis in the POL

Urinalysis is the testing of a urine specimen. It is one of the most common tests performed in the physicians ofce laboratory (POL). Urinalysis can tell a lot about the patients metabolism and overall health as well as diagnose conditions of the urinary system. The medical assistant must know the structures and functions of the urinary system as well as proper collection, storage, and testing procedures in order to provide quality urine specimens. As with many procedures, proper patient education is an essential component in urinalysis to ensure accurate results.

Absence of urine production

dysuria

Painful or difcult urination

glucosuria

Presence of glucose in the urine

hematuria

Presence of blood in the urine

ketonuria

Presence of ketones in the urine

nocturia

Excessive urination during the night

oliguria

Decrease in the amount of urine formation

polyuria

Urinary System Overview

The urinary system regulates uid, electrolyte, and acid-base balance and removes unwanted waste products. (See Urinary system structures and functions.) The structures of the urinary system include the kidneys, ureters, urinary bladder, and urethra. (For a more in-depth explanation of the anatomy and physiology of the urinary system, see Chapter 31, Urology and the Male Reproductive System, page 567.)

Increase in the amount of urine formation and excretion

proteinuria

Presence of protein in the urine

renal threshold

Concentration at which substances in the blood not normally excreted by the kidneys begin to appear in the urine
specic gravity

Weight of a substance compared with an equal amount of water

turbid

Degree of cloudiness

Characteristics of Urine
Urine is a liquid excreted by the kidneys, stored in the bladder, and expelled by the urethra. It is mainly composed of 95% water. The other 5% is made up of organic and inorganic waste products. The organic substances include ammonia, urea, uric acid, creatine, and creatinine. Inorganic waste products include calcium, phosphorus, and magnesium. Urine is considered a sterile uid when it is in the body and remains sterile if collected via a catheter or aspiration. When urine is discharged during normal urination, it may become contaminated from microorganisms inside or outside the urethra. The typical healthy adult will produce approximately 1000 to 1500 ml of urine per day. However, various factors can affect urine production or output:

anuria, the absence of urine production, can be caused by uremia, nephritis, or obstruction dysuria, the condition of difcult or painful urination, can be caused by cystitis, urinary tract infection (UTI), urethritis, or enlarged prostate nocturia, the condition of excessive urination during the night oliguria, a decrease in the amount of urine formation, can be caused by decreased uid intake, vomiting, diarrhea, and dehydration

CHAP TER 44

Urinalysis

921

Urinary system structures and functions

This table lists the components of the urinary system along with a description and the functions for each.

Structure
Kidneys

Description
Paired, kidney-bean shaped organs located in the back of the peritoneal cavity

Function
Filter waste materials from the blood Regulate water, electrolyte, and acid-base content of the blood Excrete urine

Ureters

Consist of two narrow tubes located behind the peritoneum

Carry urine from the kidneys to the urinary bladder Receptacle for urine Receives urine from the kidneys via the ureters and discharges urine from the body through the urethra

Urinary bladder

Muscular, membranous organ that rests on the anterior part of the pelvic oor

Urethra

Tube that extends from the bladder to the exterior of the body

Discharges urine from the bladder to outside the body

polyuria, an increase in the amount of urine formation and excretion, can be caused by diabetes mellitus, diabetes insipidus, increased uid intake, and diuretics, such as caffeine and digoxin.

Collecting a Urine Specimen

The medical assistant should be sure to obtain a urine specimen properly so that it is the true representation of the patients metabolic state. When collecting a specimen, the medical assistant should consider certain aspects, including the time and method of collection and the patients medication and diet.

Urine Specimen Types

The medical assistant may collect many types of urine specimens from a patient. The type of specimen collected will depend on the test ordered:

specimen for urine culture and detection of UTIs via routine urinalysis. The medical assistant should ensure strict adherence to the proper collection procedure to reduce false-positive results. 24-hour urine testing is used for quantitative chemical analysis. A special collection container is required and the medical assistant may need to add a preservative to the container prior to specimen collection. Catheterized testing yields the best specimen for urine culture. It may also be used for cytological testing. The medical assistant must follow aseptic technique to ensure the integrity of the specimen. (See Figure 44-1.) Suprapubic aspirate testing involves collecting aspirate from the urinary bladder by introducing a syringe directly into the bladder to withdraw urine. This test is sometimes performed on pediatric patients. This tests yields a sterile specimen for urine culture.

Collection Procedure
The clinical medical assistant is usually responsible for providing urine specimen collection instructions to the patient as well as handling and processing the specimen. (See Urine specimens in the front office, page 922.) When collecting a urine specimen in the office, the following guidelines should be followed. The medical assistant should:

Random urine testing yields the most common type of specimen collected in the medical ofce. This test is used for routine urinalysis screening. It is not recommended for urine culture. First morning urine testing yields the most concentrated type of specimen and is best for pregnancy testing and routine urinalysis because it increases the chances of the detection of abnormal results. Clean-catch, midstream (CCMS) urine testing, also known as clean voided midstream testing, yields a common type of

Make sure that specimen is correctly labeled with the patients name, collection date and time, and the type of specimen collected, being sure to place the label on the

922

UNIT 3

Clinical

Front ofceBack ofce connection

Urine Specimens in the Front Ofce

Checking a specimen to make sure it is acceptable is normally the task of a clinical medical assistant. However, there may be times when an administrative medical assistant or other front ofce staff receive a urine specimen from a patient. When this happens, the administrative medical assistant must inspect the specimen before the patient leaves the ofce. Items to check include: proper container proper labeling when the specimen was collected all information noted on the requisition form. If the administrative medical assistant notes inconsistencies, she may want to ask the patient to collect another specimen, preferably in the ofce.

FIG 44-1 Urine collection containers.

Patient Education
container itself and not the lid, because the lid might become separated from the specimen. Make sure that the volume is sufcient for the type of test ordered. Usually, 25 to 50 ml is adequate for routine testing. Always use the proper urine container as provided by the medical ofce or hospital laboratory. Specimens collected in household jars are unsterile and not acceptable for testing. Provide verbal and written instructions for specimen collection. (See Urine specimen collection, and Procedure 44-1: Instructing the patient on collecting a clean-catch midstream urine specimen.) Be sure to test specimens within 30 to 60 minutes of collection. If a delay in testing might occur, the specimen can be refrigerated for up to 4 hours. Urine that has been sitting at room temperature can go through various physical and chemical changes, altering the results for that specimen. Make sure the specimen is gently stirred prior to testing specimens that may have been sitting still or refrigerated. In such specimens, solutes may have settled to the bottom. Gentle stirring evenly distributes the solutes. (For information on pediatric urine collection, see Chapter 33, Pediatrics, page 641.)

Urine Specimen Collection

For some patients, especially children and adolescents, collecting a urine specimen may be a new experience. Such patients may be apprehensive about the procedure. The medical assistant should provide clear instructions on collection as well as show the collection container and supplies and explain their usage. Other topics to discuss include: how much specimen is needed telling a child that his parent can help him preservative in the collection container for a patient collecting a 24-hour specimen, which might be hazardous or irritating to the skin avoiding touching the inside of the container and lid because doing so may contaminate the specimen

Increase compliance
For increased collection compliance, the medical assistant should post collection instructions for collecting a cleancatch, midstream urine specimen in the bathroom used by patients. Also, she should provide written as well as verbal instructions on proper specimen collection and storage to the patient collecting a 24-hour specimen.

CHAP TER 44

Urinalysis

923

PROCEDURE 44-1

Instructing the patient on collecting a clean-catch, midstream urine specimen

Task Instruct a patient on how to collect a clean-catch, midstream urine specimen. Conditions Sterile screw-cap container Computer-generated patient label Antiseptic towelettes (2) Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully instruct a patient on how to collect a clean-catch, midstream urine specimen. Performance Standards 1. Wash or sanitize your hands and assemble the equipment. 2. Greet the patient, introduce yourself, and explain the proper collection procedure. For female patients 3. For female patients, instruct the patient to: a. Wash her hands and then open the lid of the cup and place the lid on the counter facing up. If the lid is placed facing down on the counter, it could become contaminated and cause a false-positive result. b. Lower her underwear and expose the urinary meatus by spreading the labia apart with the nondominant hand. c. Take one of the towelettes and clean one side of the urinary meatus from the front to the back on one side. Repeat the same procedure with the other towelette on the opposite side of the meatus. If the kit contains a third towelette, clean from front to back down the middle. Proper cleaning of the skin area will avoid contamination of the specimen by microorganisms on the skin. d. Continue to keep the labia spread apart and begin voiding a small amount of urine into the toilet for 1 or 2 seconds to clear the urethra of contaminants and ensure accurate results. e. Position the collection container into the stream of urine without stopping the ow. Stopping the ow could cause bacteria and other contaminants to be washed into the specimen. f. After filling the container adequately (30 to 50 ml), void the remaining urine into the toilet. g. Wipe the area and wash her hands. h. Securely cap the specimen container and place it in the specied area. (The area in the physicians ofce laboratory or hospital laboratory designated for specimens.) Placing specimens in the proper collection area ensures prompt specimen testing and results reporting. For male patients 4. For male patients, instruct the patient to: a. Wash his hands and then open the lid of the cup and place the lid on the counter facing up. If the lid is placed facing down on the counter, it could become contaminated and cause a false-positive result. b. Lower his underwear and, if uncircumcised, retract the foreskin and hold it back during the entire procedure to avoid contaminating the specimen with microorganisms present on the foreskin, which can cause erroneous results. c. Clean the area around the penile opening (glans penis) by starting at the tip of the penis and cleaning downward using a separate towelette for each side. d. Void a small amount of urine into the toilet. Excreting a small amount of urine before collection clears the urethra of contaminants and thus ensures accurate results. e. Collect the next amount of urine by voiding into the sterile container, being careful not to touch the inside of the container with the hand or penis. f. After lling the container adequately, void the last amount of urine into the toilet. g. Dry the area and wash his hands. h. Securely cap the specimen container and place it in the specied area. Placing specimens in the proper collection area ensures prompt specimen testing and results reporting.

924

UNIT 3

Clinical

Preparation for Urinalysis

Before conducting a urinalysis, the medical assistant must make sure that she is familiar with the equipment, including the reagent strip and urine analyzer, and quality control measures involved in the procedure.

Patient name: Maggie Benjamin Date of collection: 06/21/08 Time of collection: 8:13 a.m. Initials: mag, CMA Test Color Clarity Specific gravity pH Protein Glucose Ketones Bilirubin Blood Urobilinogen Nitrite Leukocytes MICROSCOPIC Epithelial cells wbc rbc Casts Crystals Bacteria Mucus Miscellaneous Results

MR#: 036218

Reagent Strip
There are several commercial testing strips commonly used in the POL, including Bayer Multistix 10SG and Roche Chemstrip 10SG. (See Figure 44-2.) The test strip contains individual color pads that correlate with a urine component, such as glucose or blood. After the medical assistant dips the test strip in the urine, she compares the individual color pads to a color chart and records each result on a urinalysis reporting form. (See Figure 44-3.) The strips can also be read automatically on a urine analyzer, where the results would be printed out by the analyzer. Some results are recorded as an actual amount or value and would be considered quantitative. For example, a urobilinogen result of 0.2 mg/dl is considered normal. Other results may be qualitative and interpreted by using results such as positive or negative. Although testing urine using a reagent strip is quick and easy, the medical assistant should be aware of the following guidelines:

dark yellow clear 1.020 6.0 neg neg neg neg trace 0.2 neg neg 2-5/lpf None 0-5/hpf None None None None

Carefully read and follow the manufacturers instruction provided in the reagent strip package.

FIG 44-3 Completed urinalysis report.

Always check the expiration date and do not use strips that are outdated. Do not use test strips if a color change has occurred to the reagent pads. Store reagent strips in a cool, dark area with the cover always on the container. Do not refrigerate the strips.

Urine Analyzer
Many POLs read the urine reagent strip using a urine analyzer, such as the Clinitek analyzer manufactured by Bayer Corporation. (See Figure 44-4.) The benets of using the analyzer include:

computer printout of the results (color and clarity included) with abnormal values agged ability to process results for a greater number of urine tests in a shorter amount of time decreased exposure of the medical assistant to the urine specimen, compared with reading the results manually.

FIG 44-2 Urinalysis reagent strip and container with color chart.

If, at any time, the medical assistant questions the results obtained by the urine analyzer, she should conrm the

CHAP TER 44

Urinalysis

925

Urinalysis Components
Although relatively simple, urinalysis consists of three components:

physical chemical microscopic.

Under regulations set by the Clinical Laboratory Improvement Amendment (CLIA) of 1988, the medical assistant is qualied to perform only physical and chemical analysis; the physician or other CLIA-sanctioned professional must perform and record the microscopic evaluation.

Evaluating the Physical Components of Urine

The physical examination of urine evaluates the specimens color, clarity, odor, and specific gravity. The medical assistant should make sure that the urine is collected in a clear container or should transfer the specimen into a clear glass or plastic container so that color and clarity can be determined.

Color
Urochrome is a pigment responsible for giving urine its varying shades of yellow color. The normal color of urine can vary from pale yellow or straw-colored to amber. Urine that is colorless or pale is diluted, while urine that is dark yellow is concentrated. The rst urine voided in the morning tends to be a darker yellow because it is more concentrated, which means that it contains a greater amount of substances compared to the volume of water. The more water or uid a person takes in, the greater the volume of water, which would dilute the urine and cause its color to be lighter. Urine that has a color other than yellow may indicate an underlying disorder, including:

FIG 44-4 Bayer Clinitek urine analyzer with printed results.

results by performing a manual (visual) chemical reagent test using a new test strip.

Quality Control
Regardless of which method the medical assistant uses to read a urine reagent strip, she must perform quality control to ensure accurate results. Performing quality control not only certies that the reagent strips are acceptable for use but also tests the procedure and technique of testing personnel. As with any quality control procedures, quality control should be run prior to any patient testing and results must be documented properly and according to the manufacturers and laboratory protocol. Most manufacturers that supply reagent test strips also provide quality control reagents and supplies as well as instructions for testing, control ranges, results reporting, troubleshooting, and corrective action procedures.

orange or brownish colorpossible liver disease, such as hepatitis red or reddisha UTI, trauma, or a renal disorder milkypossibly fat globules in the urine or a UTI.

Certain foods, vitamins, and drugs cause urine to change color as well. (See Urine color changes, page 926.)

Clarity
The clarity, or transparency, of urine is one aspect of the evaluation of its appearance. Fresh urine is usually clear or transparent but it may become cloudy when refrigerated or left standing at room temperature. Such substances as mucus, bacteria, and cells can contribute to the cloudy appearance of urine. When assessing the

926

UNIT 3

Clinical

Urine color changes

Certain foods, vitamins, or medications a patient ingests could cause his urine to be a different color. Generally, if the color change is caused by something the patient normally ingests, it is not considered an indication of a pathological condition. The following lists include foods, vitamins, and medications that can cause a urine color change.

Foods
Carrotsorange Beetsred-tinged Blackberriesred-tinged

Vitamins
Vitamin Cbright yellow or orange B vitaminsbright yellow or orange

urine measures the concentration of dissolved substances in urine and is an indication of how well the kidneys are functioning. The specific gravity of water is 1.000, whereas the normal range for urine is 1.005 to 1.030. Urine that is too concentrated will have a higher specific gravity, and urine that is diluted will have a lower specific gravity. A persons specific gravity may change throughout the day, depending on that persons fluid intake and output. Specific gravity is highest upon the first morning voiding, because the urine has concentrated during the night. Conditions that may affect a specific gravity result include dehydration, heart disease, renal disease, and diabetes mellitus. Specic gravity can be measured manually, using a refractometer, or chemically, using a reagent testing strip. Because most urine reagent strips have a specic gravity test component, most POLs use this method rather than the refractometer method.

Medications
Antibiotics, such as sulfamethoxazole (Bactrim) and nitrofurantion (Furadantin)yellowish-brown Rifampin (Rifadin) or phenazopyridine (Pyridium) reddish-orange

Evaluating the Chemical Components of Urine

Urine may contain various chemical substances that, when detected, could indicate a range of pathological conditions, such as renal disorders, UTIs, and diabetes. Urine may also contain various hormones and metabolites that, if detected, can help determine pregnancy or detect drug use. Routine urinalysis chemical tests include pH for alkalinity or acidity, glucose, protein, ketones, blood, bilirubin, urobilinogen, nitrite, and leukocytes.

clarity of urine, the medical assistant should use such terms as clear, cloudy, slightly cloudy, or turbid, which means thick or opaque.

pH
Alkalinity or acidity of urine is represented by pH. The pH scale ranges from 0.0 to 14.0, with a pH of 7.0 being neutral. An acidic measurement ranges from 0.0 to 6.0, and an alkaline measurement ranges from 8.0 to 14.0. Although normal urine pH can range from 4.5 to 8.0, freshly voided urine tends to be more acidic than alkaline and generally has a pH result around 6.0. If urine is not tested when received and sits at room temperature, it will become alkaline and its pH will become elevated. Results of pH testing vary due to changes in a persons diet or condition. An acid pH may indicate acidosis, diabetes mellitus, or starvation; an alkaline pH may indicate a UTI.

Odor
A fresh urine specimen normally has a slight aromatic odor; however, upon standing, urine develops an ammonia odor. This odor is caused by the breakdown of urea by bacteria that may be present in the specimen. A sweet or fruity odor may be an indication of the presence of ketones, which are found in urine of patients with uncontrolled diabetes. Foul-smelling urine may be a symptom of a UTI, while a mousy, or musky, smell from an infants urine may indicate phenylketonuria. Certain foods can also change the odor of urine. For example, asparagus can cause a strange or musty odor, and saffron or sandalwood oil may create a spicy odor. Although urine can have varying degrees of odor, the odor is not generally recorded when performing a urinalysis unless something abnormal is noted.

Glucose
The presence of glucose in the urine is not a normal condition. Normally, the kidneys will lter and then reabsorb glucose back into the bloodstream. However, if glucose levels in the bloodstream increase, glucose will reach its renal threshold. Renal threshold is the concentration at which substances in the blood not normally excreted by the kidneys

Specic Gravity
Specific gravity is the weight of a substance compared with an equal amount of water. The specific gravity of

CHAP TER 44

Urinalysis

927

begin to appear in the urine. The renal threshold for glucose is 160 to 180 mg/dl. If blood glucose levels exceed the renal threshold, glucosuria, a condition where glucose spills back into the urine, will result. The main cause of glucosuria is diabetes mellitus but it can also result from pancreatic insufciency, disorders of the endocrine glands, and excessive carbohydrate intake. Urine glucose results may be reported as negative, trace, 1 , 2 , 3 , and 4 . However, some reagent strip charts provide quantitative results measuring 100 mg/dl to 2 g/dl.

urine without red blood cells (RBCs), called hemoglobinuria, is a rare condition that can be caused by a transfusion reaction, hemolytic anemia, arsenic poisoning, or malaria. Blood results are graded as negative, trace, small, moderate, or large or as negative, trace, 1 , 2 , or 3 . Reasons for blood in the urine include trauma to the kidneys, UTI, and kidney stones.

Nitrite
Nitrate (NO3) is a compound of nitrogen and oxygen found in many food items in a persons diet. It is normally precipitated out in urine. Some pathogenic bacteria possess the ability to convert nitrate to nitrite. Nitrite in the urine suggests the presence of these pathogenic bacteria and indicates a possible UTI. Because not all bacteria that can cause a UTI produce nitrite, leukocyte test results must also be taken into consideration when considering an infection. Nitrites are reported as negative or positive. A positive nitrite test should be followed by a urine culture and identication of the organism.

Protein
The presence of a large amount of protein in the urine is called proteinuria. Protein results are graded as negative, trace, 1 , 2 , 3 , or 4 . A temporary increase in urine protein may be caused by fever, stress, or strenuous exercise. Chronic proteinuria may be due to renal failure or other renal conditions.

Ketones
Ketones are the by-products of excessive fat metabolism and are oxidized by the muscles as a source of energy. Ketonuria is the presence of ketone bodies in the urine and can result from a starvation or high-fat diet, pregnancy, or uncontrolled diabetes mellitus. Ketone results are recorded as negative, trace, small, moderate, or large or as negative, 1 , 2 , or 3 .

Leukocytes
The presence of leukocytes, or white blood cells (WBCs), in urine usually indicates a UTI and should be compared with a nitrite test. Leukocyte results are graded as negative, trace, small, moderate, or large. Microscopic evaluation of the specimen should conrm the reagent strip results with a visual conrmation of leukocytes.

Bilirubin
Bilirubin is formed as a result of the breakdown of hemoglobin. It is carried to the liver via the bloodstream, where it is then excreted as bile. Urine that contains high levels of bilirubin may be yellow-orange to dark brown in color. High levels of bilirubin in the urine can indicate liver damage or obstruction, hepatitis, or cirrhosis. Bilirubin results may be recorded quantitatively as negative, small, moderate, or large or qualitatively as negative, 1 , 2 , or 3 .

Evaluating the Microscopic Components of Urine

Physicians or other qualified personnel examine the microscopic components of urine to evaluate the sediment, or solid material, found in urine. (See Common microscopic components in urine, page 928 to 932.) This method is also used to confirm the results of the physical and chemical urine evaluation. Although the medical assistant can prepare a urine specimen for microscopic evaluation, according to CLIA, a physician or other qualified health care profession must read and record the results. Upon completing the physical and chemical aspects of urinalysis, the medical assistant should centrifuge the urine, pour off the excess fluid, and prepare the sediment for microscopic examination. The examiner may look at the sediment with or without the aid of a stain, based on her preference. The examiner will rst observe the specimen under a low power eld and scan it for casts. Then she may view it under a high power eld to look for the presence of RBCs, WBCs, epithelial cells, crystals, bacteria, and other substances. (See Procedure 44-2: Performing a urinalysis, page 932.)

Urobilinogen
As bilirubin passes through the intestines, it is converted to urobilinogen by bacterial enzymes and then excreted through the feces. Small amounts of urobilinogen in the urine are normal; however, increased amounts may indicate a biliary obstruction, cirrhosis, heart failure, or excessive red blood cell destruction. Urobilinogen results may be from 0.2 mg/dl (normal) to 8 mg/dl.

Blood
Hematuria is the condition in which blood is found in the urine. Blood is not normally present in urine except as a contaminant during menstruation. The medical assistant should always document if the patient has her menses during urine collection. The presence of hemoglobin in the

928

UNIT 3

Clinical

Urine Pregnancy Testing

There are various rapid methods of determining pregnancy. All of them rely on detection of the human chorionic gonadotropin (HCG) hormone, which is secreted by the developing fertilized egg. HCG levels are detectable in the

urine or blood as soon as 1 to 5 days after conception. HCG levels continue to rise during the beginning of the rst trimester, with levels peaking at about 8 weeks. There are many CLIA-waived pregnancy test kits on the market. Most of them are based on the same immunologic principle (immunoassay) and perform a qualitative detection

Common microscopic components in urine

The following table lists common components found in urine using microscopic examination along with a description of each.*

Component
Red blood cell (RBC)

Description
Round, colorless, biconcave disc that is highly refractile in unstained urine Not normally seen in urine sediment, but may be present during menstruation If present, commonly reported as 0 to 2, 2 to 5, 5 to 10, 10 to 20, >50, >100, or too numerous to count (TNTC) per high power eld (hpf)

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 77, with permission.)
White blood cell (WBC) Slightly larger than RBCs and possibly granular or containing a multilobed nucleus Possibly indicating a urinary tract infection (UTI), prostatitis, or urethritis in amounts greater than 5 to 10/hpf If present, commonly reported as 0 to 5, 5 to 10, 10 to 20, up to TNTC per hpf

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 79, with permission.)

CHAP TER 44

Urinalysis

929

Common microscopic components in urinecontd

Component
Epithelial cells

Description
Larger than WBCs Three different types: squamous, renal tubular, and transitional Possibly seen in urine; presence of transitional and renal epithelial cells considered normal If present, commonly reported as rare, few, moderate, or many per hpf or low power eld (lpf), depending on physician ofce laboratory (POL) protocol.

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 81, with permission.)
Casts Usually clear and rectangular in shape but possibly containing blood cells Formed in the lumen of the tubules of the nephron Mainly consisting of protein but, when forming, possibly include urinary substances, such as RBCs and WBCs Various kinds, classied by what they contain, including the most common type, the hyaline cast, but also RBC, WBC, waxy, and granular Usually indicative of a pathological condition If present, commonly reported as 0 to 2, 2 to 5, 5 to 10, up to TNTC per lpf If present, formal identication of cast type made at high power eld

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 87, with permission.)

Continued

930

UNIT 3

Clinical

Common microscopic components in urinecontd

Component
Crystals

Description
Can be many different shapes that refract light and appear shiny or colored (as in a prism) on microscopic evaluation Formed when there are changes in urine pH, temperature, or concentration Usually classied based on urine pH and include calcium oxalate, tyrosine, amorphous urates, triple phosphate, uric acid, and calcium carbonate Possibly caused by certain foods, medications, or disorders If present, commonly reported as rare, few, moderate, or many per hpf

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 96-97, with permission.)
Bacteria Tiny round or rod-shaped structures Possibly indicating a UTI in large amounts If present, commonly reported as rare, few, moderate, or many per hpf

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 85, with permission.)

CHAP TER 44

Urinalysis

931

Common microscopic components in urinecontd

Component
Yeast

Description
Single-celled or budding oval structure that is larger than bacteria Grouped under miscellaneous on the laboratory report form If present, commonly reported as rare, few, moderate, or many per hpf

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 77, with permission.)
Trichomonas vaginalis Parasite that causes trichomonas infection Grouped under miscellaneous on the laboratory report form If present, commonly reported as rare, few, moderate, or many per hpf

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 64, with permission.)
Sperm cells Possibly seen in urine sediment Grouped under miscellaneous on the laboratory report form If present, commonly reported as few, moderate, or many per hpf

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 85, with permission.)

Continued

932

UNIT 3

Clinical

Common microscopic components in urinecontd

Component
Mucus threads

Description
Possibly seen in urine sediment Grouped under miscellaneous on the laboratory report form If present, commonly reported as few, moderate, or many per hpf

(From Strasinger/Di Lorenzo. Urinalysis and Body Fluids, 4th ed. FA Davis, Philadelphia, 2001, p 86, with permission.)
* Please note: Normal values and reporting ranges for urine sediment constituents are not clearly dened. Use suggested reporting ranges as a guide and always refer to your physicians ofce laboratory reporting protocol.

PROCEDURE 44-2

Performing a urinalysis
Task Perform and document a urinalysis. Conditions Sterile specimen cup Computer-generated label Urine reagent strips or Cliniteck automatic urine analyzer Clean glass microscope slide Clean glass microscope coverslip Microscope Blank urine report form or the patients chart Paper towel Disposable examination gloves Plastic centrifuge tube Gown or laboratory coat with a zipper or button closure Biohazard waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform and document a urinalysis. Performance Standards 1. Assemble the supplies. Accurately complete the label and afx it to the specimen cup (not to the lid). Efciency during procedures is greater with advance preparation. Applying the label to the cup ensures that the specimen will remain accurately labeled and not confused with other specimens in the laboratory after the lid has been removed. 2. Greet and identify your patient. Introduce yourself and explain the procedure for collecting a clean-catch, midstream urine specimen to prevent errors and ease patient anxiety. 3. Wash or sanitize your hands and apply gloves to ensure infection control. 4. Obtain the urine specimen from the patient. 5. Observe the specimen for physical characteristics, such as color, clarity, and odor. 6. Record your observations on the blank urine report form or in the patients chart.

CHAP TER 44

Urinalysis

933

PROCEDURE 44-2contd

7. Pour the specimen into a conical centrifuge tube. Testing with a reagent strip is easier to perform in a centrifuge tube than in a specimen container. 8. Test the urine using a chemical reagent strip, making sure all test pads have been exposed to the urine. 9. Tap the side of the strip gently on a paper towel to remove excess urine. 10. After waiting for the required time, according to the manufacturers guidelines, read each reagent pad and record the results on the urine report form or in the patients chart. 11. Centrifuge the tube for 5 minutes at 1500 rpm. 12. Pour off the uid and tap the bottom of the tube to mix the remaining contents. 13. Place a drop of sediment on a glass slide and cover with a coverslip. 14. Place the slide on the microscope stage.

15. Notify the physician that the slide is ready for evaluation and provide the urine report form or the patients chart so the physician can document the results. According to CLIA regulations, only physicians or other trained health care professionals are qualied to read a urine microscopic slide. 16. Dispose of the biological materials in appropriate containers. 17. Remove your gloves and wash your hands. 18. Record the procedure in the patients chart.
Date 06/11/08; 9:35 a.m. Urine specimen collected and urinalysis performed. -------------------------------------------------------------------- S. Gonzales, CMA

of HCG. (See Figure 44-5.) All of these kits have the benets of procedural ease, specicity, and rapid results. (See Condentiality and pregnancy results.) Some kits now allow for serum as well as urine testing and most include an internal control, in addition to containing positive and negative control reagents. The medical assistant should follow the manufacturers instructions for testing, specimen requirements, and storage. As with performing any laboratory testing, the medical assistant should check the kit for expiration date and degradation or contamination of reagents. (See Procedure 44-3: Performing a urine pregnancy test, page 934.)

Front ofceBack ofce connection

Condentiality and Pregnancy Results

In some medical ofces, reporting test results is the responsibility of the clinical medical assistant. However, the administrative medical assistant should be familiar with the procedure as well as the confidentiality issues involved. The medical assistant must take care when reporting pregnancy test results and should never leave the results on the patients answering machine. Conversely, if a patient calls looking for her pregnancy test results, the administrative medical assistant must take care to make sure she is giving the results to the correct patient. She should follow all ofce policies and procedures for such calls.

Chapter Summary

FIG 44-5 QuickVue urine pregnancy test kit.

The urinary system includes the kidneys, ureters, urinary bladder, and urethra. Urine is mainly composed of 95% water. The other 5% is made up of organic and inorganic waste products. Various types of urine specimens include random, rstmorning, clean-catch midstream, catheterized, suprapubic, and 24-hour. A complete urinalysis consists of physical, chemical, and microscopic evaluation.

934

UNIT 3

Clinical

PROCEDURE 44-3

Performing a urine pregnancy test

Task Perform a urine pregnancy test according to the manufacturers instructions. Conditions Disposable examination gloves Patient urine specimen Urine pregnancy test kit Biohazard waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform a urine pregnancy test according to the manufacturers instructions. Performance Standards 1. Wash or sanitize your hands to ensure infection control and gather the supplies. 2. Obtain a testing cassette or stick, reagents, and a urine specimen. 3. Following the manufacturers instructions, perform and document the necessary quality control measures. Quality control ensures that the test kit is working properly. 4. Following the manufacturers instructions, apply urine to the testing cassette or stick. 5. Wait the appropriate time interval to ensure the accuracy of results. 6. Apply other reagents if specied by the manufacturer. 7. Read the results. 8. Remove your gloves and wash your hands to ensure infection control. 9. Document the procedure to ensure the accuracy of the medical record.
Date 02/07/08; 11:15 a.m. Urine pregnancy test results: negative. ------------------------------------------------------------------------------------ S. Gonzales, CMA

The physical components of urine include color, clarity, odor, and specic gravity. Chemical components of urine include pH, glucose, protein, ketones, bilirubin, urobilinogen, blood, nitrite, and leukocytes. The microscopic portion of the urinalysis must be performed by a physician or CLIA-approved health care professional. Urine pregnancy testing is a CLIA-waived test performed in the POL.

disease and relates the testing performed in the urinalysis department to the diagnosis or monitoring of that condition or disease.

Case Studies
1. Mrs. Robidoux has come to the ofce with a complaint of ank pain. She has brought in a urine specimen (rstmorning) for a possible urinalysis and culture. The urine was in a glass fruit jar and she claims that she boiled the container. What would you say to Mrs. Robidoux about the urine specimen? 2. Linda Piniela has just given Robin, CMA, a freshly voided urine specimen. Robin performed a urine dipstick and the specimen was positive for blood. What questions should Robin ask Linda?

Team Work Exercises

1. Separate into groups of 2 to 3 students. Your instructor will assign one of the following components of urinalysis collection and testing: a. collection for female b. collection for male c. physical component of testing d. chemical component of testing e. microscopic component of testing. Each group should gather information on its component and work together to develop a presentation that includes a demonstration to the rest of the class. 2. Separate into groups of 2 to 3 students. Your instructor will assign each group a different condition or disease of the urinary system for the group to research. The group should design a poster that explains the condition or

Resources

King Strasinger, S., and Schaub DiLorenzo, M.: The Phlebotomy Workbook, 2nd ed. Philadelphia: F.A. Davis, 2003. CLIA categorization of laboratory tests: www.cms.hhs .gov/CLIA/10_Categorization_of_Tests.asp Information on urinalysis: labtestsonline.org/understanding /analytes/urinalysis/test.html Information and current issues and procedures on urinalysis: www.labcorp.com and www.ascp.org

CHAPTER

Microbiology
Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary discuss the major scientists who have contributed to the eld of microbiology describe the importance of normal ora explain the different groups of microorganisms capable of causing human disease discuss the different types of microbiological specimens and proper specimen collection techniques describe the procedure for culturing a microbiological specimen describe the types of microbiological tests performed in a physicians ofce laboratory (POL) discuss the procedure involved in rapid streptococcal testing describe antimicrobial susceptibility testing.

45
Chapter Outline
History of Microbiology Infection and Disease Normal Flora Types of Microorganisms
Bacteria Cocci Bacilli Spiral Viruses and Prions Fungus Protozoa and Parasitic Worms

CAAHEP Competencies
Clinical Competencies Specimen Collection
Obtain specimens for microbiological testing

Diagnostic Testing
CLIA-waived tests Perform microbiology testing

ABHES Competencies
Clinical Duties
Obtain throat specimen for microbiological testing Perform wound collection procedure for microbiological testing Perform microbiology testing

Microbiological Testing
Bacterial Culture Antimicrobial Susceptibility Testing

Microbiology Procedures
Specimen Collection for Microbiological Analysis Microbiological Testing Performed in the POL Rapid streptococcal test Throat culture test

Procedures
Collecting a throat specimen for microbiological testing Collecting a wound specimen for culture Collecting a sputum specimen for culture Performing a rapid streptococcal test Processing a throat culture

Chapter Summary Team Work Exercises Case Studies Resources

935

Key Terms
antimicrobial agent

History of Microbiology
Microbiology is the study of microorganisms. Microorganisms are living organisms that cannot be seen by the naked eye and can only be viewed through the use of a microscope. Clinical microbiology focuses on identifying the pathogens that cause disease in humans. One of the most important events early in the eld of microbiology was the invention of the microscope by Anton van Leeuwenhoek in 1673. Van Leeuwenhoeks microscope, albeit crude, enabled him to view various samples, such as rainwater and scrapings from his teeth, to observe live microorganisms. He was the rst to view such organisms, and he described the various shapes he viewed in letters to scientic groups, such as the Royal Society of England. Since van Leeuwenhoeks invention and subsequent discoveries, the eld of microbiology has grown considerably. (See Microbiology contributors.)

Any chemical substance that has the ability to kill or stop the growth of microorganisms
bacilli

Rod-shaped bacteria
bacteria

One-celled microorganisms that sometimes produce disease in humans

cocci

Round or spherical bacteria that can arrange themselves in chains, clusters, or tetrads
contagious

Easily spread from one person to another

culture

Growth of microorganisms in a laboratory-prepared medium

fungus

Organism that is most commonly not pathogenic (includes yeasts, molds, and mushrooms)
incubation period

Period of time it takes for a microbiological culture to grow and multiply before actual bacterial colonies are visible on the medium.
infectious disease

Infection and Disease

An infectious disease is one in which a microorganism is transmitted directly or indirectly between individuals, causing infection. The direct link between infection and disease is well proven. Medical assistants should understand the sources of infection as well as the ways in which infectious diseases can spread. Sources of human infection include other humans, animals, and, sometimes, the soil. When a pathogen enters the body, it attempts to invade the tissues so it can grow and multiply. The body then responds to the invasion by producing antibodies and white blood cells that together try to ght off the infection. If the pathogen is successful in evading the bodys response, then an infection occurs, and the person becomes sick. Many infectious diseases are contagious, which means that the disease-causing pathogen can spread from one individual to another through different transmission routes. Various routes of transmission include contact, airborne, or droplet. Contact transmission can occur through direct contact with an infected person, such as touching or kissing, or indirect contact, such as touching a door knob that an infected person just touched after he sneezed into his hand. Airborne and droplet transmission spread infectious particles through such activities as coughing and sneezing. (See Proper specimen storage.)

Any disease that may be directly or indirectly transmitted between individuals, causing infection
microorganism

Living organism too small to be seen by the naked eye

normal ora

Organisms found in the body that do not cause disease and are sometimes benecial
parasite

Pathogen requiring another living organism in order to survive

pathogenic

Causing disease
prion

Proteinaceous infectious particle that can cause a spongiform encephalopathy

protozoa

Unicellular, animal-like microorganism

resistance

Microorganisms ability to withstand the effects of an antimicrobial agent

smear

Bacterial growth sample that is spread onto a microscope slide for staining purposes
susceptibility

Degree to which a microorganisms growth can be inhibited by an antimicrobial agent

virus

Normal Flora
Not all microorganisms are pathogenic, or cause disease. Some organisms normally live in the body and can be

Pathogen that can grow and reproduce only after infecting a host cell

CHAP TER 45

Microbiology

937

Microbiology contributors
The accompanying table provides a brief history of contributions to the eld of microbiology.

Year
1673

Scientist
Anton Van Leeuwenhoek

Contribution
Unofcially known as the Father of Microbiology Creator of the rst microscope First person to observe and describe live microorganisms

1798

Edward Jenner

Invented the rst vaccine (for smallpox) Successfully vaccinated against smallpox by injecting the cowpox virus into a healthy boy to vaccinate him against the deadly smallpox virus

1864 1867

Louis Pasteur Joseph Lister

Invented the process of pasteurization, a method of sterilizing liquids Practiced aseptic surgery by using phenol to kill bacteria on surgical instruments and wounds

1876

Robert Koch

Developed Kochs Postulates, a series of experimental steps to prove that a disease is caused by a certain microorganism Discovered Bacillus anthracis, the causative organism for anthrax

1884

Hans Christian Gram

Developed the Gram stain, a method of staining bacteria in order to further classify them

1910

Paul Ehrlich

Discovered a chemical means to kill a pathogen inside a host without harming the host and coined the phrase magic bullet to describe it Discovered chemotherapeutic agent salvarsan

1928

Alexander Fleming

Discovered antibiotic penicillin

Front ofceBack ofce connection

Proper Specimen Storage

Although the clinical medical assistant will usually be responsible for collecting and handling clinical specimens, there may be times when the administrative medical assistant will receive patient specimens that cannot be processed immediately and must be stored in a refrigerator. The medical assistant must ensure that she places the specimens in the refrigerator that is designated solely for patient specimens. Conversely, she should never place her personal food items in a refrigerator designated for specimens. All medical ofce staff should adhere strictly to this major safety guideline to avoid contaminating food and infecting employees.

benecial to the body. Normal ora, also known as indigenous ora, are harmless microorganisms that normally reside in many different parts of the body but do not cause disease. They are permanent residents of certain body sites, especially the skin, nasopharynx, gastrointestinal tract, and vaginal tract. Although normal ora extensively populate many areas of the body, the internal organs are usually sterile. Normal ora mainly consists of bacteria, which are one-celled microorganisms that sometimes produce disease in humans. Examples of bacteria that are considered normal ora include Staphylococcus epidermidis, Streptococcus mitis, and Lactobacillus species. Such areas as the central nervous system, blood, lower bronchi and alveoli, liver, spleen, kidneys, and bladder are essentially free of all organisms. Although normal ora does not usually cause disease, if these bacteria are introduced into another body site, infection could occur. For instance, normal gastrointestinal tract

938

UNIT 3

Clinical

bacteria such as Escherichia coli can cause a urinary tract infection if it is introduced into the urinary tract.

microbiology. There are vast numbers of different microorganisms; however, most of them can be classied into a few main types:

Types of Microorganisms
Although not all microorganisms are pathogenic, the pathogenic forms are of most importance when studying clinical

bacteria viruses and prions fungi protozoa and parasitic worms. (See Common pathogenic microorganisms.)

Common pathogenic microorganisms

The following table lists the various types of microorganisms and the common human infections they may cause.

Microorganism
Bacteria Bacillus anthracis Borrelia burgdorferi Chlamydia trachomatis Clostridium difcile Escherichia coli Helicobacter pylori Klebsiella pneumoniae Haemophilus inuenzae Mycoplasma pneumoniae Neisseria meningitidis Neisseria gonorrhoeae Pseudomonas aeruginosa Salmonella species Staphylococcus aureus Streptococcus agalactiae (Beta Streptococcus group B) Streptococcus pneumoniae Streptococcus pyogenes (Beta Streptococcus group A) Fungi Aspergillus niger Candida albicans Cryptococcus neoformans Viruses Adenovirus Avian inuenza Ebola Human herpesvirus 1 Human immunodeciency virus Rubella Varicella-zoster

Associated Conditions
Anthrax Lyme disease Genitourinary infection, neonatal sepsis Pseudomembranous colitis Urinary tract infection, gastrointestinal infection, bacteremia Peptic ulcer Pneumonia, urinary tract infection, bacteremia Otitis media, pneumonia, conjunctivitis, bacteremia, meningitis Pneumonia Meningitis, bacteremia Gonorrhea, neonatal conjunctivitis Nosocomial infections, pneumonia, urinary tract infection Food-borne illness, bacteremia Wound infection, bacteremia, food-borne illness, impetigo, boils, carbuncles, pneumonia Neonatal sepsis, wound infections Otitis media, pneumonia, sinusitis, bronchitis, bacteremia Streptococcal throat infection, impetigo, wound infections, scarlet fever, rheumatic fever

Pneumonia Thrush, genitourinary infection Meningitis

Common cold Infectious bronchitis Hemorrhagic fever Genitourinary infections and skin infections Acquired immune deciency syndrome German measles Chickenpox

CHAP TER 45

Microbiology

939

Common pathogenic microorganismscontd

Microorganism
Protozoa Cryptosporidium Entamoeba histolytica Giardia lamblia Plasmodium species Trichomonas vaginalis Parasitic Worms Ascaris lumbricoides Enterobius vermicularis Gastrointestinal infection Pinworm Gastrointestinal infection Gastrointestinal infection Gastrointestinal infection Malaria Genitourinary infection

Associated Conditions

Bacteria
Bacteria are microscopic unicellular organisms that do not have a nuclear membrane enclosing their genetic material. Such a simple cell is called a prokaryote (prenucleus). Bacteria are classied into three basic groups based on their shape:

cocci bacilli spiral bacteria.

Bacteria can be further classied based on their characteristics upon a Gram staining. The Gram stain, discovered by Hans Christian Gram, is a simple method to further classify bacteria into two groups: gram-positive and gram-negative. For a Gram stain, the examiner must prepare a smear, which is a bacterial growth sample spread onto a microscope slide. After the slide has dried and the examiner has ensured that the smear is attached, or xed, to the slide using heat or alcohol, the slide is ready for staining. (See Gram staining, page 940.) The examiner can determine the Gram classication based on the color (purple or pink) that the organism stains as well as the bacterias shape by viewing the smear under a microscope. Because it is a quick, relatively simple test, the Gram stain can aid the physician in quickly determining the proper treatment for a patient. Most bacteria are easily treated with antibiotics such as penicillin, ciprooxacin (Cipro), or azithromycin (Zithromax), and the selection of an antibiotic is partially based on the bacterias Gram stain reaction. (See Figure 45-1.)

and pneumonia, especially in children) and Neisseria gonorrhoeae (a common sexually transmitted disease) tetrads, which are arranged in double pairs that appear to look like a square and include Micrococcus luteus that, although considered normal respiratory ora in humans, has been known to cause infection in immunocompromised patients streptococci, which are arranged in chains and include Streptococcus pyogenes (cause of streptococcal throat infection, or strep throat, and scarlet fever as well as the emerging disease necrotizing fasciitis) staphylococci, which are arranged in clusters sometimes known as grapelike clusters and include Staphylococcus aureus, commonly known as Staph aureus (common cause of skin infections and toxic shock syndrome). (See Figure 45-2.)

Bacilli
Bacilli are rod-shaped bacteria that are commonly found in the soil and air. Like cocci, bacilli can have different arrangements. However, unlike the cocci in which a specific bacterium always arranges itself in only one way, most bacilli bacteriawith the exception of coccobacillido not adhere strictly to one arrangement type. For example, most of the bacteria found in the gastrointestinal tract, such as Escherichia coli and Enterobacter, can be in any arrangement of bacilli except for coccobacilli. Bacilli arrange themselves as:

Cocci
Cocci are round or spherical bacteria that, depending on their pattern of growth or arrangement, can be further categorized as:

diplococci, which are arranged in pairs and include Streptococcus pneumonia (common cause of otitis media, bacteremia,

single bacilli, which are arranged as single, separate rods diplobacilli, which are arranged in pairs streptobacilli, which are arranged in chains coccobacilli, which are rods with rounded ends and include Bordetella pertussis (cause of whooping cough) and Haemophilus inuenzae (cause of bacteremia and pneumonia). (See Figure 45-3.)

940

UNIT 3

Clinical

Gram staining
Although most medical assistants will not be performing Gram stains in the medical ofce, it is necessary to understand the theory and practice of Gram staining as it applies to identication of pathogenic bacteria. Bacteria can be classied into two different categories based on their staining. Gram-positive bacteria stain a dark purple, and gramnegative bacteria stain a pink color. After smearing a few colonies of bacteria on a sterile glass microscope slide, an examiner will follow these steps to stain the slide: 1. Flood the slide with crystal violet stain and let it sit for 1 minute. 2. Rinse the slide with running tap water or sterile water. 3. Flood the slide with iodine and let it sit for 2 minutes. 4. Rinse the slide with water. 5. Flood the slide with acetone and let it sit for 5 seconds. 6. Rinse the slide with water. 7. Flood the stain with safranin red stain and let it sit for 30 seconds. 8. Rinse with water. 9. Let the stained slide air-dry and read it under a microscope.
Cocci

Bacilli

Gram Stain Slides. (A) Gram-Positive Bacteria. (B) Gram-Negative Bacteria. (From Bartlet. Diagnostic Bacteriology. FA Davis, Philadelphia, 2000, color plate #2 & #5, with permission)

Spiral bacteria FIG 45-1 Classication of bacteria based on shape.

CHAP TER 45

Microbiology

941

Spiral
Unlike bacilli and cocci, spiral bacteria are classified as rods having a curved or spiral shape. They can be further classified as:

spirilla, which appear as curved rods and include Vibrio cholera (cause of cholera) spirochetes, which appear as helical, or corkscrew-shaped, and include Borrelia burgdorferi and Treponema pallidum. (See Figure 45-4.)

Viruses and Prions

Viruses are pathogens, consisting of a nucleic acid surrounded by a protein coat, that can grow and reproduce only after infecting a host cell. They are extremely small microorganisms and require the use of an electron microscope to view them. Structurally, viruses come in various shapes and sizes. They are considered nonliving because they cannot exist on their own, but require a living cell to reproduce. For example, a virus enters a host cell, takes over that cell, and uses the cells nutrients to multiply. Once the virus has multiplied within the cell, the cell will then burst, thus releasing more virus into the body. (See Figure 45-5.) Viruses possess DNA or RNA and they are insensitive to antibiotics. Unlike bacteria, viruses are not easily classied, but they are distinguished by their size and shape and whether they contain RNA or DNA. Viral shapes also differ from bacterial shapes, with viruses considered more three dimensional, such as helical, icosahedral, and spherical. (See Figure 45-6.) Virus taxonomy is slightly different from that of bacteria and quite complicated. They are grouped as families and their names do not include a genus or species name (although their detailed classication can include subfamilies and genus groupings). Instead, viruses are usually named after the infection they cause or the family in which they are classied. For example, the virus that causes rubella (German measles) is known as the rubella virus and is classied under the Togaviridae family of viruses. Like other pathogenic microorganisms, viruses have the ability to spread from host to host. Infectious diseases caused by viruses include smallpox, chickenpox, rubeola (measles), rubella (German measles), mumps, rabies, herpes simplex, herpes zoster, yellow fever, and hepatitis. Viral infections cannot be treated with antibiotics. There are a few antiviral medications, such as ribavirin (Rebetol) to treat patients with respiratory syncytial virus, acyclovir (Zovirax) for various viral infections, and zanamivir (Relenza) and oseltamivir (Tamiu) for the inuenza virus. A prion, also classied as nonliving, is even less complex than a virus because it consists of only a protein. A prion is a proteinaceous infectious particle that, when transmitted to a human, can cause a spongiform encephalopathy. Creutzfeldt-Jakob disease and kuru are two untreatable and fatal human diseases caused by a prion.

Tetrads

Streptococci (chains)

Staphylococci (clusters)

FIG 45-2 Cocci

942

UNIT 3

Clinical

Single

Diplobacilli

Streptobacilli FIG 45-3 Bacilli.

Coccobacilli

Fungus
A fungus is an eukaryotic organism, which means it possesses a true nucleus with a nuclear membrane. There are unicellular types of fungi, such as yeasts, and more complex multicellular types, such as molds and mushrooms. Fungi play an important role in the environment by decomposing plant and animal wastes. Additionally, some fungi are still used as a source of antibiotics. Human fungal infections can be caused by:

molds, such as the black mold Aspergillus niger (possible cause of lung and ear infections in humans).

As with viral infections, fungal infections cannot be treated with antibiotics. Some antifungal medications, such as amphotericin (Amphocin), miconazole (Lotrimin), and uconazole (Diucan), are used to treat systemic and local fungal infections. (See Figure 45-7.)

yeasts, such as Candida albicans (cause of such local infections as thrush or vulvovaginal infection) and Cryptococcus neoformans (cause of serious systemic infections, such as meningitis, especially in patients with suppressed immune systems)

Protozoa and Parasitic Worms

Protozoa are eukaryotic unicellular microscopic organisms that inhabit soil and water. The majority of protozoa do not cause infection and many of them play an important role in ecology by preying on unicellular microorganisms such as

CHAP TER 45

Microbiology

943

Vibrio FIG 45-4 Spiral bacteria.

Spirochetes

Virus

Host cell

Viruss genetic material

Step 1: Virus encounters and attaches to host cell.

Step 2: Virus enters host cell and injects genetic material into host cell.

Step 4: New virus particles burst out of host cell and are released into the body to infect more cells.

Step 3: Virus's genetic material takes control of host cell and makes copies or replicates within the host cell.

FIG 45-5 Life cycle of a virus.

944

UNIT 3

Clinical

Helical

Icosahedral FIG 45-6 Virus shapes.

Spherical

bacteria, breaking down organic material, and serving as a food source for other animals. Some protozoa are parasitic, which means they require another living organism in order to live and reproduce. Human infections caused by protozoa are serious and can sometimes be difcult to diagnose because, unlike bacteria that simply divide to reproduce, protozoa have a life cycle that includes a trophozoite stage and a cyst stage. The trophozoite stage is considered the growth phase while the cyst stage is the dormant stage. During this dormant stage, the protozoa is protected from various environmental factors that may kill it. If a cyst is ingested by a human, the protozoas life cycle begins and human infection will occur. Medically important protozoa include Giardia lamblia, Trichomonas

vaginalis, Pneumocystis carinii, Cryptosporidium, and Plasmodium. Various treatments for protozoal infections include metronidazole (Flagyl), tinidazole (Tindamax), and chloroquine (Aralen). (See Figure 45-8.) A parasitic worm is a parasite, or a pathogen that requires another living organism to survive. These worms are not microscopic. However, they are commonly discussed with protozoa because many parasitic worm infections involve the ingestion of soil or water that may be contaminated with microscopic worm eggs. Most parasitic worms infect a humans intestinal tract; however, some can migrate to other body systems, such as the lungs and liver. If a person accidentally ingests the worm eggs, the eggs will hatch in the persons intestines and release a worm. Diagnosis is determined by

Pseudohypha Budding

Single

Yeasts FIG 45-7 Fungi.

Mold

CHAP TER 45

Microbiology

945

viral culture acid-fast bacillus (AFB) stain potassium hydroxide (KOH) stain ova and parasite (O&P) determination.

Cyst

Trophozoite FIG 45-8 Giardia lamblia.

visual examination of parasite eggs in the feces or the capture of the actual worm. Commonly seen parasitic worm infections include Enterobius vermicularis, otherwise known as pinworm, and Ascaris lumbricoides. (See Figure 45-9.) Treatment of parasitic worm infections includes the use of medications such as albendazole (Albenza), mebendazole (Vermox), and niclosamide (Niclocide).

The specicity of the testing is not in the type of test, but, instead, in the body site or specimen type collected for testing. The most common test in the microbiology department is called a culture and sensitivity (C&S) test. In order to ensure accurate, specic results from a C&S test, the medical assistant must indicate the site from which the specimen was collected. For example, if the patient comes in with a rash on his lower right arm that looks infected, the physician will order a C&S test of the rash. The medical assistant should collect the specimen from the arm, check off culture and sensitivity on the requisition slip, and write in the site area infected rash from lower right arm. The site of the specimen tells the microbiologist exactly how to process the specimen in order to cultivate the suspected pathogen. In addition to the C&S test, another commonly ordered test is a Gram stain. Although a Gram stain helps identify bacteria that have already grown in a culture, it also helps the microbiologist observe potential bacteria directly from the patients specimen. (See Figure 45-10.)

Bacterial Culture
A bacterial culture is the most common test performed by a typical hospital microbiology laboratory. A physician can request a viral or fungal culture of a patient sample; however, these requests require highly specialized processing and testing. If a physician suspects a person has a protozoal or parasitic gastrointestinal infection, she should order an ova and parasite (O&P) examination of the patients feces. Because the method of testing and the procedure for specimen collection may be different from collecting the typical specimen for a bacterial culture order, the medical assistant should contact

Microbiological Testing
Although many different types of microorganisms cause human infection and disease, only a few general tests are used to detect them, including:

culture and sensitivity (C&S) test Gram stain fungal culture A

FIG 45-9 Enterobius vermicularis. (A) Egg stage. (From Leventhal/Cheadle: Medical Parasitology, 5th ed. FA Davis, Philadelphia, 2002, color plate #1, with permission.) (B) Worm stage. (From Leventhal/Cheadle: Medical Parasitology, 5th ed. FA Davis, Philadelphia, 2002, color plate #5E, with permission.)

946

UNIT 3

Clinical

HARTELL MEMORIAL HOSPITAL LABORATORY

LAB REQUISITION
NAME: ADDRESS: PHONE: DX: DR.

STAT CALL RESULTS

FASTING

NON FASTING ROUTINE

D.O.B.: DATE & TIME DRAWN: SYMPTOM: Medex BCBS Subscribers name: CHEMISTRY MAGNESIUM PSA RUBELLA T3 UPTAKE T4 F4 FREE TSH VALPROIC ACID VITAMIN B12 COAGULATION PRO TIME-INR PRO TIME PTT FIBRINOGEN BLEEDING TIME HEMATOLOGY CBC w DIFF. PLTS CBC wo DIFF HCT HGB HCT/HGB PLATELET COUNT RETIC CT SED RATE WBC WBC/DIFF SEROLOGY ANA ASO CMV IgG CMV IgGM CRP RH. PYLORI ab Mono RA/RF RPR RUBELLA OTHER STOOL ANALYSIS BLOOD S S S S PK B U U R U U R G L S COLLECTION CODES Blue Red Green Lavender Stool U SS F Urine SST Fluid FECAL FAT (Quant) FECAL WBC C. DIFFICILE OVA & PARASITES URINALYSIS URINALYSIS 24 HR. URINE HCG-SERUM HCG-URINE MICROALBUMIN R R SS SS R R R R SS SS L L L L L L L L L L B B B B B CC LG R R R LG LG LG R R LG R FLUIDS SOURCE FLUID CELL CT FLUID DIFF FLUID GLUCOSE FLUID PROTEIN FLUID LDH FLUID CHLORINE FLUID CULTURE FLUID CRYSTALS FLUID PH POST VAS SPERM MICROBIOLOGY AFB STAIN AFB CULTURE ANAEROBIC CULTURE BLOOD CULTURE CHLAMYDIA/GC PROBE EAR CULTURE R L FLUID CULTURE SOURCE FUNGAL CULTURE GC CULTURE GRAM STAIN SOURCE KOH PREP NOSE CULTURE RAPID STREP RAPID UREASE SPUTUM CULTURE STOOL CULTURE THROAT CULTURE URINE CULTURE VAGINAL CULTURE VIRAL CULTURE SOURCE WOUND CULTURE SOURCE VAGINAL VP3 F F F F F F F F F F AFP CA 125 CLOZARIL CORTISOL AM CORTISOL PM CYCLOSPORINE ESTROGEN FSH LH HEP BE Ag HEP BE Ab HEP Bs Ag HEP Bs Ab HEP C LEAD RUBEOLA ADDITIONAL TESTS CC BLOOD BANK ABO/RH BLOOD TYPE DIRECT COOMBS TYPE & SCREEN TYPE & CROSS 1U TYPE & CROSS 2U TYPE & CROSS 3U TYPE & CROSS 4U OTHER TESTS CC R L R R R R R CC SS SS R SS SS L SS SS SS SS SS SS SS Patient Other

BILL TO: (CIRCLE ONE) Policy #:

MICROBIOLOGY
Medicare

AFB STAIN
R/G LG LG R R LG

CHEMISTRY PANELS ELECTROLYTES BASIC METABOLIC COMP METABOLIC RENAL HEPATIC LIPID CARDIAC *

AFB CULTURE CC BLOOD CULTURE EAR CULTURE LG R L FLUID LG CULTURE R SOURCE R

U

ANAEROBIC CULTURE PHENOBARB LG

SALICYLATE LG CHLAMYDIA/GC PROBE

ACUTE HEPATITIS OBSTETRICAL

THYROID SCREEN S DRUGS ABUSE U DRUGS ABUSE CHEMISTRY ALB ALK PHOS

THYR CASCADE *

FUNGAL CULTURE GC CULTURE LG GRAM STAIN LG SOURCELG

LG KOH PREP LG LG LG

ALT (SGPT) ALT (SGOT) AMYLASE T BILI D BILI BUN CALCIUM CHOL CREAT CK GLUC GLUC 1 HR HDL LDH PHOS NA K CHLORIDE CO2 T PROTEIN TRIG URIC ACID

NOSE CULTURE LG RAPID LG STREP RAPID LG UREASE LG SPUTUMLGCULTURE STOOL LG CULTURE THROATLGCULTURE URINE LG CULTURE
LG LG LG LG LG LG LG LG

LG

SS HIV 1.2 MASTERTUBE SS L SS

GLUC TOLERANCE

LDL (Quant)

VAGINAL CULTURE VIRAL LG CULTURE SOURCELG WOUND LG CULTURE

R R R SS SS SS SS L R R R R R VAGINAL VP3

ACETAMINOPHEN ALCOHOL B-HCG (Quant) B-HCG TUMOR CEA DIGOXIN DILANTIN GENTA TROUGH GENTA PEAK GLYCOHEM FERRITIN FOLIC ACID IRON IBC CARBAMAZEPINE

OCCULT DOG BITE ARM SOURCELG

PHYSICIAN ACKNOWLEDGMENT The undersigned physician certifies for the laboratory: 1) the tests ordered on this requisition are medically necessary for the diagnosis and treatment of the patient; the physician is treating the patient in connection with the diagnosis or symptoms listed on this requisition; and the medical necessity of each test ordered on the requisition is appropriately documented in the patients medical record. 2) tests ordered using customized panels may result in denial of payment by Medicare and, 3) the physician believes the tests ordered are appropriate for patient care, and payment may be denied by Medicare for reasons explained to the patient, who has agreed to pay for the tests personally by signing an Advanced Beneficiary Notice (ABN).

SIGNATURE

DATE

FIG 45-10 Laboratory requisition slip with microbiological tests.

the clinical laboratory for the proper collection procedure for a viral or fungal culture request or O&P determination. There are a few ways that the testing performed in the microbiology department of the clinical laboratory differs from tests performed in other departments, such as hematology and chemistry. First, while most testing in hematology and chemistry departments involves blood samples, the majority of microbiological testing involves body substances other than blood. Second, specimen processing is more involved in microbiological testing. Most hematological or chemistry testing is done by putting the blood sample in an autoanalyzer; microbiological specimens require specialized cultures that involve placing the specimen on various culture media and then putting them in a temperature-controlled

environment for 24 to 72 hours. The culture mediums main ingredient is agar, a gel-like substance. Thus, the medium is commonly known as an agar plate. It also contains various substances that the bacteria need in order to grow (if present in the patient sample). Some of the common growth substances used in manufacturing commercially prepared culture media include glucose, sucrose, maltose, and sheeps blood. (See Figure 45-11.) The laboratory maintains the required temperature-controlled environment by using an incubator. Because most pathogenic bacteria grow best at body temperature (37C), the incubator is usually set to 37C. (See Figure 45-12.) Finally, the laboratory tests typical blood samples when they arrive and usually generates a nal report within a few

CHAP TER 45

Microbiology

947

interprets the bacterial growth, identies the type or types of bacteria present, and generates a laboratory report indicating the name of the pathogen and the quantity present in the sample. (See Figure 45-13.)

Antimicrobial Susceptibility Testing

Susceptibility is the degree to which a microorganisms growth can be inhibited by an antimicrobial agent, which is any chemical substance (such as an antibiotic) that has the ability to kill or stop the growth of a microorganism. A pathogenic bacteria that is reported as being susceptible to ciprooxacin (Cipro), for example, indicates that this drug will kill or inhibit the growth of the bacteria and may be used to treat the patients infection. Resistance refers to a microorganisms ability to withstand the effects of an antimicrobial agent. Thus, a drug to which bacteria are reported as resistant should not be used to treat a patients infection because the test demonstrates that the drug does not kill or inhibit the growth of the bacteria. When a culture enables the microbiologist to identify a pathogenic bacteria in a patient specimen, the microbiologist will most likely perform an antimicrobial susceptibility test. This test determines the correct antimicrobial agent to use to kill the pathogen. An antibiotic is a type of antimicrobial agent. There are two types of antimicrobial susceptibility testing in the microbiological laboratory: the disk-diffusion method and minimum inhibitory concentration (MIC) method. The disk-diffusion method is an older, more manual method that involves diluting the pathogenic bacteria and spreading the sample onto the surface of a Mueller-Hinton

C B

FIG 45-11 Culture media used in the microbiology laboratory. (A) Blood culture bottles. (B) Blood agar plate. (C) Nutrient agar plate.

hours. However, the laboratory may wait up to 72 hours to generate a nal patient report on a microbiological specimen because of the bacterias incubation period, or the time the bacteria need to multiply and grow. If bacteria are present in the patient sample, colonies of bacteria will become visible on the culture media. The microbiologist then identies and

FIG 45-12 Typical microbiological incubator in which the agar plates are placed.

948

UNIT 3

Clinical

Physician or medical assistant calls patient with results.

Medical assistant collects throat specimen from patient.

Throat specimen is labeled, requistioned, and packaged.

Medical assistant shows report to physician.

Specimen is sent to the microbiology laboratory.

Medical assistant receives patients laboratory report.

Microbiologist inoculates blood agar plate (BAP) with specimen.

Patients laboratory report is generated and sent to physicians office.

Blood agar plate is incubated at 37 for 24 hours.

Results are recorded.

If culture is positive for Beta Strep Group A, the test is completed.

Blood agar plate is observed for Beta Strep Group A.

Blood agar plate is observed again for Beta Strep Group A.

If culture is negative after 24 hours, it is incubated for an additional 24 hours.

FIG 45-13 Life cycle of a throat culture.

agar medium. Then, individual paper discs that are impregnated with a known concentration of an antibiotic are placed on the agar plate. Usually ve to ten antibiotics are tested against one known pathogenic bacteria. The microbiologist sets the agar plate in the incubator for 18 to 24 hours and then observes the plate to see if a zone of inhibition appears around any of the antibiotic discs. (See Figure 45-14.) The microbiologist then measures each zone and lists the susceptibility of the pathogen to each antibiotic qualitatively as sensitive, moderately susceptible, or resistant, based on guidelines developed by the National Committee for Clinical Laboratory Standards (NCCLS). The MIC is a more advanced and, usually, automated method of determining an antimicrobial agents usefulness against certain bacteria. However, the MIC tests only for antibiotics and not other antimicrobial agents. Thus, it is useful when testing for susceptibility to bacteria but not viruses and other pathogens. Instead of using an agar medium for testing, the MIC involves the use of a plastic,

FIG 45-14 Disk-diffusion method for antimicrobial susceptibility testing. (From Bartlet. Diagnostic Bacteriology. FA Davis, Philadelphia, 2000, color plate #54, with permission)

CHAP TER 45

Microbiology

949

square panel with rows of wells. Each well has a predetermined dilution of antibiotic as provided by the manufacturer and is labeled with the antibiotic name and the dilution. The microbiologist introduces the pathogenic bacteria suspended in sterile saline solution into each well, incubates the panel for 24 to 48 hours, and then looks at each well to see if there is growth, determined by a cloudiness within the well. A well that is clear is considered no-growth, which means that the pathogen is susceptible to the effects of the antibiotic in that well. The no-growth well with the lowest dilution of an antibiotic is considered the minimum inhibitory concentration (MIC), or the lowest level of antibiotic that will be effective against the pathogen. The microbiologist reports the MIC dilution number for each antibiotic tested. Although the pathogen may be isolated prior to MIC testing, it may not be identied. Thus, sometimes MIC testing involves identication of the pathogen in the patient sample. In such a case, the microbiologist will use a special panel from the manufacturer, called an ID-MIC panel, that will also include wells in an identication section. The identication section is a series of wells that contain different chemicals that may change color, depending on the type of bacteria tested. The microbiologist will analyze the various color change patterns in the wells and identify the pathogen. (See Figure 45-15.) Regardless of the method, the microbiologist generates a report that will indicate to the physician the best antimicrobial agents to use to treat the patients infection. (See Figure 45-16.) The physician will read the entire susceptibility report and make a decision based on the patients condition and his medical history of tolerance or allergy to antimicrobial agents, if any. The report will usually identify the pathogen as susceptible, moderately susceptible, or resistant. Some bacteria are highly resistant to most antimicrobial agents and, thus, create a dilemma for physicians when

prescribing a drug to treat infections caused by those bacteria. (See MRSA, page 950.)

Microbiology Procedures
Proper specimen collection procedures are the rst step in accurate patient specimen testing. Most POLs have a specimen collection procedure manual that explains the correct procedure. To ensure proper collection, the medical assistant should be sure to select the proper site, use the proper collection swab and container, provide a complete requisition slip, and, nally, package and transport the specimen appropriately. When the laboratory receives the specimen, the microbiologist will determine the adequacy of the specimen. If she nds it to be inadequate for any reason, she will reject it. (See Specimen rejection, page 951.)

Specimen Collection for Microbiological Analysis

Microbiological testing can analyze almost any body tissue, uid, or secretion. Specimens routinely collected using a sterile culture swab include:

eye drainage, usually to detect bacteria that cause conjunctivitis ear drainage, possibly to conrm serous otitis media or fungal infection throat specimen, typically to detect beta Streptococcus group A (See Procedure 45-1: Collecting a throat specimen for microbiological testing, page 951.) urogenital specimen, typically to detect a sexually transmitted disease (STD) rectal specimen, sometimes collected from babies to detect a food-borne illness wound drainage, such as drainage from a rash, an infected surgical incision, and an animal bite, to detect various kinds of bacteria. (See Procedure 45-2: Collecting a wound specimen for culture, page 952.)

Specimens routinely collected using a sterile container include:

FIG 45-15 MIC test for antimicrobial susceptibility on bacteria. (From Bartlet. Diagnostic Bacteriology. FA Davis, Philadelphia, 2000, color plate #71, with permission)

urine, to detect infections of the urinary tract, bladder, or kidneys blood, to detect any bacteria that have entered the bloodstream and caused bacteremia sputum, to conrm pneumonia (See Procedure 45-3: Collecting a sputum specimen for culture, pages 952 and 953.) feces, to conrm food-borne illness (See Stool specimen collection, page 953.) body uids, such as ascites, peritoneal uid, and synovial uid, to detect any pathogen that may have infected these normally sterile body uids.

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PATIENT LABORATORY REPORT HARTELL MEMORIAL HOSPITAL LABORATORY Name: Seth Banas M/R#: 032608 D.O.B.: 05/02/63 45 Physician: Greer, R. Location: Outpatient Sex: M Date ordered: 08/30/2008 Date collected: 08/30/2008 Time collected: 0 Date tested: 08/30/2008 Time tester: 21:41 Accession Number: 0007413225

CULTURE WOUND SOURCE: Abdominal wound GRAM STAIN: 1020 WBC few gram-negative rods <<<<<<<<<<24 HOUR PRELIMINARY REPORT>>>>>>>>>> ORGANISM #1: Many growth gram negative rods <<<<<<<<<<48 HOUR FINAL REPORT>>>>>>>>>> COLONY COUNT: Many ORGANISM: Enterobacter aerogenes drug ampicillin ampicillin/sulbactam cefazolin cepotetan ceftriaxone cefuroxime ciprofloxacin gentamicin nitrofurantoin TMP/SMX levofloxacin pipercillin/tazobact S = Susceptible MIC >16 16/18 >16 8 8 >16 1 1 2/38 1 16/4 MS = Moderately Susceptible Interpretation R I R S S R S S S S S I = Intermediate R = Resistant

FIG 45-16 Antimicrobial susceptibility report.

MRSA
Some strains of Staphylococcus aureus are resistant to most forms of penicillin, such as methicillin and nafcillin. These strains are commonly known as methicillin-resistant Staphylococcus aureus (MRSA). When the microbiology laboratory identies a strain of S. aureus as resistant to methicillin, it is most likely resistant to all other antibiotics. Patients identied as infected with this highly resistant strain of bacteria have an increased chance of mortality because there may be no other antibiotic to treat the infection.

As is with other types of specimens, the medical assistant must take care when collecting and processing a microbiological specimen to avoid contaminating the specimen or exposing herself to a pathogenic microorganism. The medical assistant should observe standard precautions at all times:

Wear appropriate personal protective devices, such as gloves, gowns, and a mask. Upon collection, properly label the specimen with the patients name, the date and time of the culture, and the specic site of the specimen. Put the specimen in a biohazard transport bag. Wash her hands after specimen collection.

CHAP TER 45

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Specimen rejection
Clinical laboratory personnel will always assess a patient specimen submitted to the laboratory for microbiological testing before processing the specimen. If the laboratory determines that a specimen is unacceptable for processing, the microbiologist will usually call the medical ofce to tell them to collect another specimen as well as send a written report about the reason for specimen rejection. Some common reasons for rejection include: unlabeled or improperly labeled specimen delayed transport improper container (nonsterile) oropharyngeal contaminated sputum unsuitable specimen (such as a request for an anaerobic culture on a specimen collected on an aerobic swab) quantity not sufcient (QNS).

In addition to these precautions, the medical assistant should remember that proper timing is essential in many ways to successful collection and analysis of microbiological specimens. For example, the laboratory will decide if it needs optional specimens based on the infectious process being tested and the laboratorys ability to process the specimens in the required time frame. In addition, the rst early morning sputum and urine specimens are optimal for recovery of pathogens. Although specimens collected at other times are acceptable, the medical assistant should consider the best method for achieving the desired result. Finally, the physician determines blood culture timing. The standard order for blood culture collection is three cultures within a 24-hour period. (See Completing a microbiological requisition slip, page 953.)

Microbiological Testing Performed in the POL

The most common microbiological tests performed in the physicians ofce laboratory (POL) is the rapid streptococcal test. The second most common test in the POL is a complete throat culture. Both tests detect the presence of the

PROCEDURE 45-1

Collecting a throat specimen for microbiological testing

Task Collect a throat specimen for culture or rapid Strep testing. Conditions Disposable examination gloves Tongue depressor Sterile culture swab Label Laboratory requisition slip Biohazard specimen transport bag Biohazard waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully collect a throat specimen for culture or rapid Strep testing. Performance Standards 1. Greet and identify your patient. Introduce yourself and explain the procedure to prevent errors and ease patient anxiety. 2. Wash or sanitize your hands to ensure infection control and gather supplies. 3. Position the patient in an upright, sitting position and adjust the light if necessary to maximize the viewing of and access to the patients oropharynx. 4. Put on the gloves and mask per standard precautions. Instruct the patient to open his mouth widely. 5. Remove the swab from the tube. While depressing the patients tongue with a tongue depressor, swab the back of the patients throat and tonsils, taking care to thoroughly swab areas that appear inamed or covered in exudate. Also take care to avoid touching the patients tongue or teeth to ensure accuracy of results. 6. Place the swab back in the tube and crush the transport media ampule to moisten and preserve the specimen. 7. Dispose of the tongue blade in the waste container to ensure infection control. Apply the label to the culture tube and attach the completed requisition slip per laboratory policy to ensure timely processing of the specimen. 8. Remove the gloves and mask and wash your hands to ensure infection control. Document the procedure to ensure accuracy of the medical record.
Date 06/11/08; 9:35 a.m. Sputum specimen collected and sent to lab for culture. ------------------------------------------------------------- S. Gonzalez, CMA

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PROCEDURE 45-2

Collecting a wound specimen for culture

Task Collect a wound specimen for culture. Conditions Sterile culture swab Label Laboratory requisition slip Biohazard specimen transport bag Disposable examination gloves Gown or laboratory coat with a zipper or button closure Biohazard waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully collect a wound specimen for culture. Performance Standards 1. Assemble the supplies. Advance preparation facilitates efciency during the procedure. 2. Greet and identify your patient. Introduce yourself and explain the procedure to prevent errors and ease patient anxiety. 3. Wash or sanitize your hands to ensure infection control. 4. Clean and decontaminate the surrounding skin area to avoid contaminating the specimen with normal skin ora. 5. Swab the infected area, being sure to swab any purulent discharge. Purulent discharge contains pathogenic organisms. 6. Properly insert the swab into the collection tube and activate the transport medium by squeezing the bottom of the tube to moisten and preserve the specimen. 7. To ensure timely processing of the test, label the culture swab with the patients name, the date and time, and the specic site of the specimen and place it in the proper biohazard transport bag. 8. Complete the laboratory requisition slip and attach it to the specimen bag, according to facility policy. Send the specimen to the laboratory in a timely manner. A lost or missing requisition slip will delay specimen processing, which may compromise the accuracy of test results. 9. Properly dispose of all supplies and wash your hands to ensure infection control. 10. Document the procedure to ensure the accuracy of the medical record.
Date 02/07/08; 11:15 a.m. Throat specimen collected and sent to lab for culture, ------------------------------------------------------------- S. Gonzalez, CMA

PROCEDURE 45-3

Collecting a sputum specimen for culture

Task Collect a sputum specimen for culture. Conditions Sterile specimen cup Label Laboratory requisition slip Approved specimen container bag Disposable examination gloves Face shield or mask and goggles Gown or laboratory coat with a zipper or button closure Biohazard waste container Cup of water Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully collect a sputum specimen for culture. Performance Standards 1. Assemble the supplies. Advance preparation facilitates efciency during the procedure. Complete the label and afx it to the specimen cup (not to the lid) to ensure that the specimen will remain labeled and will not get confused with other specimens in the laboratory after the lid is removed. 2. Greet and identify your patient. Introduce yourself and explain the procedure to prevent errors and ease patient anxiety. 3. Wash or sanitize your hands and apply the face shield or mask and goggles to ensure infection control. 4. Hand a glass of water to the patient and ask her to rinse her mouth to remove food particles from her mouth. 5. Instruct the patient to take two deep breaths, cough deeply, and spit the sputum into the cup. Deep

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coughing is needed to bring secretions up from the lungs. Saliva from the mouth will not provide an adequate specimen. 6. Make sure that no one touches the inner surfaces of the cup or lid to ensure that external microorganisms do not enter the cup to compromise the results, and apply the lid and secure it snugly to ensure that the specimen does not leak out. Place the specimen cup into the specimen bag and seal it. 7. Afx the requisition slip to the specimen bag, according to facility policy, and send it to the laboratory in a timely manner. A lost or missing requisition slip will

delay specimen processing, which may compromise the accuracy of test results. 8. Properly dispose of all supplies and wash your hands to ensure infection control. Document the procedure to ensure accuracy of the medical record.

Date 06/12/08; 9:10 a.m. Infected surgical wound, Specimen collected for culture and sent to lab. ----------------------------------- S. Gonzalez, CMA

bacteria beta Streptococcus group A, also known as Streptococcus pyogenes, in throat specimens. Streptococcus group A is the causative agent for streptococcal throat infection, commonly called Strep throat or streptococcal pharyngitis.

Rapid Streptococcal Test

Early diagnosis and treatment of streptococcal throat infection is important because the pathogen can develop into a

more severe systemic infection, such as scarlet fever or rheumatic fever. Most commercially prepared streptococcal test kits are CLIA-waived, are easy to perform, and provide results in 5 minutes. The medical assistant should familiarize herself with the quality control steps required for the kit as well as the proper procedure for performing the test. (See Procedure 45-4: Performing a rapid streptococcal test, page 954 and 955.)

Throat Culture Test

Patient Education
Although most commercial rapid streptococcal test kits are extremely sensitive for the pathogen that causes streptococcal throat infection, these kits may sometimes give a falsenegative result. For this reason, manufacturers instructions may instruct the physician to order a throat culture if the patients clinical assessment warrants the test. For this

Stool Specimen Collection

A patient may be confused about how to collect a stool specimen for analysis and may feel uncomfortable discussing it. However, the medical assistant must explain the procedure clearly so that the patient can collect the specimen properly. The medical assistant should include these steps: 1. Using the plastic wrap, loosely line the outside of the toilet seat so that it will catch the specimen. 2. Do not collect the specimen from the toilet bowl because it may be contaminated with urine. 3. Use the plastic wrap to handle the stool and carefully slide the required amount of the specimen from the wrap into the container. 4. When collecting a specimen from an infants diaper, line the diaper with plastic wrap as well. Because an infants stool is commonly loose in consistency, it may be absorbed into the diapers bers; a specimen that contains diaper bers would be unacceptable. Use the plastic wrap to handle the stool and carefully slide the specimen into the sterile container supplied by the ofce.

Front ofceBack ofce connection

Completing a Microbiological Requisition Slip

Usually, the clinical medical assistant is responsible for completing a laboratory requisition slip for microbiological testing. However, in a small ofce or on a busy day, the administrative medical assistant may be required to ll out the slip. Although the slip may not list the exact specimen type, it should always include an area where the medical assistant can indicate the specimen type. For instance, for a specimen collected from a wound caused by a dog bite, the medical assistant should indicate the cause of the wound instead of simply writing wound on arm. Such information is essential for the laboratory technologist, because wounds caused by a dog or cat bite may be infected with rare bacteria that a technologist may not normally attempt to detect when testing a specimen.

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PROCEDURE 45-4

Performing a rapid streptococcal test

Task Perform a rapid streptococcal test. Conditions Commercial rapid streptococcal test kit Disposable examination gloves Gown or laboratory coat with a zipper or button closure Biohazard waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully perform a rapid streptococcal test. Performance Standards 1. Assemble the supplies and prepare the test kit. Advance preparation facilitates efciency during the procedure. Run quality control procedures before testing the patient specimen. Quality control results must be within limits or the patient specimen cannot be tested. 2. Greet and identify your patient. Introduce yourself and explain the procedure to prevent errors and ease patient anxiety. 3. Wash or sanitize your hands and put on the gloves to ensure infection control. 4. Properly collect a throat specimen, taking care to avoid touching the patients tongue or teeth with the swab because doing so will contaminate the specimen. 5. To ensure the accuracy of results, follow the manufacturers directions and place the required number of reagent drops into the plastic testing tube. 6. Place the throat specimen swab into the swab chamber of the test cassette. 7. Add the extraction solution to the chamber. Fluid should ll the chamber to the rim (approximately 10 drops). When the uid has been added, watch for the liquid to move across the results window, which indicates that you performed the test properly.

Putting the required amount of drops in the test cassette

8. Begin timing after adding the solution. 9. After 5 minutes, read the results using the manufacturers result chart.

Placing the throat swab into the test cassette

Positive result for beta Streptococcus group A

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PROCEDURE 45-4contd

10. Dispose of the throat swab and all testing supplies in a biohazard waste container to ensure infection control. Document the results in the patients chart to ensure accuracy of the medical record.

Date 06/13/08; 10:30 a.m. Rapid strep test performed. Result: positive. -------------------------------------------------------------------------- S. Gonzalez, CMA

reason, some medical ofces prefer to perform the actual throat culture instead of conducting a rapid streptococcal test. Results of a throat culture will not be available for 24 to 48 hoursconsiderably longer than a rapid streptococcal test result. However, because a throat culture is a simple procedure that can be done in the POL, preliminary results may be available within 24 hours.
PROCEDURE 45-5

In addition to collection of a throat specimen, the medical assistant must also be familiar with the processing and testing of the actual culture procedure. (See Procedure 45-5: Processing a throat culture.)

Processing a throat culture

Task Process a throat culture. Conditions Sterile culture swab Tongue depressor Sheep blood agar media plate Sterile disposable inoculation plastic loop Bacitracin disc 37C incubator Approved specimen container bag Disposable examination gloves Gown or laboratory coat with a zipper or button closure Biohazard waste container Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully process a throat culture. Performance Standards 1. Assemble the supplies. Advance preparation facilitates efciency during the procedure. 2. Greet and identify your patient. Introduce yourself and explain the procedure to prevent errors and ease patient anxiety. 3. Wash or sanitize your hands and put on the gloves to ensure infection control. 4. Properly collect the throat specimen, taking care to avoid touching the patient tongue or teeth because doing so will contaminate the specimen. 5. Roll the swab onto the top quarter of the blood agar plate to reserve room on the plate to make subsequent streaks and enable an accurate reading of the results. This streak is known as the primary streak.

Rolling the throat swab onto the top quarter of the blood agar plate Continued

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6. Using a sterile disposable plastic inoculation loop, spread the specimen from the primary streak into a secondary and tertiary streak to dilute the specimen and make it easier to read the results.

Making a third streak using the same disposable loop

Streaking the primary streak into a secondary streak using a sterile disposable plastic loop

7. Place the bacitracin disc on the primary streak of the sheep blood agar plate.

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PROCEDURE 45-5contd

8. Incubate the sheep blood agar plate in the 37C incubator for 18 to 24 hours to facilitate growth of the pathogen, if present. Do not incubate the specimen for more than 24 hours because overincubation could cause overgrowth of normal ora and may cause erroneous results. 9. After 18 to 24 hours, remove the sheep blood agar plate from the incubator and read the results. If beta Streptococcus group A is present, there will be a zone of inhibition around the bacitracin disc. 10. Properly dispose of all supplies and wash your hands to ensure infection control. Document the procedure in the patients chart to ensure accuracy of the medical record.
Date 06/27/08; 1:25 p.m. Throat culture taken and processed. Culture will be read tomorrow and patient will be notified of results. ----------------------------------------------------------------------- S. Gonzalez, CMA

Applying the bacitracin disk to the primary streak

Chapter Summary

Microbiology is the study of microorganisms. Although there are thousands of microorganisms in the world, only about 5% are pathogenic to humans. The scientists Van Leeuwenhoek, Jenner, Ehrlich, Pasteur, Koch, Lister, Gram, and Fleming made great contributions to the eld of microbiology. Not all microorganisms are pathogenic. Some bacteria are considered normal flora because they reside in the body and do not cause harm and can be beneficial to the body. Bacteria are prokaryotic microorganisms that are classied according to their shape and Gram stain characteristics. There are three basic shapes of bacteria: cocci, bacilli, and spiral.

Viruses are nonliving parasites that cause disease. They require a host to live and replicate. Prions are protein particles that, when introduced into the body, can cause an incurable condition. Fungi are eukaryotic microorganisms that can be unicellular or multicellular. Fungi are classied as yeasts or molds. Protozoa are eukaryotic microorganisms that inhabit soil and water. Many protozoa cause gastrointestinal infections. Parasitic worms start out as microscopic eggs but grow to be a macroscopic animal. The majority of testing performed in the microbiology department consists of such bacterial cultures as throat culture, sputum culture, and wound culture. Viral and fungal cultures require special collection and testing techniques.

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After a microbiologist isolates and identies a pathogenic bacteria, she will perform an antimicrobial susceptibility test to help the physician determine which antibiotic will treat the specic infection. The rapid streptococcal test is the most commonly performed microbiological test in the POL. The throat culture test can also be performed in a POL but requires more specialized supplies, equipment, and interpretation than a rapid strep test.

to test for streptococcal throat infection (rapid streptococcal test kit, throat culture, or sending the specimen out to a reference laboratory). Ask the ofce the reason for its testing choice. Then compare your results with the class.

Case Studies
1. You just performed a rapid streptococcal test on Alyssa Gadois, a 4-year-old girl who did not hold still while you were taking the throat specimen. The quality control was in range, and her test result was negative. What is your next course of action? 2. Dr. Yang has just nished examining Gary Quinns abdominal surgical wound. She has asked you to take a culture of the wound. Describe what you would do.

Team Work Exercises

1. Divide into groups of 2 to 3 students. Your instructor will assign each group a different microbiological infection for your group to research. Please provide the following information in your report: a. name of the infection b. causative agent for the infection c. how the infection is diagnosed d. how the infection is treated. 2. Divide into groups of 2 to 3 students. Your instructor will assign a local medical ofce for your group to contact. Ask your assigned ofce about which method it is using

Resources

American Society for Microbiology: www.asm.org Centers for Disease Control and Prevention: www.cdc.gov Clinical Laboratory Standards Institute: www.nccls.org Tortora, G.J., et al.: Microbiology: An Introduction, 9th ed. Menlo Park, CA.: Benjamin Cummings, 2007.

CHAPTER

Bioemergency Response and Preparedness

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary discuss the importance of bioemergency preparedness for the medical ofce list various biological agents that have the potential to be used in bioterrorism events discuss the importance of the laboratory response network in relation to a bioterrorism event explain the safety implications of handling suspected organisms in clinical specimens and isolates discuss the importance of planning for a pandemic inuenza outbreak explain the role of the medical assistant during a bioterrorism event and a pandemic inuenza outbreak.

46
Pandemic Response Plan

CAAHEP Competencies
Clinical Competencies Fundamental Principles
Dispose of biohazardous materials Practice standard precautions

Bioterrorism Response and the Medical Assistant Pandemic Inuenza Chapter Summary Team Work Exercises Case Studies Resources

Specimen Collection
Obtain specimens for microbiological testing

ABHES Competencies
Clinical Duties
Collect and process specimens

Chapter Outline
Emergency Preparedness Bioterrorism
Agents Used in Bioterrorism Categories of bioterrorism agents Laboratory Response Network Federal laboratory Reference laboratory Hospital clinical laboratories

959

Key Terms
bioterrorism

Emergency Preparedness
Two of the largest threats to public health in the United States include a bioterrorism attack and an inuenza pandemic. Bioterrorism is the intentional or threatened use of biological agents or toxins to produce death, disease, or fear in an individual or a population for political, religious, or personal reasons. A pandemic is the occurrence of a disease that has reached epidemic proportions in many different parts of the world at the same time. After the events of September 11, 2001, U.S. local, state, and federal governments began developing procedures and protocols in the event that either of these threats occurs. This proactive preparedness has in turn spurred preparedness planning by health care facilities, local school systems, colleges and universities, businesses, and individuals. Preparedness activities include planning responses to an attack or outbreak, monitoring an outbreak, determining methods of communicating with the public and emergency responders, and establishing diagnosis and treatment plans as well as evacuation plans.

Intentional or threatened use of biological agents or toxins to produce death, disease, or fear in an individual or a population
bioterrorism agent

Any substance, such as a bacteria, virus, or other germ that is released during a bioterrorism attack
covert event

Unannounced event that involves the release of an agent or toxin without any advanced warning
epidemic

The occurrence of a disease or health-related event in which many individuals within an area or population are affected at the same time
inuenza

Highly infectious acute respiratory infection that is characterized by a sudden onset of fever, chills, body aches, and cough
overt event

Attack that is announced prior to or after the release of the bioterrorism agent
pandemic

Occurrence of a disease that has reached epidemic proportions in many different parts of the world at the same time
pandemic u

Bioterrorism
The threat of a bioterrorism attack has been in the forefront of U.S. national security planning since the attacks on September 11. However, bioterrorism attacks are not something new to this era. In fact, they have occurred throughout history and as far back as 600 B.C.E., when the Assyrians poisoned the wells of their enemies with rye ergot. During American colonial times, colonists supplied a Native American tribe with blankets infected with smallpox, eventually wiping out the tribe. Bioterrorism attacks can be classied as overt or covert events. An overt event is an attack that is announced prior to or after the release of the bioterrorism agent by the individual or group responsible. Such an announcement might name the agent that has been released as well as the location. An overt event may be a hoax; however, an emergency response must occur until the threat can be disproved. A covert event is an unannounced event that involves the release of an agent or toxin without advanced warning. If a covert event occurs, medical ofce staff may observe an increase in the number of patients with the same symptoms from unknown causes or an infection that is not normally seen in that area. Regardless of the nature of the potential attack, a rapid response and notication of the proper authorities is essential to the successful management of the attack.

Virulent human u that causes a global outbreak, or pandemic, of serious illness

Agents Used in Bioterrorism

A bioterrorism agent is any substance, such as a bacteria, virus, or other germ, that may be released during a bioterrorism

CHAP TER 46

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attack. Agents involved in an attack may be biological or chemical. If an incident were to occur in a community, medical ofce personnel such as medical assistants, nurses, and physicians would most likely be the rst heath care professionals to see patients who may have been exposed to such agents. Health care professionals must take some important steps if they suspect a patient has been exposed to a bioterrorism agent. The rst step is to have knowledge of various bioterrorism agents and the infectious diseases they cause. Second, once a health care professional suspects that a patient has been exposed to a bioterrorism agent, she should limit exposure to the patient. She should isolate the patient from other patients and protect herself and other health care professionals by ensuring that they are wearing the proper

personal protective equipment (PPE). (For a review of proper standard precautions as well as a list of PPE, please refer to Chapter 19, Infection Control and Medical and Surgical Asepsis, page 285.)

Categories of Bioterrorism Agents

The Centers for Disease Control and Prevention (CDC) has separated bioterrorism agents into three categories based on the ease with which each can spread disease and the severity of that disease. The categories range from A to C, with category A considered the highest risk and category C an emerging threat for disease. (See Bioterrorism agents.) Individuals can suffer exposure to most of these agents through inhalation, ingestion, or physical contact.

Bioterrorism agents
The following table lists three categories of bioterrorism agents, as dened by the Centers for Disease Control and Prevention (CDC), along with the major characteristics of those agents and some examples of each.

Category
Category Ahighest risk to public health and national security

Characteristics
Potential for mass casualty Easily disseminated if aerosolized Easily spread from person to person Could cause high death rates Causes high level of panic Requires special action for public health preparedness

Example
Bacillus anthraciscausative agent of anthrax Clostridium botulinumcausative agent of botulism Yersinia pestiscausative agent of the plague Francisella tularensiscausative agent of tularemia Variola major viruscausative agent of smallpox

Category Bsecond highest risk to public and national security

Moderately easy to spread Results in moderate illness rates and low death rates Requires specic enhancements of CDCs laboratory capacity and enhanced disease monitoring

Brucella speciescausative agent of brucellosis Coxiella burnetiicausative agent of Q fever Salmonella speciescausative agent of salmonellosis Escherichia coli O157:H7causative agent of hemolytic uremic syndrome and food poisoning

Category Cthird highest risk to public and national security

Emerging pathogens Easily available Easily produced and spread Potential for high illness and death rates

Mycobacterium tuberculosiscausative agent of tuberculosis (TB) Nipah virus Hantaviruscausative agent of hemorrhagic fever or pneumonia

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Laboratory Response Network

The key to identifying a possible threat to public health is the development of a network consisting of national, governmental, private reference, state public health, and local hospital laboratories. In 1999, the CDC, along with the Association of Public Health Laboratories (APHL), the Federal Bureau of Investigation (FBI), the Department of Defense (DOD), and each states public health laboratories established a collaborative, voluntary system of laboratories called the Laboratory Response Network (LRN) for Bioterrorism. Staff at the laboratories in this network are trained in identifying and handling not only bioterrorism attacks but any other threat to public health, such as emerging infectious diseases and a possible pandemic caused by a known or unidentied microorganism. The goals of the LRN are early detection and disease prevention. The role of clinical laboratories in early detection and disease prevention is critical to preventing or limiting the effects of a bioterrorism attack or a pandemic. These laboratories would be the rst to isolate or identify microorganisms from such an event. They must develop the capability to rule out suspected microorganisms in a given specimen or

send isolated microorganisms to another laboratory for identication. Development of a fully capable LRN is based on strengthening existing local, state, and federal public health laboratories and improving relationships among all laboratories in the network. The LRN organizes laboratories based on their diagnostic capabilities and safety facilities into a three-tiered network, including:

federal laboratories reference laboratories hospital clinical laboratories.

Federal Laboratory
A federal laboratory is one that receives funding as well as direction from the federal government. These laboratories are able to perform specialized identication procedures and contain the highest level of biosafety isolation equipment to handle highly infectious agents. Laboratories such as the CDC, U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID), and the Naval Medical Research Center (NMRC) are examples of federal laboratories. Most federal laboratories have the highest biosafety level designation from the CDC. (See Laboratory biosafety levels.)

Laboratory biosafety levels

The Centers for Disease Control and Prevention (CDC) developed biosafety levels to ensure the safe handling of materials in biological laboratories. A laboratorys biosafety level is determined based on several criteria, the most important of which is the agents isolated or tested in that laboratory. The more potentially dangerous an agent is, the higher the biosafety level classication for that laboratory. Other criteria address the type of personnel who can perform the testing, specialized training for laboratory personnel, facility management, decontamination practices, medical surveillance, safety equipment, and security procedures. Specialized training in handling pathogenic agents for laboratory personnel Restricted access to laboratory Biosafety cabinets used when handling agents Medical surveillance provided and appropriate immunizations offered to laboratory personnel

Biosafety Level 3
Handle agents that may cause serious or potentially lethal disease via inhalation exposure and may be exotic in nature, including Mycobacterium tuberculosis, Rickettsia rickettsii, West Nile virus, human immunodeciency virus, and hepatitis B and C viruses Special training, handling, and environmental control requirements Laboratory personnel with demonstrated prociency in specialized procedures Specialized clothing for laboratory personnel, such as scrub suits and coveralls, that must be put on prior to entering the laboratory Self-closing laboratory doors with locks and sealed windows

Biosafety Level 1
Handle agents not known to consistently cause disease in most people and present minimal potential hazard to laboratory personnel, including Escherichia coli, Bacillus subtilis, and Chlamydia species No special facility or containment requirements Use of basic PPE

Biosafety Level 2
Handle agents that pose a moderate hazard to laboratory personnel and the environment, including Streptococcus pneumonia, Staphylococcus aureus, and the rhinoviruses

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Laboratory biosafety levelscontd

Biosafety Level 4
Handle dangerous and exotic agents that pose a high risk of life-threatening disease and may have an unknown risk of transmission, including Ebola virus, Marburg virus, and hemorrhagic fever virus Special training, handling, and environmental control requirements Special decontamination procedures followed by laboratory personnel Positive pressure protective suits worn by laboratory personnel, as necessary Strict clothing removal and changing procedures Strict medical surveillance and support of laboratory personnel Strictly controlled access to the laboratory For example, laboratories at the CDC and U.S. Army Medical Research Institute for Infectious Diseases

Reference Laboratory
A reference laboratory is able to perform some specialized biological agent identication procedures and may have a lower level of biosafety than federal laboratories. When a reference laboratory isolates a potential bioterrorism agent, proper procedure may include sending the isolate to a federal laboratory, such as the CDC, for additional specialized testing. Reference laboratories may be public health, private, or international (outside the United States) clinical laboratories as well as veterinary laboratories and laboratories that perform environmental testing, such as water and soil testing.

Specimen procurement may include specialized collection, packaging, and transporting to a laboratory such as the CDC or state public health laboratory. The medical assistant must be sure to follow the exact directions for collection and processing of the specimen to ensure the integrity of the specimen and protection from the suspected bioterrorism agent. (See Bioterrorism specimen collection and submission.)

Bioterrorism specimen collection and submission

The medical assistant may collect many types of specimens to test for a suspected bioterrorism agent, including blood, stool, sputum, enema fluid, food samples, nasal swabs, bronchial or tracheal washings, biopsies, scabs, or vesicular fluid. The medical assistant should follow these guidelines when collecting and submitting a specimen that is suspected of containing a bioterrorism agent: Always note the specimen site and volume collected. Use the correct requisition form, specimen container, test kit, and shipping requirements for safe transport of the specimen. Submit good-quality specimens for analysis.

Hospital Clinical Laboratories

A hospital clinical laboratory may be the rst facility to obtain a patient specimen that could contain a potential bioterrorism agent. Such a laboratory may be unable to rule out a potential bioterrorism agent and would need the assistance of a more specialized laboratory for further identication. Clinical laboratories include those in hospitals and larger clinics.

Bioterrorism Response and the Medical Assistant

A medical assistant can play a key role in the initial response to a suspected bioterrorism attack. Actions a medical assistant might take include initiating communication protocols as well as conducting specimen collection and transport. For example, if a physician suspects that her patient may have been exposed to a bioterrorism agent, she may ask the medical assistant to call the local hospital and health department to report the ndings and transcribe and deliver instructions provided by the hospital or health department. The medical assistant must make sure that these essential contact numbers are easily accessible. In addition, the medical assistant may be required to collect a body specimen for testing.

Properly label all specimens for identication. Include a complete requisition form with all the necessary and pertinent patient health history and information with each specimen submitted. Do not attach the specimen to the requisition form or wrap the requisition form around the specimen. In serological testing, collect the specimen at the appropriate times and note in the form the time it was collected. Follow instructions for proper temperature control.
Continued

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Bioterrorism specimen collection and submissioncontd

Transport or ship the specimen to the laboratory as soon as possible Make sure the correct laboratory name is printed on the return address label. Many state laboratories and departments of public health will supply collection and transport containers to medical ofces. Make sure the medical ofce has plenty of these containers on hand. Follow proper state and federal biological hazardous material transportation guidelines if you are mailing the specimen. If you have a question about how to collect or process a specimen, call the laboratory before collecting it to get the exact directions.

animals, such as pigs, as well as conrmed cases of human infection by avian H5N1 in various Asian countries.

Pandemic Response Plan

Because the medical office may be the first to experience an increase in patients suspected of having the flu, the office should have a plan in place that includes steps for preparing for a pandemic before it happens as well as a response plan if a pandemic occurs. It is also important for the office to inform patients about preparing for disaster or a pandemic. (See Preparing for pandemic.) Following are some ideas for preparing for a pandemic before it happens:

WHO pandemic phases

The following table lists six pandemic phases dened by the World Health Organization (WHO) along with characteristics of each.

Pandemic Inuenza
Three pandemic inuenza outbreaks have occurred in the 20th century. The most severe, the Spanish inuenza pandemic, occurred in 1918 and caused around 500,000 deaths in the United States and 40 million deaths worldwide. Other pandemics include the 1957 Asian u and the 1968 Hong Kong u pandemics. (See Epidemic or pandemic?) Scientists worldwide think the world is on the brink of another pandemic. Many scientists and health ofcials believe an inuenza (u) pandemic may occur in the near future and that a new virus such as avian u or an old virus such as the Hong Kong u will begin infecting people and then spread worldwide. (See WHO pandemic phases.) An inuenza pandemic can occur when a new virus subtype emerges that has not previously circulated in humans. Because people have never been exposed to this new subtype, their bodies have not produced the antibodies to ght off the virus in their system. Currently, the avian H5N1 virus has mostly affected birds, but there have been documented cases in which the virus has infected other

Phase
Phase 1

Characteristics
Interpandemic phase No new human inuenza virus subtypes Subtype that can infect humans may be present in animals

Phase 2

Interpandemic phase No new human inuenza virus subtypes, but existing virus subtype in animals poses a signicant risk to humans

Phase 3

Pandemic alert Human infection with a new subtype but no human-to-human spread

Phase 4

Pandemic alert Small clusters with limited human-to-human transmission Virus not well adapted to humans

Phase 5

Pandemic alert Larger clusters of human-to-human spread Virus better adapted to humans (substantial pandemic risk)

Epidemic or pandemic?
An epidemic occurs when more individuals than normally expected are infected with a disease. Usually, an epidemic is contained within a certain area or region. A pandemic is an epidemic involving an infectious disease that has spread from region to region and the people infected are from many geographical areas.

Phase 6

Pandemic period Increased and sustained transmission in general population

CHAP TER 46

Bioemergency Response and Preparedness

965

Keep important information handy, such as phone numbers for local hospitals, pharmacies, and state and local public health departments. Practice and promote good hygiene techniques, such as frequent hand washing and proper disinfection of surfaces. Promote yearly inuenza vaccinations to your patients. Make sure the ofce has an ample supply of inuenza vaccine. Be alert to symptoms of the u, such as fever, muscle pain, cough, and runny nose. These symptoms are similar to seasonal u but may be more severe. Stay informed of the latest updates. Go to http://www .pandemicu.gov for the most current information.

Front ofceBack ofce connection

Pandemic Plan
It is essential for a medical ofce to establish a plan for responding to a pandemic well before the event occurs. The plan should include how to deal with patients and how to run the day-to-day operations of the medical ofce. Essentially, medical staff from the front and back ofce should come together to create a plan for such an emergency. To avoid straining already crowded appointment schedules, many ofces choose to conduct such planning during a working lunch so that everyone can be involved.

It is estimated that if an inuenza pandemic occurs, approximately 25% of the population may become infected. In the event that a pandemic occurs, the medical ofce should also have a plan in place for communicating with patients, potentially closing the ofce, addressing payroll practices, and handling other financial responsibilities such as vendor payment and billing. (See Pandemic plan.)

Making a Plan
To start planning, staff members should explain their daily responsibilities to help assign tasks and responsibilities during an emergency. For example, the administrative medical assistant may be responsible for backing up the billing system and the clinical medical assistant may back up the other computer applications. With a little planning and training, only one of these medical assistants may be responsible for backing up both systems in the event of an emergency so that the other person can be assigned another task. Likewise, an administrative medical assistant may normally call patients to remind them of their next days appointment, while the clinical medical assistant may call patients with laboratory results. When making an emergency plan, both of these persons may share the responsibility of calling patients to alert them to the closing of the ofce.

Patient Education

Preparing for Pandemic

Many local, state, and federal public health agencies have developed guides for individuals and families on how to plan for a pandemic inuenza outbreak. The medical ofce staff should obtain the information these agencies have and distribute it to patients. It is important to display or distribute the information in a way that does not cause the patient to panic. Some suggestions for patients include: Keep a list of important phone numbers handy, such as the numbers for the local police and re departments, nearest hospital, and pharmacy, as well as the numbers of relatives and neighbors. Keep some items handy, such as ashlights, batteries, candles, matches, a battery-powered radio, wood, bottled water, canned foods and juices, a manual can opener, a rst-aid kit, pet food (if applicable), bleach, and hand sanitizer. Remember to keep a list of medications for each member of the family, including the full name of the medication, the dosage, and instructions for administering it.

Chapter Summary

Bioterrorism is a real threat and the medical ofce should have an emergency plan already in place in the event of such an occurrence. Various microorganisms such as Bacillus anthracis, Yersinia pestis, and Clostridium botulinum are biological agents that can be used in a biological attack. The medical assistant should know how to communicate with local, state, and federal public health and safety agencies in the event of a bioterrorism threat. The medical assistant should know how to properly collect, package, and transport specimens that may contain a possible biological agent. Health ofcials think it is a matter of time before the United States will be involved in a pandemic inuenza outbreak.

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Medical ofces should have a pandemic response plan in place as well as educational material for their patients.

Team Work Exercises

1. In groups of 2 to 3 students, develop a fact sheet on pandemic inuenza as well as a checklist or plan for patients on how to prepare for such an incident. 2. Working in groups of 2 to 3 students, research the various microorganisms that can be classied as bioterrorism agents. Provide the following information on each agent: a. type of microorganism b. pathogenicity and virulence c. mode of transmission for infection d. symptoms of human infection e. treatment.

2. During her many ofce visits, Mrs. Szlozek frequently tells you about her granddaughter, who works for the CDC. She states that her granddaughter mentioned she is doing surveillance studies of Rift Valley fever. You are intrigued by this because you have never heard of this disease. How would you go about nding more information on this disease? What regions have experienced outbreaks of Rift Valley fever?

Resources

Case Studies
1. Your seventh graders principal has asked you to speak to the middle school students about what inuenza is, how it is spread, and the ways to prevent it. What type of information will you access and present? What will you take into consideration when speaking to this age group?

Association of Public Health Laboratories: www.aphl.org Centers for Disease Control and Prevention (CDC): www.cdc.gov CDC emergency preparedness and response guidelines: www.bt.cdc.gov CDC National Laboratory Training Network: www.nltn.org Examples of state health department checklists for specimen transport: www.state.ma.us/dph/bls U.S. government avian and pandemic u information: www.pandemicu.gov/index.html

CHAPTER

Ofce Emergencies
Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary describe steps medical ofce personnel can take to prepare for emergencies list the typical contents of a crash cartz differentiate between a standard debrillator and an AED explain the concept of triage list and describe the ABCs of basic emergency care list the information that needs to be gathered in a medical emergency describe typical presenting symptoms and emergency treatment for various emergencies seen in the medical ofce.

47
Responding to Common Ofce Emergencies
Common Signs and Symptoms in Ofce Emergencies Dyspnea Chest Pain Altered Consciousness Acute Abdominal Pain Common Ofce Emergencies Hemorrhage Poisoning Environmxental Injuries Musculoskeletal Injury Eye Injury

CAAHEP Competencies
General Competencies Patient Instruction
Instruct individuals according to their needs

ABHES Competencies
Clinical Duties
Recognize emergencies Perform rst aid and CPR

Instruction
Teach patients methods of health promotion and disease prevention

Chapter Outline
Emergency Preparedness
Emergency Planning Common Emergency Equipment Triage

Chapter Summary Team Work Exercises Case Studies Resources

967

Key Terms
automated external debrillator

Emergency Preparedness
Everyone who works in a medical ofce should be trained and prepared to respond to emergencies. Such preparation includes establishing a written plan of response in case of re, disaster, workplace violence, or medical emergency. Fortunately, most emergencies in the medical ofce are minor and include such events as a patient arriving unexpectedly with a nosebleed or fractured arm. However, emergencies of all types can and do occur in the medical ofce. Therefore, the professional medical ofce team must always be ready for any emergency, small or large. All health care facilities must make an effort to create an environment that is safe for patients and staff alike. Workplace safety programs provide instruction in cardiopulmonary resuscitation (CPR), standard precautions, proper body mechanics, and other safety issues. New employees undergo safety training upon hire and are required to update their knowledge and regularly demonstrate competence (usually annually) on specic skills, such as CPR. The appropriate response to an emergency depends on the nature of the emergency, the patient population being served, and the proximity of other medical facilities. The physician or most highly trained clinician in the office should be summoned for immediate help. If the office has staff trained in advanced cardiac life support (ACLS) and the needed equipment is on hand, the staff can provide ACLS measures at the ofce. In the case of life-threatening emergencies, the staff should institute basic cardiac life support (BCLS) measures while summoning emergency medical service (EMS) personnel. EMS staff are experienced experts in evaluation, treatment, and transport of persons experiencing a medical emergency. (See ABCs of first-aid.)

Small automated device used to deliver an electrical shock to a patient suffering from a life-threatening cardiac arrhythmia
crash cart

Wheeled supply cabinet in which emergency equipment and supplies are kept
debrief

Discussion of events, thoughts, and feelings among persons who have experienced an important or stressful event
debrillator

Specialized device used to deliver an electrical shock to a patient suffering from a life-threatening cardiac arrhythmia
mock code

Practice drill for responding to a medical emergency

protocol

Expected behavior during a given situation

recorder

Person designated to document a medical emergency

team captain

Person designated to coordinate activities of all team members during a medical emergency
triage

Process of sorting patients and setting priorities for their treatment

Emergency Planning
The medical assistant must understand the basics about responding to an emergency. (See General emergency guidelines, page 970.) In addition to the basics, however, the medical assistant and each member of the medical ofce staff must understand how to respond to specic emergencies. To ensure an effective, smooth response to medical emergencies, everyone in the medical ofce must respond according to a protocol, which is a predetermined plan about how to respond. Such treatment protocols, agreed upon in advance, help ensure that all members of the medical team understand their roles so they can work together cohesively. Such a protocol might include supplies and equipment needed, the roles for each staff member, and the step-by-step procedure for responding to that particular emergency. All members of the health care team should know where the emergency equipment is located and obtain proper

CHAP TER 47

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969

ABCs of rst-aid
All health care providers, regardless of their credentials or role in the health care team, must understand the basics of rst-aid. These basics are designated as the ABCs, for airway, breathing, and circulation, the three highest priorities, in order of importance, when assisting a person in an emergency. face and look to see if his chest is rising, listen for breath sounds, and see if she can feel his breath on the side of her face. If not, she must reposition the patients head again to open the airway. She should then begin rescue breaths if necessary.

Circulation
Circulation is necessary to deliver oxygenated blood to the brain and other parts of the body. The rescuer should check the patients circulation by evaluating the carotid pulse in the unconscious patient or radial pulse in the conscious patient. If the patient is pulseless, the rescuer should place her hands, one on top of the other, on the lower half of the patients sternum and begin chest compressions. The rescuer should continue these basic cardiac life support (BCLS) measures until more advanced help arrives. She should alternate 15 chest compressions with two breaths (for adults) and recheck for a pulse every few minutes.

Airway
Establishing the presence of an adequate airway is the top priority in rst-aid. If the patient cannot get oxygen, other interventions are futile. To open the patients airway, the rescuer uses the head tiltchin lift maneuver or the jawthrust maneuver for patients with potential cervical spine injuries.

Breathing
To determine a patients breathing, the rescuer should look, listen, and feel. She should lean low over the patients

Jaw-thrust maneuver

Head-tiltchin-lift maneuver

training in its use. In some cases, a team captain is designated to guide members of the team throughout the emergency. The team captain may be the physician; however, in many cases a charge nurse or another staff member will serve as the captain in order to leave the physician free to focus on immediate patient care. Many facilities routinely run mock codes, which are drills that allow all members of the health care team to practice

and develop their skills in responding to medical emergencies. Such drills rehearse the staff s response to bomb scares, res, infant or child abduction, a threat of violence and, most commonly, a patient experiencing cardiac or respiratory failure. These drills are referred to as codes because most facilities have a special code system that assigns each type of emergency its own code. When an emergency occurs, a staff member announces the code, usually through an intercom

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Clinical

General emergency guidelines

General guidelines apply to any emergency in the medical ofce, including: Follow standard precautions and wear personal protective equipment (PPE) to prevent the transmission of disease through blood or body secretions. Follow airway, breathing, and circulation (ABCs) to prioritize actions. Act in a manner consistent with the standard of care. Perform tasks only within your scope of practice. Summon help early. It is better to summon more help than is needed than to fail to call for adequate help in a timely manner. Never leave an unstable patient alone. Document the event carefully, including the action taken by medical ofce staff and the patients response.

cart, which is specifically used for emergencies. (See Figure 47-1.) Specic equipment stored on the cart varies, depending on the patient population seen by the ofce. One item almost always present on a crash cart is a debrillator. This specialized device is used to deliver an electrical shock to a patient suffering from a life-threatening cardiac arrhythmia, such as ventricular brillation and ventricular tachycardia. During such arrhythmias, some or all heart muscle bers contract in a disorganized fashion. Delivery of an electrical shock causes all cardiac muscle bers to contract in unison, which sometimes stimulates the heart to convert back to normal sinus rhythm. Because some risk is associated with operating this device, all staff members who use it must be properly trained. (See Common crash cart supplies and equipment.)

system, to alert all staff so they can respond according to the specic protocol for that type of emergency. After each mock code, members of the team should debrief, which is a discussion of the event among all team members to determine what worked during the event and what did not, so that appropriate changes can be made in the response plan. Such debrieng should also take place after an actual emergency as well. An important, but sometimes overlooked, part of emergency preparedness is the designation of a team member to document the emergency, called a recorder in some care settings. This person should assume her role from the beginning of the emergency so she can accurately record the events in a chronological fashion. Otherwise, reconstructing events after the fact will be difcult, especially in a complex medical emergency. In addition to protocols, availability of critical supplies and properly working equipment are essential in an emergency. Therefore, medical staff must be sure to maintain inventory of needed supplies and medications and restock following each emergency event. In addition, staff must carefully maintain and routinely check emergency equipment so that it is always ready.

Handheld resuscitation bag (adult and pediatric) Sharps container Seal to secure crash cart contents

Cardiac monitor and defribillator

Waste basket

Common Emergency Equipment

Not all medical ofces keep emergency equipment on hand; however, many do. If an ofce does stock emergency equipment and medication, the physician and other staff members must be familiar with its use. Many supplies are stored in a portable, wheeled supply cabinet, called a crash cart or code

FIG 47-1 Typical crash cart.

CHAP TER 47

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971

Common crash cart supplies and equipment

The specic items kept in a crash cart vary with the ofce specialty and patient population seen. Here are some of the most common types of equipment, supplies, and medications kept in a crash cart for emergencies. IV tubing Bandage scissors Biohazard sharps container Assorted syringes

Emergency Equipment
Personal protective equipment, including: gowns masks goggles examination gloves Portable oxygen delivery equipment, including: oxygen tanks oxygen tubing various types of oxygen masks handheld resuscitation bags airways (oral and nasal) endotracheal tubes laryngoscopes Blood pressure cuffs Suction equipment Debrillator or automated external debrillator (AED) Stethoscope

Assorted needles

Emergency Medication
Activated charcoal Antihistamines Aspirin Atropine Dextrose Diphenhydramine Dopamine Epinephrine Furosemide Glucagon Insulin Ipecac syrup Digoxin Lidocaine Nitroglycerine Pancuronium Sodium bicarbonate Sterile water Sterile saline Xylocaine Controlled substances (must be kept in a locked compartment), including: morphine diazepam midazolam lorazepam

Emergency Supplies
Adhesive tape Assorted dressings and bandages Alcohol wipes Constriction band Cotton swabs Antibiotic ointment Sterile and nonsterile gloves Flashlight or penlight Hot and cold packs (instant) IV catheters Assorted IV uids

Recently, development of simpler devices known as automated external debrillators (AEDs) make operation of this type of emergency equipment much easier. In addition, the AEDs manufacturers have programmed them to give automatic, step-by-step instructions for their use. They are smaller and more portable than the original debrillators. Because of these technological advances, AEDs are now present in many places in addition to medical ofces, including tness centers, airplanes, college campuses, ski resorts,

and even shopping malls. As a result, persons suffering from cardiac arrest receive help more quickly and the survival rate for this population is increasing.

Triage
The term triage is derived from the French word trier, which means to sort. In the medical setting, triage involves making a quick determination about the nature of the patients emergency, the type of immediate care needed, and

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the most appropriate response. If more than one patient is involved, triage may also involve determining which patient should be treated rst. In many settings, a registered nurse performs triage; however, other staff members may perform this task, depending on their qualications. In some cases, medical assistants must perform triage. Most ofces have written guidelines in place that guide the process. Even so, no guidelines are as valuable as experience and practice. Therefore, the person assigned triage duties should be an experienced health care provider. A signicant number of the phone calls received by the medical ofce involve potentially urgent or even emergency situations. In such cases, the administrative medical assistant sometimes transfers the call to a nurse or clinical medical assistant. However, she should never put a caller with a medical emergency on hold. Therefore, anyone who answers telephones in the medical ofce must know how to handle such calls. (For more information on telephone triage, see Chapter 11, page 121.)

the severity may range from temporary loss of breath to total airway obstruction or respiratory failure. (See Common causes of dyspnea.) When in doubt regarding severity, the medical assistant should summon a nurse or physician to perform a quick assessment of the patient and provide help. Appropriate intervention depends on the nature and severity of the problem and ranges from assisting the patient to a chair where he can catch his breath to calling EMS and beginning rescue breathing. In order to determine the severity of the patients dyspnea, the medical assistant must quickly obtain the patients vital signs, including his oxygen saturation level. Such information helps determine the severity of the emergency and provides important baseline data for later comparison. The medical assistant can also look for other clues to determine severity. Paying close attention to these clues will help the medical assistant determine an appropriate response. Such clues include:

Responding to Common Ofce Emergencies

When a medical emergency occurs, the patients exact diagnosis may be unclear at rst. The patient may simply display a collection of signs and symptoms, such as dyspnea or chest pain. Thus, the medical assistants response to such an emergency should be to evaluate the signs and symptoms, rather than attempt to determine a diagnosis. In other situations, the cause of the patients condition may be clear, as in a laceration to the hand. Thus, the medical assistant must be aware of common signs and symptoms of emergencies as well as the potential causes.

skin appearance character of respirations respiratory rate use of accessory muscles breath sounds mental or emotional state.

Skin Appearance
In mild dyspnea, skin appears pink or pale (in light-skinned people) with possible diaphoresis (sweating). In moderate dyspnea, the skin appears dusky with circumoral cyanosis (blue tint around the mouth) and diaphoresis. In severe dyspnea or apnea (absence of breathing), the skin appears cyanotic (bluish tint) and is moist and clammy.

Character of Respirations
In a patient with mild dyspnea, respiratory effort and depth is regular or the depth of respirations is slightly deeper than normal. In moderate dyspnea, respirations may be labored and deep or, if breathing is painful, shallow and rapid. In severe dyspnea or apnea, respirations are labored, deeper, or more shallow than normal, and irregular in pattern.

Common Signs and Symptoms in Ofce Emergencies

Ofce emergencies commonly involve such signs and symptoms as dyspnea, chest pain, altered consciousness, and acute abdominal pain.

Respiratory Rate
A patient with mild dyspnea will have a normal respiratory rate or slight tachypnea (rapid breathing). In moderate dyspnea, respiratory rate is moderately tachypneic. A patient with severe dyspnea or apnea has severe tachypnea or severe bradypnea (slow breathing).

Dyspnea
Any time a patient complains of dyspnea (difculty breathing), a potential emergency exists. The medical assistant should make a quick evaluation to determine the severity of the dyspnea and institute appropriate interventions. When possible, the medical assistant should attempt to identify the underlying cause, which is useful in formulating a treatment plan. However, the medical assistant should not ask a patient in extreme distress to answer questions that would delay treatment. There are many potential causes of dyspnea and

Use of Accessory Muscles

A patient with dyspnea commonly uses his accessory muscles to breathe. These muscles include the intercostal and supraclavicular muscles. In mild dyspnea, use of these muscles is mild. In moderate dyspnea, the use of accessory muscles becomes more pronounced. Slight nasal aring may also be present. In severe dyspnea, nasal aring and the patients

CHAP TER 47

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use of accessory muscles become even more apparent. He also will insist on sitting upright in order to make full use of his diaphragm and commonly displays a wide-eyed, panicked expression.

severe dyspnea or apnea, the medical assistant may hear extreme wheezing, crackles, rhonchi, stridor, and other abnormal sounds, or breath sounds may be abnormally quiet, signaling respiratory failure.

Breath Sounds
In mild dyspnea, the patients breath sounds are clear with minimal noise. The medical assistant may hear mild crackles, rhonchi, or wheezing with a stethoscope. In moderate dyspnea, the medical assistant should be able to hear wheezes or other signs of congestion without a stethoscope and moderate crackles, rhonchi, or wheezing with a stethoscope. In

Mental or Emotional State

In mild dyspnea, the patient may seem alert and slightly anxious. In moderate dyspnea, the patient may be alert, anxious, or even frightened. In severe dyspnea or apnea, the patient may be extremely anxious; however, his level of consciousness rapidly declines as fatigue and lethargy from oxygen deprivation set in.

Common causes of dyspnea

The following table lists some of the most common causes of dyspnea, along with typical signs and symptoms, and emergency management measures.

Cause
Complete foreign body airway obstruction (choking) ICD-9-CM code: 934.9 (complete or partial obstruction)

Signs and Symptoms

Universal choking sign by person with his hands at his throat and his eyes wide and frightened Absent breath sounds Rapid development of cyanosis and loss of consciousness

Emergency Management
Call for immediate assistance from the physician or nurse and follow these steps: 1. Ask the victim, Are you choking? If the person nods yes or is unable to speak, cough, or breathe, administer the Heimlich (abdominal thrust*) maneuver until it is effective or the person loses consciousness. 2. Check the mouth of an unconscious person for a foreign body. 3. Open the persons airway and attempt to deliver rescue breaths. 4. Continue these steps until they are effective or other help arrives. Allow the person to cough as long as coughing is forceful and breathing is adequate. If the persons efforts become weak and ineffective, begin the Heimlich (abdominal thrust*) maneuver. Summon emergency medical services (EMS).

Partial foreign body airway obstruction ICD-9-CM code: 934.9 (complete or partial)

Universal choking sign by person with his hands at his throat and his eyes wide and frightened Abnormal breath sounds with possible whistling or stridorous sound With severe obstruction, cyanosis and possible loss of consciousness as efforts to breathe become less effective

Asthma attack ICD-9-CM code: 493.90

Mild to severe wheezing Dyspnea Possible coughing

Assist the patient to use an inhaler if he has one. Administer medications such as a nebulizer per a physicians order. Apply oxygen if ordered. Administer medications per a physicians order, which may include epinephrine, prednisone, and antihistamines. Apply oxygen per order.

Anaphylaxis ICD-9-CM code: 995.0 (unspecied cause; use additional codes for cause and E code for external cause)

Stridorous breath sounds as the airway closes Wheezing Anxiety and other signs of severe dyspnea Possibly blotchy skin with hives Possibly rapidly decreasing blood pressure

Continued

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Common causes of dyspneacontd

Cause
Pneumonia ICD-9-CM code: 486 (organism unspecied)

Signs and Symptoms

Chest discomfort with breathing Productive cough with yellow or green sputum General ill appearance Mild to moderate dyspnea

Emergency Management
Pneumonia is not an emergency. Administer antibiotics per a physicians order. Administer oxygen per order.

Chronic obstructive pulmonary disease (COPD) exacerbation ICD-9-CM code: 492.9 (emphysema)

Mild to severe dyspnea Wheezing Prolonged expiratory phase Other signs of dyspnea, depending on severity

Administer oxygen and medications per a physicians order.

Pneumothorax ICD-9-CM code: 512.8

Depending on severity, possibly includes: dyspnea sharp chest pain with inspiration cyanosis decreased oxygen saturation tachycardia hypotension tachypnea anxiety decreased or absent breath sounds on affected side

Administer oxygen. Place an occlusive dressing over the injury site taped on three sides (if injury is present). Position the patient for comfort and optimal lung expansion (usually in semi-Fowler position). Prepare to assist with possible chest tube insertion.

Myocardial infarction (MI) or heart failure ICD-9-CM code: 410.9 (MI, unspecied site), 428.0 (heart failure)

Dyspnea as primary symptom (in patients suffering from a silent MI or from heart failure)

Administer oxygen, morphine, nitroglycerine, aspirin, thrombolytic agents, and, if needed, anti-arrhythmic agents per a physicians order. Instruct the person to rest in a position of comfort to reduce the hearts oxygen demands. Provide BCLS or advanced cardiac life support (ACLS) as needed.

* Use chest compressions for pregnant patients.

Chest Pain
The medical assistant must always take seriously any complaint of chest pain because it could indicate a myocardial infarction (MI). (See Common causes of chest pain.) During an MI, the heart is starved for oxygen. Therefore, the medical assistant must take immediate action to decrease the hearts workload and maximize oxygen supply. The medical assistant should immediately notify the physician and then assist the patient to an examination room by wheelchair and position him in a manner that maximizes comfort and breathing. Most offices have a protocol for such situations that includes removing clothing above the waist, obtaining a stat ECG, and administering oxygen. If the ofce has an emergency code cart, a medical assistant or other staff member should bring it into the room. The medical

assistant or other staff member should do a quick review of the patients medications and ask him what medications he has taken that day. (See Working as a team.)

Altered Consciousness
ICD-9-CM code: 780.09 (alteration of consciousness excluding coma) There are many causes of a sudden alteration in consciousness. Common causes include seizures, conditions related to diabetes management, and head injury as well as stroke, cardiac arrhythmias, and cardiac arrest; however, the cause is usually unclear at rst. (See Medical alert, page 977.) Regardless of the cause, when a patient suddenly loses consciousness in the medical ofce, the medical assistant must immediately summon help and check the patients ABCs. When a

CHAP TER 47

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Front ofceback ofce connection

Working as a team
There are few emergencies more serious than the patient with a possible myocardial infarction (MI). Therefore, all members of the ofce team should be alerted so they can make themselves available to help as needed. Having a written protocol and practicing mock codes will help everyone perform their jobs more efciently. Some considerations might include designating the following assignments to the following team members: Administrative medical assistant: make phone calls and enter orders into the computer system for stat blood draws and lab tests, emergency cardiology consultations, and contacting EMS for hospital transport and contacting a family member for the patient. Second administrative medical assistant, receptionist, or ofce manager: attend to other patients who are checking in and if necessary reschedule their appointments. Team captain (needed in the event of a code): coordinate the activities of everyone involved in direct patient care. Clinical medial assistant: assist in patient care as directed by the physician. Nurse (if present): may also serve as team captain, aid in direct patient care including starting the IV and administering IV medications.

Common causes of chest pain

The accompanying table lists some of the most common causes of chest pain along with the typical signs and symptoms and emergency management measures.

Cause
Myocardial infarction (MI) ICD-9-CM code: 410.9 (unspecied site)

Signs and Symptoms

Sensation of pain, discomfort, squeezing, or heaviness in the chest, jaw, left arm, or left shoulder that is unrelieved by nitroglycerine, oxygen, or rest Dyspnea Diaphoresis Nausea In female patients, any of the above symptoms or back pain, syncope, gastric symptoms, heart palpitations

Typical Emergency Management

Monitor airway, breathing, and circulation (ABCs). Administer oxygen, morphine, nitroglycerine, aspirin, thrombolytic agents and, if needed, antiarrhythmic agents as ordered by the physician. Provide the patient with a restful environment, encourage him to rest, and move the patient in a wheelchair, rather than letting him walk. Provide basic cardiac life support (BCLS) or advanced cardiac life support (ACLS) measures as needed.

Angina ICD-9-CM code: 413.9

As in MI, sensation of pain, discomfort, squeezing, or heaviness in the chest, jaw, left arm, or left shoulder, except that symptoms are relieved by nitroglycerine, oxygen, or rest Dyspnea Diaphoresis Nausea In female patients, any of the above symptoms or back pain, syncope, gastric symptoms, heart palpitations

Administer nitroglycerine and oxygen. Provide the patient with a restful environment and encourage rest.

Continued

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Common causes of chest paincontd

Cause
Gastroesophageal reux disease (GERD) ICD-9-CM code: 530.81

Signs and Symptoms

Belching with heartburn triggered by large meals, spicy foods, alcohol, and eating before bedtime Worsening of symptoms about 1 hour after meals

Typical Emergency Management

GERD is not an emergency. Tests may rule out cardiac causes. Treatment includes GI evaluation and medications to reduce stomach acid production.

Pericarditis ICD-9-CM code: 420.91 (unspecied; if applicable, code underlying cause rst)

Chest pain that is worse with inspiration Fever Malaise Dyspnea Chills

Pericarditis is not an emergency. Tests may rule out other cardiac causes. Treatment includes anti-inammatory medication and, possibly, antibiotics.

Cholecystitis ICD-9-CM code: 575.12 (acute and chronic)

Colicky epigastric pain that radiates into the right upper quadrant (RUQ), right shoulder, and back Nausea and vomiting Fever Jaundice and pruritus Tachycardia Light stools and dark urine

Cholecystitis is not an emergency, although pain may be severe. Tests may rule out cardiac causes. Patients may be hospitalized for cholecystectomy or lithotripsy.

Costochondritis ICD-9-CM code: 733.6

Chest pain over the sternum that may radiate into the shoulders and arms and is worse with a deep breath Tenderness on and around the sternum to palpation

Costochondritis is not an emergency and is usually identied by a brief physical examination. Tests may rule out a cardiac cause. Treatment includes nonsteroidal anti-inammatory drugs (NSAIDs) and ice (or cold) application. Monitor ABCs. Administer oxygen and ventilatory support as needed and ordered by a physician. Measures to rule out a cardiac cause may include ECG and cardiac enzyme studies.

Pulmonary embolism ICD-9-CM code: 415.1

Chest pain with inspiration Cough Low-grade fever Dyspnea Tachypnea Occasional hemoptysis Cyanosis Shock

Spontaneous pneumothorax ICD-9-CM code: 512.8

Sudden, sharp, pleuritic chest pain Mild to moderate dyspnea Decreased breath sounds on affected side Decreased oxygen saturation Tachycardia Tachypnea Anxiety

Administer oxygen as directed by a physician. Position the patient for comfort and optimal lung expansion. The physician may order chest x-ray to conrm diagnosis. Prepare to assist with possible chest tube or Heimlich valve placement. Patient may be transported to the hospital for further care.

Panic attack ICD-9-CM code: 300.01

Sudden onset of chest palpitations, tachycardia, diaphoresis, trembling, dyspnea, chest pain, nausea, paresthesias, dizziness, chills or hot ashes Feelings of anxiety or impending doom

Panic attack is not an emergency. Tests may rule out cardiac and GI causes. Treatment may include reassurance and anti-anxiety medications.

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person loses consciousness and falls, he may suffer an injury from the fall itself. Therefore, the medical assistant should keep the patient still until a nurse or physician can evaluate him, even if she must keep him on the oor for a few minutes. Well-intentioned staff members can cause further injury to a patient by moving him prematurely. If the physician or nurse suspects a spinal injury, the medical assistant should summon EMS to properly immobilize and move the patient. Causes of a slower change in consciousness include hyperglycemia, hypoglycemia, drug toxicities, dementia, and other neurological disorders. Although these conditions can be quite serious or even life-threatening, the changes generally occur gradually, which enables evaluation, diagnosis, and initiation of treatment before the situation becomes an emergency.

struck and placing something soft under his head. She should not place or force anything into his mouth, because in doing so she risks injuring the patient and herself. A general misconception regarding seizures is that the patient could swallow his tongue, which is, in fact, not possible. However, the medical assistant can help protect the patients airway by placing him on his side and can increase his comfort by loosening his tie or other tight clothing. She should also note the duration of the seizure and type of activity. After the seizure, the medical assistant should reorient and reassure the patient, obtain a set of vital signs, allow the patient to rest, and provide other care as directed by the physician. She should not offer the patient anything to eat or drink until he is fully awake.

Syncope
ICD-9-CM code: 780.2 (blackout, fainting, or code according to identied cause) When a patient experiences syncope (fainting) and quickly regains consciousness, she is sometimes embarrassed by the attention that ensues. However, it is still important that the physician evaluate her before the medical staff allows her to leave. The physician must investigate two potential problems. First, there may be an underlying disorder that triggered the syncopal episode. Second, the patient may have suffered injury when she fainted and fell.

Generalized Seizure
ICD-9-CM code: 345.90 (epilepsy, unspecied) Many triggers may cause loss of consciousness from a generalized seizure. While a seizure may signal a serious condition, it is not usually life-threatening on its own unless prolonged. The medical assistant should not attempt to restrain the patient experiencing a tonic-clonic seizure (also called grand mal seizure) but should keep him as safe as possible by removing nearby objects that might inict injury if

Patient Education

Medical Alert
Many patients have chronic conditions that can result in life-threatening emergencies, such as those with severe allergies and diabetes. Because altered consciousness may occur as a result of many of these conditions, the medical assistant should encourage these patients to wear a medical alert bracelet or necklace. Doing so can provide essential information to a health care provider in the event that the patient is unable to provide the information himself. Data may include: nature of the condition, such as allergy and diabetes persons name code status emergency contact number.

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Clinical

Diabetic Emergencies
ICD-9-CM code: 250.90 (diabetes mellitus, coding digits added according to clinical manifestations, diabetes type, and specic pathology) A patient with diabetes can experience altered consciousness when his blood glucose level rises to dangerously high levels (hyperglycemia) or drops to dangerously low levels (hypoglycemia). A person with hyperglycemia demonstrates a gradual change over a period of hours or days. Typical symptoms include fatigue, dry skin, tacky (semi-dry) mucous membranes, and lethargy that progresses to stupor and then coma. Respirations become increasingly deep and rapid and the patient has a fruity breath odor, which is sometimes mistaken for alcohol breath. The medical assistant can help by keeping the patient safe, performing glucometer testing, and assisting the physician with evaluation and treatment as directed. She may also need to arrange for transfer of the patient to the hospital for careful management, including administration of IV uids and insulin. The patient with hypoglycemia demonstrates a more sudden change in consciousness (minutes to hours) with hunger, irritability, confusion, combativeness, weakness, tremulousness, headache, dizziness, sweating, seizures, coma, and death. The medical assistant can help by keeping the patient safe, performing glucometer testing, and assisting the physician with evaluation and treatment as directed. If the patient is alert enough to safely swallow, the medical assistant may administer some form of oral sugar, such as fruit juice, per ofce protocol. If he is unable to safely swallow, the nurse or physician must start an IV for administration of IV dextrose. Hypoglycemia has the potential to progress more quickly than hyperglycemia and can rapidly result in death. Therefore, when the cause of altered consciousness is unknown in a patient with diabetes, the medical staff should treat the situation as an emergency, as if he has hypoglycemia, until an accurate diagnosis is determined.

time the event occurred whether the event was witnessed and, if so, whether the witness is available to answer questions.

The medical assistant should also obtain baseline vital signs, monitor him for changes in consciousness, and assist the physician with patient care as directed. If there is any question of spinal cord injury, she must help immobilize the patient immediately until the physician can obtain and review x-rays.

Acute Abdominal Pain

Acute abdominal pain has many potential causes, some of which may be life-threatening. In addition, some causes of abdominal pain may not originate in the abdomen. Occasionally, disorders that originate in the pelvic region, , such as urinary tract infection (UTI) and ectopic pregnancy, or vascular disorders, such as a dissecting (tearing) aortic aneurysm, cause pain that may be felt in the abdomen or back. (See Common causes of abdominal pain.) When a patient complains of acute abdominal pain, the cause is seldom immediately clear. Therefore, the medical assistant must take all such cases seriously and provide care according to ofce protocol, including informing the physician so that she can begin prompt evaluation and treatment. Because of the possibility of emergency surgery, the medical assistant must determine when the patient last had anything to eat or drink and not allow the patient to take anything by mouth without the physicians approval. She must obtain baseline vital signs immediately as well.

Common Ofce Emergencies

Common emergencies encountered in a medical ofce include hemorrhage, poisoning, environmental injuries, musculoskeletal injuries, and eye injuries.

Hemorrhage
Numerous types of injuries result in hemorrhage (bleeding), which may be minor or life-threatening. After checking airway, breathing, and circulation, the medical assistant must take measures to control bleeding. Two of the most common conditions that involve hemorrhage in the medical ofce are laceration and epistaxis.

Head Injury
ICD-9-CM code: 852 (subarachnoid, subdural, and extradural hemorrhage caused by injury), 852.4 (epidural hematoma), 852.2 (subdural hematoma) A patient with a serious head injury is usually transported to the hospital immediately. However, a patient with a less severe head injury is common in the medical ofce. The medical assistant must always treat any patient with a head injury seriously and quickly escort him to an examination room. While beginning care, she should help gather specic data, including:

Laceration
ICD-9-CM code: 879.8 (site unspecied) A common ofce emergency involves a patient entering the medical ofce with a blood-soaked towel wrapped around his lacerated hand. A laceration is a cut or tear in the esh that may bleed slightly or may hemorrhage profusely. The medical assistant should put on examination gloves before greeting the patient and should escort him to an examination room and help him lie down. If bleeding is severe, the medical assistant should apply direct pressure with an

description of the mechanism of injury presence or absence of neck or spinal pain whether the patient lost consciousness and, if so, for how long

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Common causes of abdominal pain

The accompanying table lists some common causes of abdominal pain along with signs and symptoms and emergency management measures.

Cause
Appendicitis ICD-9-CM code: 540

Signs and Symptoms

Classic symptoms of nausea, vomiting, and severe periumbilical pain that eventually localizes to the RLQ (in less than 50% of patients) RLQ rebound tenderness to palpation possible Fever Diarrhea or constipation

Emergency Management
Keep the patient on nothing-by-mouth (NPO) status. Help arrange for appendectomy if directed. Administer antibiotics to prevent or resolve infection if ordered.

Bowel obstruction ICD-9-CM code: 560.9

More severe symptoms with complete obstruction than with partial obstruction Nausea and vomiting Abdominal pain Abdominal distention Inability to pass gas or stool

Keep the patient on NPO status and assist with care as directed. The patient will require hospitalization for further care and possible surgery.

Cholecystitis ICD-9-CM code: 575.12 (acute and chronic)

Colicky epigastric pain that radiates into the right upper quadrant, right shoulder, and back Nausea and vomiting Fever Jaundice Tachycardia Light stools and dark urine Pruritus

Cholecystitis is not an emergency, although pain may be severe. Tests rule out cardiac causes. The patient may be hospitalized for cholecystectomy or lithotripsy.

Crohn disease (also called regional enteritis) ICD-9-CM code: 555.9

Chronic diarrhea Fever Weight loss, anorexia Fatigue Abdominal pain Cramping that may localize to right lower quadrant (RLQ)

Crohn disease is not usually an emergency. However, surgery may be necessary in cases of perforation or to remove the involved portion of the colon. Administer uid replacement, anticholinergics, and opioid analgesics to control pain and reduce bowel motility; antimicrobials for infection; and corticosteroids to reduce inammation per the physicians order. Diverticulitis is not normally an emergency. However, surgery may be necessary in cases of bowel perforation. Administer antibiotics to treat infection and analgesics for pain per the physicians order. Gastroenteritis is rarely an emergency. Administer uid and electrolyte replacement, antiemetics, and antibiotics per the physicians order. Provide a restful environment and encourage the patient to rest.

Diverticulitis ICD-9-CM code: 562.11 (without hemorrhage), 562.13 (with hemorrhage) Gastroenteritis ICD-9-CM code: 558.9

Fever Nausea Blood-streaked stools Left lower quadrant abdominal pain Varies with the cause Watery diarrhea Abdominal cramps Anorexia Nausea and vomiting Headache Fever Weakness

Continued

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Common causes of abdominal paincontd

Cause
Peptic ulcer disease ICD-9-CM code: 531.90 (gastric), 532.90 (duodenal), 533.90 (peptic)

Signs and Symptoms

Indigestion Heartburn Epigastric pain Uncomfortable fullness Nausea and vomiting Peak of symptoms about 2 hours after eating

Emergency Management
PUD is usually not an emergency. Tests may rule out cardiac causes. Treatment includes GI evaluation, anti-ulcer medications, and, possibly, antibiotics.

Ulcerative colitis ICD-9-CM code: 556.9

Episodic are-ups with as many as 10 to 20 episodes of bloody, mucoid diarrhea per day Pain Cramps Urgency to defecate Weight loss Fever Malaise

Ulcerative colitis is not usually an emergency. However, surgery may be necessary in cases of severe hemorrhage or perforation. Administer anticholinergic and antidiarrhea medications per the physicians order to reduce bowel motility, corticosteroids to reduce inammation, and analgesics for pain.

adequate amount of absorbent dressing material and remain with the patient while another staff member summons the physician. (See Tourniquets.) She should measure vital signs as quickly as possible to establish baseline information because hemorrhage can quickly result in tachycardia, hypotension, and shock. In such a case, the medical assistant or other staff member should summon EMS to transport the patient to the hospital. The physician or a nurse may also begin intravenous (IV) uid administration in order to stabilize the patient for transport.

For less severe lacerations, the physician may choose to administer a local anesthetic to the wound so the medical assistant can clean it. Most commonly, the medical assistant will use sterile saline solution or warm water and antibacterial soap. If the patient has not had a tetanus vaccination in more than 10 years, the physician will usually order a booster. The physician will also typically close minor lacerations with a buttery closure, adhesive strips, or a tissue adhesive. (See Tissue adhesive: Why use it?) The medical assistant may help the physician close more severe lacerations with sutures.

Epistaxis
Patient Education
ICD-9-CM code: 784.7 Epistaxis (nosebleed) is caused by erosion or rupture of small vessels within the nasal mucosa. In most cases, epistaxis is minor; however, it can be severe in the case of an arterial bleed. Causes of epistaxis are numerous and include trauma, irritation from nasal sprays, abuse of drugs inhaled nasally, and bleeding disorders. Contributors include hypertension and the use of antiplatelet medications, such as aspirin, or anticoagulant medications, such as warfarin. To treat epistaxis, the medical assistant should immediately escort the patient to an examination room and position him sitting up and leaning forward while applying direct pinching pressure high on the nostrils. Unless the patient is feeling faint, the medical assistant should not have him lie down because doing so will cause drainage of blood down to the patients stomach, which will likely result in nausea and

Tourniquets
Tourniquet use is no longer an approved care measure for bleeding, because a tightly applied tourniquet cuts off circulation to the distal extremity. Resulting tissue death may require amputation of the extremity. Instead, the medical assistant should teach patients to control hemorrhage by taking one of these measures: applying direct pressure with an absorbent dressing applying direct pressure to the nearest pulse point applying a constricting band tight enough to reduce, but not completely stop, bleeding, which still allows some circulation to distal tissue.

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Tissue adhesive: Why use it?

In some cases, minor lacerations can be sealed with a liquid tissue adhesive, such as Dermabond, rather than sutures. There are several advantages to using tissue adhesive, including: It is brushed on and bonds in less than 3 minutes. It comes off naturally as the wound heals. It forms a strong, exible seal that protects the wound while it heals. It acts like glue to hold skin edges together. Bandages are usually not required. Getting the wound wet is not a problem. Needles are not necessary, so children (and some adults) experience less anxiety.

whether the patient vomited any rst-aid measures attempted whether the patient has dyspnea.

If the patient calls before coming to the medical ofce, the medical assistant should instruct the caller to bring the poison container (if known) and, if possible, the emesis if the patient vomited. The best treatment for poisoning is prevention, so the medical assistant should always take the opportunity to educate patients about ways to prevent poisoning. (See Preventing poisoning.)

Environmental Injuries
Occasionally, patients enter the medical ofce with environmental injuries, such as burns, animal bites, or insect stings. Less common environmental injuries seen in this setting include heat stroke, hypothermia, and others. (See Less common environmental injuries, page 982.) After attending to ABCs, the medical assistant must gather information about the mechanism of injury, which helps guide the physician in appropriate treatment.

vomiting. If epistaxis is severe, the physician may perform electrocautery to cauterize the bleeding vessel. The physician may also refer the patient to an otolaryngologist for follow-up care.

Patient Education

Poisoning
ICD-9-CM code: varies depending on agent and pathology (add E code to indicate accidental poisoning, E850 to E858; suicidal intent, E950 to E952.9; homicidal intent, E962 to E962.9; or undetermined intent, E980 to E982.9) Poisoning most commonly occurs from oral ingestion of a substance, such as a drug, household cleaner, plant, or vitamin. Other causes of poisoning include injection (accidental administration of medication or overdose of illicit drugs), absorption (through skin exposure to chemicals), and inhalation (as with carbon monoxide poisoning). Symptoms of poisoning vary depending on the offending agent and may include nausea, vomiting, abdominal cramps, changes in skin color, seizures, diaphoresis, dizziness, tearing, drooling, drowsiness, and decreased level of consciousness. Burns or stains may also appear on the patients hands, mouth, or clothing. When providing care for a patient with possible poisoning, the medical assistant must attend to the ABCs and provide care as directed by the physician. She should also help gather data to aid the physician in determining an appropriate treatment plan, including:

Preventing Poisoning
Most accidental cases of poisoning occur in young children (under age 6). Thus, the medical assistant should instruct parents of young children to take the following measures to try to prevent accidental poisoning: Keep toxic substances, such as pesticides and cleaning supplies, locked up and out of reach of children. Keep toxic substances in their original containers and replace them if the labels become illegible. Prior to using pesticides (indoors or outdoors), remove children and their toys from the area. Never leave pesticides, cleaning solutions, or other potentially toxic substances unattended when children are around. Keep a current bottle of syrup of ipecac in your medicine cabinet or rst-aid kit. Keep all medications and vitamins locked up and out of reach of children. Never coax children to take medication or vitamins by telling them that it is candy. Keep the telephone number of your state Poison Control Center by your telephone. All numbers are available (24 hours, 7 days per week) by calling the National Poison Control Center at 1-800-222-1222.

patient name, age, and weight substance the patient ingested or was exposed to time the poisoning occurred quantity ingested or injected

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Clinical

Less common environmental injuries

The following table lists some environmental injuries that are less commonly treated in an ofce setting, along with their signs and symptoms and emergency management measures.

Cause
Heat exhaustion ICD-9-CM code: 992.5 (unspecied effects)

Signs and Symptoms

Diaphoresis, pallor Muscle cramps, fatigue, weakness Dizziness, headache, fainting Nausea, vomiting Tachycardia, orthostatic hypotension Elevated body temperature (up to 105F)

Emergency Management
Administer cooling measures, including a cool shower or sponge bath, moving the patient to a cool environment, and rehydration with cool nonalcoholic beverages. Allow the patient to rest. Monitor the patients temperature.

Heat stroke ICD-9-CM code: 992.0 (unspecied effects)

High body temperature (above 105F); hot, ushed, dry skin Headache, confusion, agitation, anxiety, delirium, paresthesias, seizures, coma Tachycardia, hypertension Tachypnea, dyspnea Loss of coordination

Administer cooling measures, including removing excess clothing, applying cool or tepid water to the skin (but avoiding immersion in icy water), and placing covered ice packs in the arm pits and groin. Administer IV uids. Arrange transport of the patient to the hospital. Monitor the patients temperature. Warming measures, including moving the patient to a warm environment, removing wet clothes, applying dry clothing and blankets, and administering warm uids by mouth if the patient is able to swallow safely. Administer warm oxygen and warm IV uids if ordered.

Hypothermia ICD-9-CM code: 991.6

Body temperature less than 95F (mild), less than 89F (moderate), or less than 79F (severe); shivering, cold, pale skin Lethargy, fatigue, loss of coordination Confusion, slurred speech, progressive unresponsiveness, eventual coma

Frostbite ICD-9-CM code: 991.3 (unspecied sites)

Very cold or frozen tissue on exposed body parts, such as the ears, cheeks, and nose, and extremities, such as ngers and toes Skin that appears white (in light-skinned people) or ashen (in dark-skinned people) and feels little pain until it thaws Tissue that is stiff and has a waxy appearance (in deep frostbite)

Warming measures that include placing the patient in a warm environment and warming affected body parts in warm water (less than 105F). (Rewarming deep frostbite should take place in the hospital setting.) Monitor the patients vital signs. Never rub the body part because doing so will cause further injury. Administer opiate analgesics for severe pain as rewarming occurs, as ordered by the physician.

Animal Bite
ICD-9-CM code: 879.8 (uncomplicated, open wound) An animal bite normally leaves marks and may involve skin puncture, laceration or tearing, pain, bleeding, and bruising of surrounding tissue. The medical assistant should clean the wound as directed by the physician with sterile saline solution, antibacterial solution, or warm water and soap. She should apply antibiotic ointment and a dressing as directed or assist the physician with surgical repair if needed. The physician will order a tetanus booster if needed. The medical assistant should question the patient or accompanying family or friends in order to attempt to identify the animal involved and whether rabies should be a concern.

Snake Bite
ICD-9-CM code: 989.5 (venomous snakes, lizards and spiders) Snake bites may be nonvenomous or venomous. Nonvenomous bites leave fang marks in the skin, local tissue pain, discoloration, burning, edema, and inammation. Venomous snake bite symptoms vary with the type of snake and include the same local symptoms as in nonvenomous bites, plus blurred vision, convulsions, diarrhea, dizziness, diaphoresis, syncope, fever, thirst, loss of coordination, nausea, vomiting, tachycardia, and weakness. The medical assistant should calm and reassure the patient and keep the affected body part below heart level. She should assist the patient to rest in

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a position of comfort and remove jewelry on the affected body part. She should also monitor the patients vital signs and try to identify the type of snake, if possible, without putting anyone in danger by trying to capture the snake for identication purposes. She should clean the bite with warm water and soap or antibacterial solution and apply antibacterial ointment and dressing per the physicians order. She may also order antivenin if needed by calling a regional Poison Control Center (in the United States, the University of Arizona Poison and Drug Information Center at 1-520626-6016, which is available 24 hours a day.)

9%

9%

4.5%

9%

9% 1% 9% 9% 9%

9%

Insect Sting
ICD-9-CM code: 919.4 (nonvenomous insect bite) An insect sting or bite causes a sharp stinging sensation, redness, itching, and localized edema. A systemic allergic reaction may cause generalized edema, rash, itching, and, possibly, respiratory compromise (anaphylaxis). The medical assistant should determine if the stinger is still present in the skin and, if so, remove it by scraping across it with a plastic card. She should then clean the site with water and soap and apply a cold pack, anesthetic spray, or dry dressing as directed by the physician. She should continually observe for signs of allergic reaction. She may administer antihistamines, corticosteroids, and epinephrine as ordered by the physician for moderate to severe reactions and anaphylaxis.

9%

FIG 47-2 Rule of Nines.

degree burn. First-degree burns usually heal without further treatment and do not require treatment from a physician. Second-Degree Second-degree burns, also called partial-thickness burns, involve the epidermis and part of the dermis. The patient experiences intense pain and his skin appears red, edematous, and wet, shiny, or blistered. Second-degree burns usually result from exposure to flames, scalding liquids, steam, or direct contact with a very hot object. A patient with second-degree burns should be seen by the physician immediately. A patient with extensive second-degree burns should be treated in an emergency room and will most likely require hospitalization. A physician in a medical office can usually treat a patient with second-degree burns covering less than 10% of her BSA. At the direction of the physician, the medical assistant can clean the wound and apply silver sulfadiazine cream or another antibiotic ointment and a nonadherent dressing. The physician may also prescribe analgesics for pain and antibiotics to prevent infection. The medical assistant can also instruct the patient on other ways to avoid infection. (See Preventing infection in burn wounds, page 985.) At the direction of the physician, the medical assistant can help treat second-degree burns that cover a small part of the body (2" to 3" in diameter) by cooling the burn with cold water or cold compresses. However, she should never apply ice directly to the site because doing so can cause frostbite. The medical assistant should cover loosely with a sterile bandage any areas where the skin is blistered or broken. The

Burns
First-degree burnICD-9-CM code: 940.1 to 949.1 (4th digit indicates degree; 5th digit indicates BSA) Second-degree burnICD-9-CM code: 940.2 to 949.2 (4th digit indicates degree; 5th digit indicates BSA) Third-degree burnICD-9-CM code: 940.3 to 949.3 (4th digit indicates degree; 5th digit indicates BSA) Burns are classified according to severity as first-degree, second-degree, or third-degree. Part of evaluating the patient with burns includes an estimation of the percentage of the persons body surface area (BSA) affected. A commonly used tool for this process is a chart, called the Rule of Nines, which divides the body up into sections that are 9% of total BSA. (See Figure 47-2.) By referring to this chart, the medical assistant can make a quick, fairly accurate estimation. This data is essential in determining the persons condition and making appropriate treatment decisions. First-Degree First-degree burns, also called supercial burns, involve only the epidermis. (See Figure 47-3.) They are generally considered minor injuries. When a patient experiences a rstdegree burn, his skin becomes red, blanches to pressure, is moderately painful to the touch, and is dry with no blisters. Permanent tissue damage is rare and may consist of minor changes in skin color. Sunburn is an example of a rst-

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Clinical

A
Degree of damage

Epidermis Dermis

Subcutaneous

B
Degree of damage

Epidermis Dermis

Subcutaneous

C
Degree of damage

Epidermis Dermis

Subcutaneous

FIG 47-3 Classication of burns. (A) First-degree. (B) Second-degree. (C) Third-degree.

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Patient Education

Preventing Infection in Burn Wounds

Patients suffering from second- and third-degree burns are at risk for infection. Therefore, the medical assistant must be sure to explain to these patients measures to prevent infection, including: notifying the physician if you observe such signs of infection as increased pain, redness, swelling, fever, or yellow or green drainage avoiding breaking the burn blisters because intact skin helps keep bacteria out and prevents infection keeping the wound clean changing the dressing as instructed avoiding applying anything to the wound that was not prescribed by the physician avoiding using home remedies, such as the application of vitamin E oil, butter, or vinegar taking antibiotics (if prescribed) for the complete course avoiding sun exposure until the wound heals completely wearing sunscreen in subsequent sun exposure avoiding sun tanning for at least 1 year.

Patients with third-degree burns should receive treatment in a hospital, preferably one with a burn unit because of the risk of profound dehydration, shock, infection, septicemia, and other life-threatening complications. Treatment of patients with third-degree burns includes IV uid and electrolyte replacement, wound debridement, antibiotics, analgesics, a diet high in protein and calories, and extensive rehabilitation. These patients may also be candidates for skin grafting and reconstructive surgery.

Musculoskeletal Injury
Musculoskeletal injuries are common in a medical office. While they may be less serious than some conditions, many are considered emergencies that require immediate attention. The medical assistant should assist the patient into a position of greatest comfort and quickly evaluate circulation distal to the injured site. This is especially important if a fracture may be present because such an injury can impair circulation. If she is unable to confirm circulation, the medical assistant must contact the physician immediately, because the patients limb may be in peril. Common musculoskeletal injuries include fracture, sprain, and muscle strain.

Fractures and Sprains

FracturesICD-9-CM code: 800 to 829 (coded according to site, type, and other factors) SprainsICD-9-CM code: 840 to 848 (coded according to site, type, and other factors) Fractures and sprains are among the most common forms of musculoskeletal injuries seen in the medical ofce. A fracture is a break or crack in a bone. A sprain is trauma to a joint that causes a brief, partial dislocation, resulting in tearing of the ligaments that stabilize the joint. In either case, the patient may also have suffered injury to surrounding tissue, including blood vessels, nerves, muscles, and tendons. Thus, the patient commonly complains of pain, edema (swelling), ecchymosis (bruising), and decreased function. Symptoms of sprain include pain, weakness, decreased function, and, possibly, numbness. Bruising is usually not apparent. Fractures and sprains are almost always caused by some form of trauma or repetitive motion. Osteoporosis is also a major risk factor for fractures in elderly patients. With most types of fracture or sprain, the patients condition is typically unclear at rst. Thus, most medical ofce protocols include sending the patient for an immediate x-ray before seeing the physician to help determine whether the injured body part is fractured or sprained. However, the physician should immediately examine a patient with an obvious compound (open) fracture, in which the bone is protruding from the skin. Such a fracture can cause severe pain, hemorrhage, numbness, and circulation impairment and has a high risk of infection. Such patients will also need

physician may order analgesics such as ibuprofen or acetaminophen to alleviate mild to moderate pain and opiate analgesics for severe pain. The medical assistant should administer such medications as ordered. Second-degree burns covering a larger area of the body or located on the hands, the feet, a major joint, the face, the buttocks, or the groin may require special treatment because of a greater risk of complications. The medical assistant should be sure to consult with the physician for special instructions on treating such burns. Third-Degree Third-degree burns, also called full-thickness burns, destroy the epidermis, dermis, and subcutaneous layers of the skin. Fatty tissue, muscle, bone, and tendon may be involved as well, although some experts further classify burns with such involvement as fourth-degree burns. These burns may appear black and charred, brown, yellow, or even white. They are also dry and leathery. The patient feels no pain from thirddegree burns because the nerves are destroyed. However, he may have rst- and second-degree burns in the surrounding area that may be very painful. Typical causes of third-degree burns include scalding liquids, contact with ames, chemicals, extended contact with a hot object, or electrical burns.

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x-rays but should be quickly examined by the physician rst because the injury may constitute a surgical emergency. While the patient is waiting for x-rays or treatment, the medical assistant should help him into the position of greatest comfort and offer a way to stabilize his injured body part, such as with a pillow. The medical assistant can also apply ice packs or instant cold packs as approved by the physician to reduce swelling and pain. Basic care measures for a sprain or uncomplicated fracture help minimize edema formation, which helps minimize discomfort. To treat a sprain or uncomplicated fracture, the medical assistant can apply a splint and an elastic bandage or air splint, per the physicians order. Before and after applying a splint or dressing to an injured extremity, the medical assistant should always make sure there is adequate circulation to the injured tissue by checking circulation, motion, and sensation and document her ndings. (See Safety alert: CMS.) She can also continue cold therapy and help the patient elevate the injured body part above heart level. (See RICE.) In addition, the physician may prescribe NSAIDs, opiates, and muscle relaxants to alleviate pain and reduce muscle spasms.

includes the RICE approach, analgesics for pain, and muscle relaxants to reduce muscle spasm. Physical therapy may also help to ease discomfort and restore function.

Eye Injury
ICD-9-CM code: 930.9 (foreign body) The medical assistant should quickly place a patient with an eye injury or a foreign body in the eye in an examination room and gently apply patches to both eyes to minimize movement while she awaits examination by the physician. The medical assistant should instruct the patient to refrain from rubbing her eyes because doing so could cause further injury. Treatment for a foreign body in the eye usually includes irrigation with sterile saline solution. If the patient is in pain from inammation, the medical assistant can instill anesthetic drops as directed by the physician. The physician may prescribe antibiotic drops or ointment if infection is present or if the patient is at risk for infection. Other care may include application of cold compresses and administration of NSAIDs to alleviate inammation and pain. The medical assistant can help the physician with examination and treatment as needed.

Muscle Strain
ICD-9-CM code: 840 to 848 (code specic site) A muscle strain injury involves overstretching and tearing of muscles and tendons. Symptoms include pain, decreased function, and weakness. Mild cases of muscle strain resolve with rest. Treatment for moderate to severe muscle strain

Chapter Summary

Safety alert: CMS

To remember to check circulation before and after applying a splint or dressing to an injured extremity, the medical assistant should remember CMS: CirculationCheck pulses or capillary rell. MotionAsk the patient to wiggle his ngers or toes. SensationAsk the patient to close his eyes and verify when you touch his ngers or toes.

RICE
To remember basic care measures for the patient with a sprain or uncomplicated fracture, the medical assistant can use the acronym RICE: Rest (splint application) Ice (application of a cold pack) Compression (air splint or elastic bandage) Elevation of injured part above the heart.

Everyone who works in a medical ofce should be trained and prepared to respond to emergencies. Such preparation includes establishing a written plan of response in case of re, disaster, workplace violence, or medical emergency. All health care facilities must make an effort to create an environment that is safe for patients and staff alike. Workplace safety programs provide instruction in cardiopulmonary resuscitation (CPR), standard precautions, proper body mechanics, and other safety issues. Medical staff must be sure to maintain inventory of needed supplies and medications and restock following each emergency event. In addition, staff must carefully maintain and routinely check emergency equipment so that it is always ready. Many facilities routinely run mock codes, which are rehearsals for responding to specic emergencies, so that all members of the health care team can practice and develop their skills in responding to medical emergencies. An important, but sometimes overlooked part of emergency preparedness is the designation of a team member to document the emergency, called a recorder in some care settings. Not all medical ofces keep emergency equipment on hand, but many do. If an ofce does stock emergency

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equipment and medication, staff should be familiar with its use. A debrillator is a specialized device used to deliver an electrical shock to a patient suffering from a life-threatening cardiac arrhythmia to convert the heart back to normal sinus rhythm. An AED is a smaller, more portable version of a debrillator. Triage is the process of making a quick determination about the nature of the patients emergency, the type of immediate care needed, and the most appropriate response. If more than one patient is involved, triage may also involve determining which patient should be treated rst. When a medical emergency occurs, the patients exact diagnosis may be unclear at rst. The patient may simply display a collection of signs and symptoms. A common emergency is the patient with dyspnea. The medical assistant can look for clues to identify the severity of the patients distress and determine an appropriate response. Such clues include skin color, character of respirations, respiratory rate, use of accessory muscles, breath sounds, and the patients mental or emotional state. Common causes of dyspnea include choking, asthma attacks, anaphylaxis, pneumonia, COPD exacerbation, chemical or smoke inhalation, pneumothorax, and MI or heart failure. The medical assistant must always take seriously any complaint of chest pain. Common causes of chest pain include MI, angina, GERD, cholecystitis, costochondritis, pulmonary embolism, spontaneous pneumothorax, and panic attack. Numerous types of injuries result in hemorrhage (bleeding), which may be minor or life-threatening. After checking airway, breathing, and circulation, the medical assistant must take measures to control bleeding. A laceration is a cut or tear in the esh that may bleed slightly or may hemorrhage profusely. Epistaxis (nosebleed) is caused by erosion or rupture of small vessels within the nasal mucosa. Common causes include seizures, conditions related to diabetes management, and head injury as well as stroke, cardiac arrhythmias, and cardiac arrest; however, the cause is usually unclear at rst. Causes of a slower change in consciousness include hyperglycemia, hypoglycemia, drug toxicities, dementia, and other neurological disorders. Although these conditions can be quite serious or even life-threatening, the changes generally occur gradually, which enables evaluation, diagnosis, and initiation of treatment before the situation becomes an emergency. Poisoning most commonly occurs from oral ingestion of a substance. Other causes include injection, absorption, and inhalation. Occasionally patients enter the medical ofce with environmental injuries such as animal bites, insect stings, or burns. Less common injuries seen in this setting include

heat exhaustion, heat stroke, and hypothermia. After attending to ABCs, the medical assistant must gather information about the mechanism of injury to help ensure appropriate treatment. Burns are classied according to severity as rst-degree, second-degree, and third-degree burns. First-degree burns usually heal without further treatment and do not require treatment from a physician. The physician should see patients with second- and third-degree burns immediately. Those with extensive second- and third-degree burns should be treated in an emergency room and will most likely require hospitalization. Acute abdominal pain has many potential causes, some of which may be life-threatening. When a patient complains of acute abdominal pain, the cause is seldom immediately clear. Therefore, the medical assistant must take all such cases seriously and provide care according to office protocol, including informing the physician so that she can begin prompt evaluation and treatment. Common causes of abdominal pain include peptic ulcer disease, gastroenteritis, ulcerative colitis, diverticulitis, Crohn disease, cholecystitis, and appendicitis. Fractures and sprains are among the most common forms of musculoskeletal injuries seen in the medical ofce. A sprain is trauma to a joint that causes a brief, partial dislocation, resulting in tearing of the ligaments that stabilize the joint. A muscle strain injury involves overstretching and tearing of muscles and tendons. The medical assistant should quickly place a patient with an eye injury or a foreign body in the eye in an examination room and gently apply patches to both eyes to minimize movement while she awaits examination by the physician. Treatment for a foreign body in the eye usually includes irrigation with sterile saline solution.

Team Work Exercises

1. Divide into teams and select one of the following assignments. Report your ndings to the rest of the class in a manner specied by your instructor. a. Contact a medical ofce in your town and ask them to describe: what protocols they have in place for responding to medical emergencies, such as the patient with chest pain what types of patients they usually take immediately into examination rooms, rather than having them wait in the reception area whether they have an emergency cart (crash cart) and what type of equipment and supplies it contains whether they have a special code system for alerting staff to emergencies, such as a medical emergency,

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re, bomb threat, and so on, and if so, what are some examples. b. Create a protocol for dealing with a patient who walks into your ofce with chest pain. Role-play a scenario for the rest of class in which you demonstrate the protocol that you created. c. Create a protocol for dealing with a patient who walks into your ofce with a severe nosebleed. Role-play a scenario for the rest of class in which you demonstrate the protocol that you created. d. Create a protocol for dealing with a patient in your office experiencing severe dyspnea. Role-play a scenario for the rest of class in which you demonstrate the protocol that you created. e. Create a protocol for dealing with a patient who has a tonic-clonic seizure in the reception room. Role-play a scenario for the rest of class in which you demonstrate the protocol that you created. 2. Divide into teams of three to ve students each. Develop a triage plan for the order in which the following patients would be cared for (assuming they could only be seen one at a time). Present your list of patients in the order in which they would be cared for to the rest of the class and explain your rationale for the order. (Two teams will have the same list in order to compare how the teams triaged their patients.) a. Teams 1 and 2 19-year-old female with severe RLQ pelvic pain and vaginal spotting 65-year-old man with moderate dyspnea and left shoulder pain 35-year-old man with rst- and second-degree burns over his face, right arm, and chest 12-year-old boy with a bite on his right leg from a snake, which may have been a rattlesnake 51-year-old man with severe abdominal pain and a distended belly 25-year-old man with a potentially fractured right forearm 19-year-old woman with severe wheezing and history or asthma b. Teams 3 and 4 45-year-old woman with LLQ pain 72-year-old woman with second- and potentially third-degree burns on her arms from hot cooking oil 18-month-old lethargic infant who is hot, fussy, and diaphoretic and was left in the car in 90F heat while the mother was in a store for 45 minutes 47-year-old man who walks in with his hand wrapped in a blood-soaked towel 17-year-old with glass fragment in his eye 20-year-old with swollen right eye from a bee sting

38-year-old woman with nausea and pain in her RUQ and right shoulder c. Teams 5 and 6 66-year-old with COPD and moderate dyspnea 55-year-old with pneumonia, fever, chills, and moderate dyspnea 67-year-old with severe pain in the abdomen that radiates to his back 17-year-old with an obvious compound leg fracture who was brought in by friends after a skateboard accident 32-year-old woman with pelvic and low back pain, frequency, and dysuria 40-year-old man with chronic heartburn, which is worse today 27-year-old woman who fainted at the grocery store but is now alert and oriented

Case Studies
1. Albert Gomez is a medical assistant working in an urgent care clinic. He notices that a patient waiting in the reception area who brought her 9-year-old granddaughter in with a sore throat is having chest pain and dyspnea. As he walks across the room to talk with her, an elderly couple enters the reception area. The elderly woman, who appears upset, calls out I think my husband is having a heart attack! a. Describe a way in which Albert can respond to this situation so that the needs of both patients are met. b. There is currently only one unoccupied examination room and one crash cart with a debrillator available. Where should each of these patients be cared for? How should the staff allocate the use of the debrillator? c. Describe how the administrative and clinical medical assistants can work together to facilitate efcient care for these patients. d. Describe strategies the staff might employ to tend to the needs of the six other patients waiting in the reception area and the five patients currently in examination rooms. 2. Claudia Benevides is a medical assistant working in a family medicine practice. Describe how she ought to respond to the following patients who arrive at the ofce without prior notice: a. A concerned mother brings her 10-year-old son, who was stung by a bee on his right forearm 30 minutes ago. It is red and swollen to about the size of a golf ball. He has no other symptoms. b. A 32-year-old woman states that she had bloodstreaked stool this morning and thinks she might also have a fever.

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c. A 68-year-old woman arrives with her husband, who is experiencing a sudden onset of confusion, difculty speaking, and right-sided weakness. d. A woman arrives with her 14-year-old daughter, who has grease burns on her right leg and foot from a spill that occurred 20 minutes ago. e. A worried mother arrives with her 22-year-old son, who has a severe nosebleed that wont stop.

Resources

Emergency preparedness guidelines from the American Red Cross: www.redcross.org/services/prepare/0,1082,0_239_, 00.html Frequently asked questions about poisoning: www .poisonprevention.org/faq.htm Guidelines for patients on burn prevention: www .healthline.com/sw/wl-what-you-need-to-know-about -burn-prevention Guideline for treating patients with animal bites: www.nlm.nih.gov/medlineplus/ency/article/000034.htm

BCLS and ACLS certification courses from the American Heart Association: www.americanheart.org /presenter.jhtml?identier=3011795

CHAPTER

Radiology and Diagnostic Imaging

Objectives
Upon completion of this chapter, the student will be able to: dene and use the terms in the glossary list the four views for chest x-ray, describing the patient positioning for each discuss patient positioning for back, neck, and extremity x-ray and how to comfort the patient in pain explain the patient preparation necessary for mammography explain the difference between lmscreen radiography and uoroscopy explain the function of contrast media and special considerations of their use with patients describe how ultrasound waves create images of soft tissue and internal organs.
Recognize and respond to verbal communications Recognize and respond to nonverbal communications

48
Procedures
Assist x-ray technician with patient positioning as needed Schedule patients for diagnostic testing

Legal Concepts
Identify and respond to issues of condentiality

Patient Instruction
Instruct individuals according to their needs

Chapter Outline
Radiography and the Medical Assistant X-Ray
X-Ray Film X-Ray Views Patient Preparation for X-ray

ABHES Competencies
Professionalism
Maintain condentiality at all times Conduct work within scope of education, training, and ability

Mammography
Patient Preparation for Mammography

Communication
Adapt what is said to the recipients level of comprehension Serve as a liaison between the physician and others Recognize and respond to verbal and nonverbal communication Adaptation for individualized needs Application of electronic technology

Fluoroscopy
Patient Preparation

Computer Imaging
Ultrasound Patient preparation Magnetic Resonance Imaging Patient preparation Computed Tomography

Nuclear Medicine
Radiation Therapy External radiation therapy Internal radiation therapy Patient preparation Positron Emission Tomography Patient preparation

CAAHEP Competencies
Clinical Competencies Patient Care
Perform telephone and in-person screening Prepare and maintain examination and treatment areas Prepare patients for and assist with routine and specialty examinations Screen and follow up test results

Clinical Duties
Prepare patients for procedures Prepare and maintain examination and treatment area Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries

Legal Concepts
Determine needs for documentation and reporting Document accurately

General Competencies Professional Communications

Radiation Safety Scheduling Diagnostic Imaging Procedures Chapter Summary Team Work Exercises Case Studies Resources

991

Key Terms
angiogram

radiology

Diagnostic radiograph of the blood vessels using a contrast medium

cholecystogram

Branch of medicine concerned with radioactive substances, including x-rays or other sources of ionizing radiation used to assist in diagnosis and treatment
radiolucent

Penetrable by x-rays
radiopaque

Radiograph of the gallbladder

claustrophobia

Impenetrable to x-rays or other forms of radiation

tomography

Fear of closed spaces

computed tomography

Computerized procedure that views the target organ or body area from different angles in a three-dimensional view
contrast medium

Radiographic technique that selects a level in the body and blurs out structures above and below that plane, leaving a clear image of the selected anatomy
tracer

Radiopaque substance that enhances an image

digital radiographic imaging

Radioactive isotope that can identify a specic portion of a molecule to follow its course
transducer

Radiography using computer imaging instead of conventional lm or screen imaging

dosimeter

Device that moves over the skin to record sound waves

ultrasound

Device that monitors the quantity of x-ray exposure to health care workers
uoroscopy

Use of high-frequency sound waves to produce an image of an organ or tissue

upper gastrointestinal series

Radiographic imaging that can be viewed as a moving picture

intravenous pyelogram

Radiographic examination of the esophagus, stomach, and upper small intestine during and after the introduction of barium as a contrast medium; also called upper GI series or barium swallow
x-ray lm

Radiographic view of the kidneys using contrast medium injected intravenously

ionization

Special photographic lm that blackens on exposure to light

x-ray tube

Process of gaining or losing an electron from an atom

lower gastrointestinal series

Vacuum tube that creates electromagnetic radiation with a wavelength between 0.1 and 100 angstrom units

Radiographic examination of the lower intestinal tract during and after introduction of barium, which acts as the contrast medium
magnetic resonance imaging

Procedure in which a strong magnetic eld and radio waves are used to produce images to view body structures
mammography

Radiographic imaging of the breast to screen for breast cancer

nuclear medicine

Techniques that use radioactive material for the diagnosis and treatment of patients
open MRI

Imaging table with more open space than a traditional MRI tube
positron emission tomography

Procedure in which the brain is viewed using positronemitting radionuclides

radiograph

Image produced on radiosensitive lm by x-rays passed through an object

radiography

Process of producing an image for diagnosis using a radiographic modality

CHAP TER 48

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Radiography and the Medical Assistant

Radiography is a diagnostic technique that uses radiation to produce an image of the body. The branch of medicine concerned with radioactive substances, including x-rays or other sources of ionizing radiation, sound, or radiofrequencies, for diagnosis and treatment is referred to as radiology. Radiograph procedures can include x-ray, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) scan, mammogram, and radionuclide imaging. In a radiography setting, the medical assistants main duties include instructing the patient before, during, and after the procedure and assisting with positioning the patient, as directed. The patients health care provider (such as an MD or APRN) will typically order the procedure, a radiologic technologist (or radiographer), will perform the procedure, and the patients health care provider or a radiologist will interpret, or read, the image, or radiograph. (See Radiography roles.) The health care provider is responsible for explaining the images to the patient. The medical assistant can assist the provider by placing the images on the view box during a patient visit and ling the radiology report in the patients

medical record. View boxes are lighted and often mounted on the wall of the treatment room or ofce. The image is placed in front of the light and the light shining through the image allows the physician to view it. The medical assistant should check the name on the image before putting it on the view box. If the patient asks the medical assistant about the ndings, the medical assistant should not offer an interpretation. She should instead tell the patient that the physician or nurse will explain ndings when she arrives. In addition to understanding the techniques, procedures, and patient care associated with radiology, the medical assistant must have a good understanding of terminology related to radiology and diagnostic imaging. (See Radiography terminology, page 994.)

X-Ray
X-rays were discovered by German physicist Wilhelm Konrad Roentgen in 1895. X-rays are a type of light wave within the electromagnetic spectrum. A special x-ray tube is a vacuum tube that causes ionization (gain or loss of an electron from an atom) of the x-rays, creating electromagnetic radiation with a wavelength between 0.1 and 100 angstrom units. This ionization causes uorescence of certain substances, which in turn creates the x-ray picture. The process revolutionized diagnosis of disease because, for the rst time, physicians could see inside a patients body without cutting it open. X-ray imaging, typically referred to simply as x-ray, is the most common radiographic technique. In the procedure, a patient is positioned between an x-ray tube and x-ray lm, a special photographic lm that blackens on exposure to light. The x-ray machine then directs electromagnetic radiation through the patients body from the tube onto the x-ray lm. As the radiation passes through the patients body, structures that are radiopaque (impenetrable by electromagnetic radiation) prevent the radiation from reaching the lm. The radiation passes easily through structures that are radiolucent (penetrable by electromagnetic radiation). (See Figure 48-1.) Because radiopaque structures are impenetrable to electromagnetic radiation, they will appear white on the x-ray lm because the x-ray beam could not penetrate them. Bone is the densest tissue in the body and will appear white on the x-ray lm. Other radiopaque structures include teeth, surgical metal implants, and calcied structures of the body. Because radiolucent structures allow x-ray radiation to pass through the patients body to the x-ray lm, they appear darker on the lm. Such soft tissues of the body as muscle, fascia, and fat are radiolucent. Thus, the resulting image, called an x-ray or radiograph, shows denition of bony structures and absence of soft tissues. (See Figure 48-2.)

Radiography roles
In radiography, a radiologic technologist performs radiography procedures as ordered by the patients health care provider, who may interpret the results or may consult with a radiologist.

Radiologic technologist
A radiologic technologist, or radiographer, performs imaging procedures ordered by physicians or other health care providers. To become a radiologic technologist, a person must graduate from a 2- or 4-year program and then pass a national examination administered by the American Registry of Radiologic Technologies. If the person passes the examination, he can use the title Registered Radiologic Technologist (RRT).

Radiologist
The patients health care provider should interpret, or read, the radiography results. If the procedure is performed outside of the medical practice, such as at a hospital or imaging center, a radiologist (a medical doctor who specializes in x-rays) will interpret the images and send a report of his ndings along with the images to the health care provider. The provider must then read the radiologists report and view the images herself.

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Radiography terminology
The medical assistant should be familiar with the terminology used in the x-ray department or in the physicians ofce. Here are some of the most common terms she will encounter in such a setting: anteroposterior (AP)x-ray view in which the patient is positioned facing the x-ray tube or lying supine pronex-ray view in which the patient is positioned lying prone (face down) supinex-ray view in which the patient is positioned lying supine (on back) posteroanterior (PA)x-ray view in which the patient is positioned facing the x-ray lm or lying prone obliquex-ray taken at a 45-degree angle lateralx-ray taken from the side view (right or left) weightbearingindication on an x-ray order that the patient must bear weight for the view (typically used for the foot, knee, and back) plain lmterm used for an x-ray image to differentiate it from other types of images buckymoving grid device in which the cassette loaded with radiographic lm is placed cassetteholder in which the technician places the radiographic lm in the darkroom to protect it from exposure to light until exposure to x-rays.

Word Elements
In addition to radiology terms, the medical assistant should be familiar with some of the most common word elements associated with radiology. The following table lists common combining forms, prefixes, and suffixes related to radiology.

Word Element
Combining Forms actin/o anter/o uor/o later/o mamm/o oste/o poster/o pyel/o radi/o Prexes cinecontratransultra-

Meaning
ray; some form of radiation anterior, front, before luminous; uorescence side breast bone posterior, behind, toward the back pelvis radiant energy; a radioactive substance

Example
a-p actinotherapy ( n- ak-t o-THER- e) anteroinferior ( er- n-FE-re-or) an-t o- uorochrome (FLOO- or-krom) bilateral (b-LAT-er- al) o-pl mammoplasty (MAM- as-te) osteodynia ( e- IN- a) os-t o-D e- al) posteromedial (p er- os-t o-ME-de- pyelotomy (p- T-o-me) e-LO radiobiology (ra-de- -OL- e) o-b o-j

Meaning
treatment of a disease with rays of light in front and below coloring agent that adds uorescent glow to an object pertaining to or affecting two sides reconstructive surgery of the breast pain in bone toward the back and middle incision of the renal pelvis branch of biology that deals with ionizing radiation and the effects on living tissues

movement against across; over; beyond; through beyond; excess

cinematics (sn- e-MAT-ks) contraindication (kon-tr n-d-KA-sh a- un) translucent (tr ans-LU-s ent) ultrasound (UL-tr a-sownd)

science of movement any reason that makes treatment with a drug unsafe permitting the passage of some light through an object inaudible sound frequency used to create images

Sufxes -graph instrument used to make a drawing or record -scope -scopy instrument for viewing or examining examination o-p uoroscopy (oo-or-OS-k e) uoroscope (FLOO-or- op) o-sk af) radiograph (RA-de- o-gr image produced on radiosensitive lm by x-rays passed through an object instrument that produces moving images examination that produces moving images

CHAP TER 48

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995

14 14

14 (36 17 (36

36 cm) 43 cm).

X-Ray Views
X-ray views are named for the direction of the beam in relation to the body part that the beam of radiation passes through. There are ve major x-ray views:

FIG 48-1 X-ray technique.

posteroanterior anteroposterior right lateral left lateral oblique.

X-Ray Film
X-ray, or radiographic, lm is manufactured to be sensitive to energy from the x-ray machine. It is coated with a photosensitive uid on both sides, which makes it easy to load lm into cassettes. Film must be stored in a clean, cool, dry area. Humidity will fog the lm, causing poor x-ray quality. Film has an expiration date, so the medical assistant who loads lm into cassettes should check the date on the lm. Boxes of lm should be stored with the expiration date visible, with the closest date in the front to be used rst. Film and cassettes come in standard sizes:

Thus, a patient that is positioned for a chest x-ray (CXR) with his back toward the x-ray tube would produce a posteroanterior (PA) chest lm. If the patient then turns around to face the x-ray tube, the x-ray produced would be an anteroposterior (AP) view. Placing the patient at a 90-degree angle for a chest lm produces a right lateral (LAT) or left lateral chest view. When the patient is positioned at a 45-degree angle, the x-ray produces an oblique view. X-ray views of extremities have the same terminology; thus, an anteroposterior knee lm would show the front of the knee. (See Figure 48-3.)

Patient Preparation for X-ray

Before the x-ray procedure, the medical assistant should explain the procedure to the patient. If appropriate, she should ask the patient if she is pregnant because exposing a fetus to x-rays can damage its growth and development. Thus, health care providers rarely order x-rays for a pregnant

8 9 10 11 7

10 (20 25 cm) 9 (23 23 cm) 12 (25 30 cm) 14 (28 35 cm) 17 (18 43 cm)

FIG 48-2 Plain lm x-rays.

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FIG 48-3 X-ray views. (A) Posteroanterior. (B) Anteroposterior. (C) Right lateral. (D) Left lateral. (E) Oblique.

woman. In the case of an emergency, it may be acceptable to x-ray a pregnant womans extremity. The medical assistant should instruct the patient to remove all jewelry and female patients to remove underwire bras; these objects are radiopaque, so they will appear on the x-ray image and limit the view of the patients body. When the patient is ready, the medical assistant should position the patient appropriately for the x-ray. For weightbearing x-ray studies of the chest or back, the medical assistant should position the patient standing. These same areas are viewable via x-ray with the patient lying down on an x-ray table

(nonweightbearing). The medical assistant should always mark the x-rays as weightbearing or nonweightbearing. There are four major areas that undergo x-ray. The medical assistant may be asked to assist the radiologic technologist in positioning a patient for x-ray or comforting an injured patient, so she must be familiar with these areas and the appropriate patient positioning and instruction for each:

chest x-rayThe medical assistant should ask the patient to stand or lie down (as directed), remain still, and take a deep breath and hold it until directed to release it.

CHAP TER 48

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lower backThe medical assistant should ask the patient to stand or lie down (as directed) and remain still (no need to take a deep breath). cervical spineThe medical assistant should ask the patient to stand. She should then place the x-ray tube at the patients head and neck level, check the order for open- or closed-mouth x-ray, and direct the patient to open or close his mouth, as appropriate. extremitiesThe medical assistant should ask the patient to sit or lie on the x-ray table and then place the x-ray lm under the affected body part. (See Figure 48-4.) She A B

should drape a lead apron across the patients shoulders and lap to protect his reproductive organs from ionizing radiation. (See Gonad shields, page 998.) Because extremity x-rays diagnose injury, she should be careful moving the affected area. Directing the patient to move the extremity on their own (if possible) is commonly the least traumatic for the patient. She should allow the patient to move slowly without rushing him and ask him to remain still during the x-ray. (See Procedure 48-1: Preparing a patient for and assisting with x-ray examination, page 999.)

FIG 48-4 X-ray positions. (A) Chest x-ray. (B) Lower back. (C) Cervical spine. (D) Extremity (arm).

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Gonad shields
Exposure of reproductive organs to radiation can cause cellular damage that can lead to sterility. The medical assistant and radiologic technologist should always shield patients who are at reproductive age (or younger) from exposure using a gonad shield. The medical assistant can explain the need for the gonad shield to her patient and place the shield appropriately before the procedure. The shield consists of at least 0.5 mm of lead and will not interfere with the x-ray. The medical assistant can strap the shield around the patient for x-rays in the standing position or drape it over his lap for seated x-rays (such as of the arm, shoulder, or head.) For pelvic x-rays, done with the patient lying supine (face up), the medical assistant should place the shield directly over the patients reproductive organs to allow an accurate image of the pelvis while protecting reproductive organs from radiation. For male patients, the medical assistant should place the upper margin of the shield 1 below the symphysis pubis. For females, she should place the lower margin of the shield on the upper margin of the symphysis pubis. No matter the position, proper placement of the shield is vital to ensure that reproductive organs are protected from damage by ionizing radiation.

directed by the physician. Males may also undergo a mammogram if abnormalities are detected in male breast tissue. To undergo a mammogram, the patient must stand facing the mammogram machine. The radiologic technologist or medical assistant will then position the patients breast on a at plate on the machine. The machine applies pressure from the top and bottom of the breast and laterally from each side, compressing the breast. When the breast is compressed, the machine will take x-ray images of it. (See Figure 48-5.)

Patient Preparation for Mammography

Before the patient schedules a mammogram, the medical assistant should give her verbal and written instructions. She should address any questions the patient has before the examination. Instructions for the patient include:

Avoid caffeine for several days before the test to reduce swelling and soreness that caffeine may exacerbate. If possible, do not schedule the examination immediately before or during the patients menstrual cycle because the breasts are commonly tender at that time and the examination may be more uncomfortable for the patient. Do not use lotions, powders, antiperspirants, or deodorants on the morning of the test because they may interfere with the image quality. The patient will be standing for approximately 15 minutes for the procedure. If standing for this amount of time would be difcult, notify the mammography department to see if accommodations could be made before the examination. The machine will compress each breast superiorly to inferiorly and medially to laterally (top to bottom and side to side). There may be some discomfort, but full compression allows for an accurate picture of the breast. Only clothing from the waist up is removed. Slacks and comfortable shoes are recommended. After the examination, take an analgesic as directed by the physician if soreness or pain are present.

(A) Male gonad shield.

(B) Female gonad shield.

Camera unit

X-ray beam

Mammography
Mammography is the x-ray examination of the breast to detect abnormalities, such as cancer or calcium deposits. It is considered one of the most effective methods for early detection of breast cancer along with regular breast selfexaminations. Women should receive their rst mammogram at age 40 and have follow-up mammograms yearly or as
Film plate

FIG 48-5 Mammography.

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PROCEDURE 48-1

Preparing a patient for and assisting with x-ray examination

Task Prepare and position a patient for x-ray examination, label and store the x-ray, and document the procedure. Conditions Physicians order for x-ray examination Patient identication card to imprint x-ray X-ray machine and cassette with lm loaded Lead shield Patients medical record X-ray processor, darkroom Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully prepare and position the patient for x-ray examination by the radiologic technologist, label and store the x-ray, and document the procedure. Performance Standards 1. Greet and identify the patient and explain the examination procedure to reassure the patient and calm his fears about the procedure. 2. Check the x-ray examination order to ensure that the correct procedure is performed. 3. Explain the procedure to the patient and obtain consent verbally or in written form, per ofce policy. 4. Ask a childbearing-age woman if she may be pregnant. If she is or might be, discontinue the procedure because x-rays can cause injury to a developing fetus. 5. Place the x-ray cassette in the machine. 6. Ask the patient to remove clothing and jewelry, as needed for the procedure, to avoid causing obstruction and ensure the quality of the image. 7. Check to make sure that the patient has removed all metal objects from the area to be examined to avoid the need for a second x-ray and limit the patients exposure to radiation. 8. Assist the radiologic technologist with these steps, as requested: a. Position the patient against the x-ray lm cassette. Proper positioning is required to obtain a clear view. b. Align the x-ray tube and cassette at the correct distance and set controls to deliver the appropriate x-ray quantity. c. Ask the patient to hold her breath, if necessary, to prevent the diaphragm from moving, which will cause blurring of the image. 9. While the x-ray machine is in use, leave the room with the radiologic technologist and stand behind the lead shield to limit exposure to radiation as much as possible. 10. Ask the patient to relax while the x-ray develops because the patient must wait in case the x-ray quality is poor and another image is required. 11. After the radiologic technologist develops the x-ray and conrms that he does not need to repeat the procedure, ask the patient to dress. 12. Obtain the x-rays from the radiologic technologist and ensure that the lms are properly named and dated to avoid misdiagnosis or having to repeat the procedure. 13. Create a labeled x-ray envelope and place the x-rays in it. 14. Document the procedure in the patients medical record to ensure a complete, accurate medical record.
Date 05/28/08; 9:45 a.m. AP/Lat chest x-ray. --------------------------- S. Gonzales, CMA

Fluoroscopy
Unlike an x-ray that produces a still picture, uoroscopy is a type of x-ray procedure that produces a moving picture. The radiologist views the uoroscopy during the procedure and records it for the physician to review at a later time. This technique contributes valuable information on the functioning of organs, in addition to the structure. Most uoroscopic examinations require a contrast medium, which is a type of substance that makes normally radiolucent structures radiopaque. Normally, such soft tissues as the esophagus, stomach, and small intestines would be radiolucent and, thus,

appear black when viewed on x-ray lm. (See Figure 48-6.) Contrast media can be administered orally, through injection, or with an enema. When the patient swallows a contrast medium such as barium, the radiopaque substance outlines the organs, enabling the physician to view the organs. When the physician injects a contrast medium such as iodine into a vein, she can see vascular structures in the kidney. (See Common diagnostic tests requiring contrast media, page 1001.)

Patient Preparation
Patient preparation for diagnostic testing with contrast medium requires specific instructions. These instructions

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B
FIG 48-6 Fluoroscopy. (A) Barium in intestines. (From Williams & Hopper. Understanding Medical Surgical Nursing, 3rd ed. FA Davis, Philadelphia, 2007, page 650, with permission.) (B) Angiogram with iodine in veins and arteries. (From Tortorici & Apfel. Advanced Radiographic and Angiographic Procedures. FA Davis, Philadelphia, 1995, page 236, with permission.)

should always be given in writing and sometimes require a prescription for pretest medication. When scheduling testing, the medical assistant should explain to the patient the importance of following pretest instructions. She should emphasize that if the patient cannot follow the instructions, the test may not be performed. She must also discuss allergies to iodine or shellfish with the patient. If the patient is allergic to iodine, alternative testing is indicated.

techniques include ultrasound, magnetic resonance imaging, computed tomography, and nuclear medicine.

Ultrasound
Ultrasound uses high-frequency sound waves to create an image of soft tissue and internal organs. It is a noninvasive procedure and, because no ionizing radiation is used, it is considered safe to use to view a fetus. The machine consists of a computer screen to view the images, a keyboard to label and save images, a printer to save images for further review, and a transducer, which is a device that focuses sound waves into the body. Sound waves enter the body as the transducer passes over the skin. (See Figure 48-7.) The sound waves emitted from the transducer bounce off the deep tissues and differences in the tissue densities create the image. Ultrasound is painless and the patient will only feel the cool conducting gel that is applied to the skin.

Computer Imaging
Computer imaging, or digital radiographic imaging, uses x-ray technology but offers an alternative to using x-ray film. Film can expire; become exposed to light, ruining its ability to create images; or arrive from the manufacturer in damaged condition. If the medical assistant or radiologic technologist does not realize that the film is not in good condition, the patient must undergo the discomfort and inconvenience of more testing and will be exposed to more radiation. Because computer imaging does not rely on film, it provides clearer, error-free images. The computer creates the image while the patient is undergoing the test. The interpreter of the image (physician or technologist) can see the image while performing the test, ensuring that no repeat images will be necessary. Computer imaging

Patient Preparation
Patient preparation for ultrasound procedures is limited. Common ultrasound tests include abdominal ultrasound, pelvic ultrasound, and fetal ultrasound.

Abdominal
Abdominal ultrasound is used to view the liver, gallbladder, kidneys, pancreas, spleen, and aorta. Patient preparation

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Common diagnostic tests requiring contrast media

The following table lists common diagnostic tests that use a contrast medium, along with the type of medium used, the tests purpose, specic patient preparation considerations, and a description of the procedure.

Test and Purpose

Upper GI series Radiographic examination of the esophagus, stomach, and upper small intestines (duodenum) with contrast medium to detect obstruction Lower GI series Radiographic examination of the colon with contrast medium to detect polyps, inammation, diverticula, and other abnormalities

Contrast Medium
Barium sulfate

Patient Preparation
Light evening meal Nothing by mouth (NPO) after midnight

Procedure Description
Patient removes all clothing and wears a gown. Medical assistant or technologist positions the patient with his back against the lm. Patient drinks barium during examination.

Barium sulfate

Low-residue diet for 2 days No dairy products Use of special bowel preparation kit to evacuate bowel contents Light evening meal and NPO after midnight Enema and rectal suppositories the morning of the examination

Patient removes all clothing and puts on gown with opening in the back. Medical assistant or technologist positions the patient in Sims position. Physician inserts barium sulfate as an enema. Medical assistant helps patient with frequent side-to-side turning to allow barium to move through the intestines.

Intravenous pyelogram (IVP) Radiograph of the urinary tract during excretion of radiopaque material to examine the renal pelvis, ureters, and bladder to detect cysts, tumors, stones, or strictures and provide information about structure and function Cholecystogram Radiograph of the gallbladder to record movement of bile through the gallbladder

Iodine

Light evening meal Laxative taken the night before NPO after midnight Before the test, drink uids, empty bladder before procedure

Nurse or physician injects dye through intravenous (IV) catheter. As the kidneys excrete the dye, multiple radiographs record excretion of the material.

Iodine

Low-fat evening meal Oral medication the evening before NPO after medication

Technologist performs a series of x-ray lms. Patient consumes fatty meal to stimulate gallbladder after initial lms. Technologist performs subsequent series of x-rays.

Angiogram Radiographic record of the size, shape, and location of the heart and blood vessels to detect tumors and obstructions as well as lung, heart, and other organ problems

Iodine

NPO after midnight

Nurse or physician administers a sedative. Nurse or physician injects dye into a vein using an IV catheter. Technologist takes series of x-ray lms.

guidelines include nothing by mouth (NPO) after midnight before the day of the test.

bladder is full. Thus, the patient must drink four to six 8-oz glasses of uid 1 hour before the examination.

Pelvic
Pelvic ultrasound is used to view various structures in the pelvis. The approach used may be transvaginal or transrectal. Patient preparation guidelines include no dietary restrictions. However, the test must be performed while the patients

Fetal
Fetal ultrasound is used to view the developing fetus to approximate gestational age, determine the sex of the fetus, measure head circumference, and assess the position of the placenta. It can also detect abnormalities of the fetus or

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Controls Transducer

Conducting gel

FIG 48-7 Ultrasound machine and equipment.

placenta. There are no special patient preparation guidelines for fetal ultrasound.

transdermal patches, or aluminum-based antiperspirants, as they all contain metal. Does your occupation involve small particles of metal? The medical assistant should explain that welders, plumbers, and ironworkers may be exposed to particulate metal on the job. These patients may require ophthalmic x-rays before the examination to rule out metal fragments in the eyes to avoid injury during the examination. Could you be pregnant? The medical assistant should ask this question of all female patients of childbearing age. MRI scans are contraindicated during pregnancy because the effects of a strong magnetic eld on a developing fetus are not well documented. Will you be able to lie still for at least 30 minutes? The medical assistant should explain that movement will blur the image. MRI scans may not be feasible for patients with lower back pain or other conditions that induce pain when maintaining the same position for an extended time period. Do you suffer from claustrophobia (fear of enclosed spaces)? The medical assistant should explain to the patient that the MRI scanner is a tubelike structure in which the patient must remain still for an extended period. A patient who may feel anxious can receive a mild sedative before the scan for comfort.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) uses a strong magnetic eld and radio waves to view anatomical structures. MRI scans create a three-dimensional image of the body that can show blood clots, nerve damage, torn ligaments and tendons, and other soft tissue abnormalities that x-ray technology cannot differentiate. MRI scans are noninvasive and patient preparation is limited to pretest questions.

Patient Preparation
Dietary restrictions are not necessary for MRI scans. In addition, patients can continue their prescription medications without restriction. The medical assistant must ask the patient these questions before the scan:

During the examination, the patient must lie supine (on her back) with her arms at her sides. The medical assistant can place a small pillow behind the patients knees if necessary for comfort. When the patient is comfortably positioned on the bed, the technologist slides the bed into the magnetic tube. The scan takes 30 to 45 minutes, depending on the body areas to be scanned. The patient will hear a humming or thumping sound. The medical assistant can provide earplugs to lessen the noise. For obese or severely claustrophobic patients, an open MRI scanner may provide some relief from anxiety or difculty. The scanner produces the same images but the imaging table is wider and the sound less noticeable. Children who may be fearful of the noise and closed-in feeling of the MRI scanner can also benet from the open MRI. (See Figure 48-8.)

Do you have any medical devices with metal, such as pacemakers, surgical rods or pins, or dental bridges? The medical assistant must be sure to explain to the patient that the strong magnetic eld of the MRI can pull loose metal fragments out of the patients body, causing injury. She should also explain that permanent metal objects in the body will blur the picture. Objects that contain metal that can be removed for the scan include hearing aids, glasses, hair clips, and dentures. Because clothing could contain metal, the medical assistant should tell the patient that he must remove all clothing and wear the gown provided. She should also tell the patient not to wear eye shadow,

Computed Tomography
Computed tomography (CT), or computerized axial tomography (CAT), is a technology that produces cross-sectional views of the body, or slices, along varying axes (hence, the word axial). The machine is able to focus on the structures of the body in one specic plane to create each image. The computer uses these two-dimensional images to create a three-dimensional image, which can rotate in many directions to provide many views of the body. Unlike an ultrasound, which uses sound waves, or an MRI, which uses a strong magnetic eld, tomography uses x-ray. The CT scanner x-ray tube focuses a narrow x-ray beam across a layer

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FIG 48-9 CT scan of the head. (From Tortorici & Apfel. Advanced Radiographic and Angiographic Procedures. FA Davis, Philadelphia, 1995, page 312, with permission.)

Radiation Therapy
Radiation therapy delivers a specic dose of radiation to a specic area of the body to destroy cancer cells. Radiation alters the cells structure so that they can no longer reproduce. Healthy cells are affected by radiation but can repair themselves after damage. Although healthy and cancerous cells are affected by radiation, the aim is to kill more cancer cells than healthy body cells. There are two forms of radiation therapy: external and internal.
FIG 48-8 MRI scanners. (A) Regular scanner. (B) Open MRI scanner.

External Radiation Therapy

In external radiation therapy, the technologist administers calculated doses of radiation from a machine positioned at a specic distance from a tumor. The tumor must be welldened before radiation therapy begins. A CT scan or ultrasound determines the exact location and size of the tumor. The technologist then marks the patient with a small, permanent tattoo so the radiation continually hits the tumor directly and limits damage to healthy tissue. A patient receives external radiation treatments over a period of weeks or months. The physician carefully monitors the patients course of treatment and her response through reports from the radiologic technologist and physical examination of the patient.

of the body. The computer analyzes the absorption of x-ray energy by body structures (according to their density) and produces an image. CT scan may involve the use of a contrast medium introduced into an intravenous (IV) line. The nurse or physician injects the dye directly into the vein so the technologist can follow the path of the dye on the scan. (See Figure 48-9.)

Nuclear Medicine
Nuclear medicine includes techniques that use radioactive material for diagnosis and treatment. Nuclear medicine used to treat diseases such as cancer is called radiation therapy. Positron emission tomography (PET) scanning is a nuclear medicine technique used for diagnosis.

Internal Radiation Therapy

Internal radiation therapy involves implanting containers of radioactive material near a tumor. Such substances as cesium-137 and cobalt-60 are sealed in gold containers, or

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seeds, and implanted in or near the site of the tumor. The patient can also take radioactive iodine-131, phosphorus-32, or gold-198 by mouth or IV.

Patient Preparation
Patients treated with external or internal radiation therapy may experience adverse effects related to the radiation. The medical assistant can help her patient by providing strategies for reducing symptoms. Common symptoms include anorexia (loss of appetite), nausea, vomiting, and diarrhea. The medical assistant can encourage the patient to eat cool, soft foods in small portions. Because a patient will typically undergo one to two radiation treatments per week, the medical assistant should encourage her to eat on the days that she does not receive radiation in an effort to build strength for the next dose. The medical assistant should instruct the patient to plan time for sleeping and relaxing after treatment. She should also emphasize that the patient should ask a friend or family member to drive her home after the treatment.

patient that during the procedure, he will be seated in a reclining chair and receive an IV injection of sugar tracer. After 45 minutes, the radiologic technologist takes the patient to the PET scanner, and the patient lies down on the scanner table. The medical assistant should advise the patient that he will need to remain still on the scanner for up to 2 hours. Because many patients nd the test difcult, physicians typically prescribe it only when information from the scan is vital, such as to determine tumor size, activity, and location or vascular abnormalities that other testing may not identify. The patient may be concerned about a radioisotope injected into his body. The medical assistant should reassure the patient that the radioisotopes used in nuclear medicine decay within a short timefrom a few hours to a few days and that the body excretes the isotopes in the urine and feces. She should explain that the radioisotope produces less radioactivity than most x-ray examinations or even a crosscountry airplane ight.

Positron Emission Tomography

Positron emission tomography (PET) uses a tracer, which is a radioactive isotope that identies cancer cells and follows their course through the body. The nurse or physician injects tracer material into the patients vein, and the cancer cells or other cells (such as brain cells) take up the tracer. The tracer, the radioactive sugar isotope uorodeoxyglucose, attaches to the cancer cells and sends a signal to the PET scanner. The scanner converts the signal into an image on the screen that depicts the exact size and location of the cancer cells. The computer produces images in colors that indicate the degree of metabolism (activity) or blood ow. Unlike CT and MRI scans, a PET scan can show the functioning of organs. Other tracers, such as carbon-14, calcium-42, and iodine-131 (not sugar tracers), may also be chemically designed to attach to cells of the brain or heart (healthy cells) to create a picture of the functions of that organ. Patients with iodine allergies must receive a carbon or calcium tracer. PET scanning can be a useful tool in assessing potential benets of coronary bypass surgery because it shows not only obstructed blood ow but also where blood is able to ow. The functional picture obtained with PET scanning enables the physician to safely divert blood ow in a bypass procedure. It can also help in diagnosis of Alzheimer disease, Parkinson disease, and other neurological disorders by enabling a physician to view the cells of the brain and observe areas of decreased activity, an indication of such pathologies.

Radiation Safety
Because health care workers can be exposed to particles of ionizing radiation when working with x-ray machines, they must follow safety procedures to prevent exposure. Some safety measures are instituted by the facility in which they work. For example, walls of x-ray rooms are lined with lead, limiting exposure through the walls and into adjacent rooms. Also, the control panel of the x-ray machine is placed behind a lead wall so that the x-ray technician is protected while exposing the lm. Other safety measures are the responsibility of the health care worker. For example, all health care workers who work in an area with potential exposure to radiation must wear a personal monitor called a dosimeter, commonly called a lm badge. The dosimeter measures the quantity of radiation to which the person is exposed. The person must wear the dosimeter on the outside of her anterior surface, usually on her laboratory coat, between the chest and waist level. If the person wears a lead apron to assist the patient during an x-ray procedure, she must wear the dosimeter on the outside of the apron. She must wear the badge at work at all times and cannot share it with other employees. The facility will send the dosimeters for evaluation of radiation exposure weekly, monthly, or quarterly, depending on the quantity of x-rays taken at the facility and the facilitys policy. Employees receive an annual report of their occupational exposure. (See Figure 48-10.) Although the dosimeter monitors radiation exposure, health care workers can take measures to limit exposure to radiation. During x-ray examinations, the medical assistant or radiologic technologist should stand behind the lead

Patient Preparation
The medical assistant must instruct the patient to fast for 6 hours before a PET scan. She should also explain to the

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barrier so that she is not exposed to radiation. Although exposure to radiation during pregnancy can result in birth defects, the pregnant medical assistant or radiologic technologist can avoid exposure by following safety procedures and can work safely through a pregnancy if she desires to do so.

Scheduling Diagnostic Imaging Procedures

Bio Labs

. Funes, Eva N
8/31/2008 6/1/2008 to

FIG 48-10 Dosimeter.

The medical assistant commonly schedules diagnostic imaging procedures. Because patient pretest instructions are required for many tests, the medical assistant must explain the pretesting requirements and answer questions that arise at the time of scheduling. The medical assistant should give the patient written pretest instructions, an appointment card with the date and time of the test, and directions to the hospital department or imaging center. Some ofces require medical assistants to call patients to remind them of the scheduled testing 24 hours before the appointment. (See Procedure 48-2: Scheduling a patient for diagnostic examinations.)

PROCEDURE 48-2

Scheduling a patient for diagnostic examinations

Task Schedule a patient for diagnostic examinations. Conditions Physicians order for specialty examination Written instructions Appointment card Patients medical record Standards In the time specified and within the scoring parameters determined by the instructor, the student will successfully explain pretesting instructions to the patient and schedule the procedure with an outside provider. Performance Standards 1. Review the physicians order for testing to prevent mistakes in scheduling testing. 2. Give the patient written instructions for pretest preparation to avoid noncompliance that would require cancellation of the test. 3. Explain the pretest preparation verbally to the patient to allow the patient to ask questions at the visit. 4. Call the provider of the examination to be scheduled (hospital or radiology group) and ask to make an appointment for the examination. 5. Tell the patient the available dates and times for the examination and ask the patient to choose a date and time. 6. Conrm the date, time, and type of examination on the phone with the scheduling personnel to ensure that you and the scheduling personnel hear each other correctly and you give the proper date and time to the patient. 7. Give the patient an appointment card with the date and time of the examination. Provide driving directions to the examination site as needed to ensure that the patient has the correct appointment location, date, and time. 8. Record the scheduled examination in the patients medical record.
Date 05/27/08; 11:00 a.m. Scheduled MRI of left knee for 05/30/08 at 4:30 p.m. at Lincoln Memorial Hospital Radiology, written pretest ----instructions provided. ----------------------------- C. Chapin, CMA

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Case Studies Chapter Summary

Radiographic procedures provide important diagnostic information. The medical assistant can assist the radiologic technologist in proper patient placement for radiologic procedures. Having an understanding of the various types of diagnostic imaging procedures such as x-ray, mammography, ultrasound, and MRI, CT, and PET scanning enables the medical assistant to properly prepare and educate patients. Because valid test results rely on proper patient preparation, the medical assistant must communicate pretest preparations to patients and answer questions as they arise. The medical assistant can schedule diagnostic and therapeutic hospital radiologic procedures and alert hospital staff to any special needs of her patient. Awareness of safety precautions and adherence to safety procedures will allow the medical assistant to perform duties safely.

1. Gary Edwards tells the medical assistant that he suffers from claustrophobia and is unsure if he will be able to lie still for the MRI that Dr. Greer has prescribed for his knee. The medical assistant realizes that Gary does not understand that his entire body does not go into the scanner. How should the scheduling medical assistant help Gary? If Gary becomes panicked at the mere thought of the MRI scan, what should the scheduling medical assistant say or do to allay Garys fears? Should she involve Dr. Greer in the conversation. If so, why? 2. Robert Jenkins is a 78-year-old patient with Parkinson disease who fell and has a large bruise on his left knee. Dr. Rodriguez has ordered an x-ray for Mr. Jenkinss knee. What can the medical assistant do to assist the radiologic technologist in x-raying Mr. Jenkins?

Resources

Team Work Exercises

1. Divide into groups of four to six students. Each group must create a poster or computer presentation on one of these technologies: a. CT scan b. MRI scan c. PET scan d. uoroscopy. Each group should be sure to include how the machine works, what patient preparation is required for the examination, whether the technology is used for diagnosis, treatment, or both, and what contraindications or special concerns there might be with its use. 2. Divide into groups of three to ve students. Each group must create patient preparation instructions for these examinations: a. upper GI series b. lower GI series c. MRI scan d. ultrasound (fetal) e. ultrasound (abdominal) f. mammogram.

American Society of Radiologic Technologists: www .asrt.org How x-rays are made: www.colorado.edu/physics/2000/ xray/making_xrays.html Labeled normal x-rays: www.accessexcellence.org/RC/ VL/xrays/ NASA explains x-rays in medicine and space: www .science.hq.nasa.gov/kids/imagers/ems/xrays.html Radiology information for patients: www.radiologyinfo .org/index.cfm?bhcp=1 X-ray information: www.nlm.nih.gov/medlineplus/ xrays.html

CHAPTER

Externship and Career Strategies

Learning Objectives
Upon completion of this chapter, the student will be able to: dene the key terms in the glossary describe the purpose of the externship experience discuss behaviors that will help make a positive impression at the externship site list the steps to follow in searching for a job describe the purpose of an informational interview differentiate between a chronological, functional, and targeted resume prepare a professional resume and cover letter list at least 15 interviewing dos and 15 interviewing donts practice interviewing strategies by role playing with classmates. prepare a postinterview thank-you note describe a personal plan for career advancement after landing a job as a medical assistant list the steps necessary to earn the national CMA credential list the steps necessary to earn the national RMA credential describe a personal plan for preparing for the national certication or registration examinations describe the steps required for renewing the RMA and CMA credentials

49
Procedures
Applying skills for nal competency assessment

Chapter Outline
Bridging the Gap Key Benets of an Externship Externship Placement
Making a Good Impression

CAAHEP Competencies
General Competencies Professional Communications
Respond to and initiate written communications Recognize and respond to verbal communications Recognize and respond to nonverbal communications

The Job Search

Applying for a Position The Resume Resume types The Cover Letter The Interview After the interview

Career Advancement
Performance Evaluation

Credentialing
Certied Medical Assistant Registered Medical Assistant Preparing for the Credentialing Examination Recertication

ABHES Competencies
Professionalism
Project a positive attitude Be cognizant of ethical boundaries Exhibit initiative

Communication
Recognize and respond to verbal and nonverbal communications Use correct grammar, spelling, and formatting techniques in written works

Chapter Summary Team Work Exercises Case Studies Resources

1007

Key Terms
certication continuation program

Bridging the Gap

Externship, sometimes called an internship or practicum, is a scheduled work experience that helps medical assisting students bridge the gap between classroom and workplace. It involves the placement of medical assisting students in medical ofces, where they learn by observation and hands-on experience. The externship is an opportunity for the medical assisting student to apply her newly obtained skills and knowledge in a real-world setting, while still beneting from instruction and supervision from more experienced health care providers. (See Procedure 49-1: Applying skills for nal competency assessment.) The program coordinator arranges the externship, placing students in medical ofces with preceptors. Preceptors are experienced medical assistants or other health care providers who agree to work closely with students in the medical ofce to help them transition from the role of student to the role of professional medical assistant. Program coordinators make occasional site visits to evaluate the students progress and communicate with preceptors. Programs accredited by the AAMA require students to participate in 160 hours of an unpaid externship experience.

Program of documenting ongoing professional activities whereby RMAs may earn continued certication
chronological resume

Resume that lists work experience and education in chronological order, with most recent rst
cover letter

Letter that accompanies a resume to highlight the applicants qualications and requests a job interview
externship

Scheduled, on-the-job experience that helps a student bridge the gap between the classroom and workplace
functional resume

Resume that emphasizes specic skill sets and describes the most valuable experiences and abilities of the applicant
human resources department

Ofce or department that advertises job vacancies, accepts applications, arranges interviews, and manages documentation of employee benets
informational interview

Interview conducted to gain information about an organization to determine whether a person is interested in applying for work there
networking

Exchange of information related to a persons profession with coworkers, friends, and acquaintances
performance evaluation

Key Benets of an Externship

Participation in an externship provides several key benets to the medical assisting student. She receives real-world experience in her chosen profession, which increases her competence and condence. Also, an externship can help her identify possible areas for future employment. In addition, she can attain a much higher level of competence than she would if her entire training were restricted to campus classroom and laboratory settings. Employers also benet from the externship. They are able to contribute to a students learning and help students become the kind of employees they would like to hire. In addition, they have a rsthand opportunity to observe the students work behaviors, interpersonal skills, and attitudes before hiring them for a long-term position. Employers who are impressed by a students attitude, work ethic, professionalism, and eagerness to learn commonly offer the externship student a position before she graduates.

Assessment of an employees performance conducted at the end of a probationary period and annually thereafter
preceptor

Experienced medical assistant or other health care provider who agrees to work closely with a student in the medical ofce
program coordinator

Medical assistant program staff member who arranges externship placement and monitors progress
proofread

Check of a written document for accuracy in spelling, punctuation, grammar, word choice, and sentence structure
resume

Document that summarizes a job applicants experiences, qualications, and education

short-timers syndrome

Tendency of an employee to demonstrate a reduction in the quality of, quantity of, and interest in work after giving notice of the intent to leave the position
skill set

Group of related work abilities

targeted resume

Externship Placement
The program coordinator carefully selects externship sites to create the best possible experience for students. Ideal placement allows a student to get experience in clinical, administrative, and general areas with staff who are interested in

Document that identies the position desired and summarizes specic experiences and abilities that are relevant to the job for which the person is applying
white space

Blank space in a document to create a more organized, less cluttered presentation

CHAP TER 49

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PROCEDURE 49-1

Applying skills for nal competency assessment

Task Apply various skills learned throughout the clinical medical assisting course to a patient mock scenario. Conditions Patients medical record Supplies and equipment as needed for the given scenario Standards In the time specied and within the scoring parameters determined by the instructor, the student will successfully apply various skills learned throughout the clinical medical assisting course to a patient mock scenario. Performance Standards 1. Greet and identify the patient. 2. Review the patients medical record. 3. Obtain and document the patients health history and chief complaint. 4. Demonstrate professional, therapeutic communication skills throughout the scenario. 5. Recognize and respond to verbal and nonverbal communications. 6. Identify and respond to issues of condentiality and perform within legal and ethical boundaries. 7. Wash your hands. Follow standard precautions throughout the procedure. 8. Perform vital signs measurement and document appropriately. 9. Measure height and weight and document appropriately. 10. Put on appropriate PPEs for the procedure. 11. Prepare the patient for the procedure. 12. Perform the specialized procedure and quality control if applicable, according to the given scenario. 13. Dispose of biohazardous materials. 14. Provide patient education, including instruction on health maintenance and disease prevention. Instruct the patient according to his needs. 15. Document the procedure and teaching in the patients medical record.

supporting their learning. Some of the best externship placements are with staff who realize that the externship student they work with today may well become their work colleague tomorrow. The externship gives such staff members the opportunity to help train students to become the type of future team members they would like to work with. In some cases, students are offered positions before graduation. Although this may be an exciting development for the student, it can confuse the issue of paid work hours versus unpaid externship hours. Programs accredited by the American Association of Medical Assistants (AAMA) require the externship to be an unpaid experience. Therefore, the medical ofce that wishes to hire the externship student before the externship is complete must make an arrangement for the student to spend additional unpaid time on the job. Although there may be some advantages for students who get their externship hours in a familiar setting, there are disadvantages as well. The top priority for students is learning, which allows them the luxury of asking questions and observing and participating in procedures purely for learnings sake. The top priority for an employee is to meet the needs of employer and patients, which may mean sacricing the students opportunity to observe interesting procedures and ask questions. When students try to get externship hours in the place they normally work, these two priorities may come into conict.

Making a Good Impression

Medical ofce staff members must observe a student throughout the externship and note student behaviors regarding attendance, punctuality, attitude, exibility, willingness to learn, work ethic, and professionalism. Students who display good work habits are quickly hired, commonly before they graduate. Even if the externship site is not currently hiring, students should try to make the best impression possible because they may want to list their externship experience on their resume. Students who work hard and seek opportunities to learn and help others quickly earn the trust and respect of the ofce staff. Receiving correction and constructive feedback does not come easily for many people. However, students who receive such feedback in a positive, professional manner and modify their performance accordingly will earn high praise from preceptors. During their time in the externship rotation, students are expected to demonstrate an increasing ability to work independently. At the same time, they must be aware of their limitations and always be willing to ask for advice or guidance when unsure of themselves. A key ability of the professional medical assistant is to maintain an awareness of and respect for professional boundaries. Therefore, students should never attempt to develop a romantic relationship with patients or coworkers. They should not ask the physician for prescriptions to treat themselves or family members and should never use ofce drug

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samples unless specically given permission to do so by the physician. Even entering the drug storage area alone or without permission should be avoided.

Tips for the informational interview

The medical assisting student should keep these tips and guidelines in mind when conducting an informational interview.

The Job Search

The medical assistant has a reputation as one of the health care industrys most versatile members. For this reason, medical assistants are in high demand and some graduating students may nd it easy to obtain their rst job. On the other hand, job markets change over time and demand for medical assistants may uctuate, so students should never assume that they will obtain their dream job as soon as they graduate. Therefore, all students should know how to conduct an effective job search. Many people learn about job opportunities through networking, which is the exchange of information about job opportunities with coworkers, friends, and acquaintances. Students should begin networking early in their training and continue throughout their careers. The medical assistant can obtain all kinds of information through networking, including information about nancial aid, job openings, and educational opportunities. By graduation, many students have identified some of the places they would like to work. Direct contact with these facilities can be an effective method of searching for a job. If a student is unsure where she would like to work, she must conduct some research. She can learn a lot about an organization by visiting its website or reading brochures or the annual report distributed by the organization. Other methods include communicating with friends or acquaintances who work there and setting up an informational interview. Rather than applying for a job, the student uses such an interview to learn more about the organization to determine if she would like to work there. The student should dress and behave professionally, because making a good impression may lead to a future job. However, she should not ask for a position at the time of the interview. (See Tips for the informational interview.) Other traditional methods of conducting a job search include searching newspaper classied advertisements and working with employment agencies. Such agencies charge a fee for their services to the employer or the applicant. In a tight job market, using such services may be well worth the fee if it means the difference between landing a good job or remaining unemployed.

General Tips
Arrive on time. Dress professionally. Make eye contact. Use a rm handshake. Do not ask for a job. Send a thank-you note.

Topics to Ask About

company mission statement size of the organization (such as number of employees, physicians, nurses, and medical assistants) typical ratio of medical assistants to physicians qualities the organization looks for in employees.

enough to hand her resume and cover letter to the receptionist, she must take care to make a positive, professional impression. Good hygiene and professional attire are an absolute must. Making a positive impression will virtually guarantee that the resume and cover letter will be read by a person with hiring authority. A bad impression may make the receptionist or other staff member toss the resume and cover letter in the nearest garbage can. In small ofces, the applicant may meet directly with the ofce manager or even the physician. In larger facilities, she will be directed to the human resources department (also called the personnel ofce), which advertises job vacancies, accepts and reviews all applications, and arranges initial interviews as well as manages documentation of employee benets.

The Resume
A resume is a document that lists contact information, such as address, phone number, and e-mail address, and summarizes the applicants experiences, qualifications, and education. The resumes purpose is to help the applicant obtain a job interview. Therefore, the applicant should resist the temptation to put too much information in the resume. In most cases, the resume should be just one page long. A resume that appears organized and uncluttered with strategic use of white space, or blank space, is more likely to be read. The applicant should always resist the temptation to include untrue information in her resume in an attempt to

Applying for a Position

When a medical assistant decides to apply for a position, she should submit her resume in person, along with a cover letter that requests an appointment for a job interview. Although the applicant may be in the ofce just long

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make a good impression. Such practices reect dishonesty and a lack of integrity and create unrealistic expectations on the part of an employer. In addition, lying on a resume is grounds for termination if discovered after the organization hires the applicant. Finding creative ways to highlight and emphasize true experiences and qualications, regardless of how limited they may be, is the best course of action when compiling a resume. With time, experience, and effort, the medical assistant will accumulate plenty of impressive information to include. When the applicant creates the resume, she should always keep a computerized and hard copy for future modication and use. In addition to the resume, the applicant should keep a list of references ready in case the hiring ofce requests them. They should be neatly typed in a style similar to the resume and on the same type of paper. The applicant may also wish to include a comment on the resume that she will provide references upon request. However, she should not use valuable space on the resume for this information.

of the job market for several years or has a history of many short-term jobs.

Targeted Resume
A targeted resume identies the position desired and summarizes the applicants specic experiences and abilities that are relevant to the job. (See Figure 49-3.) This type of resume is ideal for applicants who know exactly what position they want.

The Cover Letter

The purpose of a cover letter is to highlight the applicants best qualications and to request a job interview. Cover letters should be professional in appearance and should sell the applicant without being too grandiose (that is, exaggerated with the intention of impressing someone). The applicant should carefully proofread the letter, checking for accuracy in spelling, punctuation, grammar, word choice, and sentence structure, to make sure the letter is free of errors. In addition, she should tailor the cover letter to the resume it accompanies and the specic job the applicant is applying for. The cover letter should be addressed respectfully to the appropriate person. If this information is unknown, a phone call is appropriate to ask to whom she should address a letter of application. The applicant should never send a photocopied, generic resume and cover letter, which usually make a poor impression. Inexperienced job applicants commonly nd that one of the most challenging aspects of writing cover letters is determining how to sell themselves without appearing conceited. As a result, they tend to be overly modest and create cover letters that are too vague or reect a lack of condence. Thus, it is essential for the applicant to demonstrate self-condence and assertiveness in her resume and cover letter, as well as to explain how her best qualities would benet the employer, in order to obtain an interview. (See Figure 49-4.)

Resume Types
There are many types and styles of resume. The applicant may purchase software to help her design her resume or nd examples and services on the Internet. The applicant should never copy another resume entirely. Instead, she should create one that is unique and specic to her own experiences and qualications. The three most common types of resume are the chronological resume, the functional resume, and the targeted resume.

Chronological Resume
A chronological resume summarizes the applicants qualifications and experiences in chronological order, with the most recent information listed first. It includes information on two key areas: education and work experience. The applicant should list rst whichever information she thinks is her greatest strength. For example, new graduates with little or no relevant work experience should list education rst. Because this same applicant may have limited work experience of any kind, she can highlight community activities and professional affiliations as well. (See Figure 49-1.) As the medical assistant accumulates more relevant professional experience, she can modify her resume to reflect such experience and condense the sections on community activities and professional affiliations. The medical assistant with many years of experience should list her work experience first.

The Interview
After the applicant has submitted a resume and cover letter, the organization may invite her to come for a job interview. The applicants goal in an interview should be to convince the prospective employer that she would make a valuable contribution to the organization. She must do this in a way that demonstrates a positive, professional demeanor, without appearing overly condent or aggressive. The applicants behavior can also cause her to lose a job opportunity. The inability to secure a position is usually related to behaviors or mannerisms demonstrated during the interview process, of which the applicant may be unaware. Some applicants never understand the reason why they do not obtain the job they are hoping for. (See Interviewing tips, page 1016.) Depending on the type and size of the organization, the applicant may interview with the human resources manager,

Functional Resume
A functional resume does not follow a chronological pattern but emphasizes specic skill sets (groups of related work abilities) and describes the most valuable experiences and abilities of the applicant. (See Figure 49-2.) This type of resume may be best for the job applicant who has been out

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Nicole Daniels 305 Apple Lane Fruitdale, CT 06101 Home: (860) 123-3827 Cell: (861) 453-2345 E-mail: ndan@fruit.com Education 2008 Certificate, Fruitdale Community College, Fruitdale, CT Major: Medical Assisting 2005 Diploma, Fruitdale High School, Fruitdale, CT Work Experience 6/06 6/08 Food server, Julios Ristorante Italiano, Fruitdale, CT Duties: waited tables, filled in for hostess and busser, inventoried and ordered supplies, assisted with scheduling Barista, Coffee Cupboard, Fruitdale, CT Duties: made assorted coffee drinks, cashiered, weekend opener

8/04 5/06

Professional Affiliations American Assocation of Medical Assistants Connecticut Society of Medical Assistants Douglas County Chapter of Medical Assistants Community Activities American Cancer Society volunteer Fruitdale Community Theater Fruitdale Middle School Volunteer Reading Tutor References: Furnished upon request

FIG 49-1 Sample chronological resume.

the ofce manager, the physician, or all of them. One person or a committee may conduct the interview. The interview process is commonly a stressful experience for an applicant. However, she can reduce her stress by preparing carefully, including identifying where the interview will take place. If the location is unknown, the applicant may want to drive to the facility the day before to avoid getting lost on the day of the interview. In addition, preparing clothing ahead of time and practicing answering typical interview questions will help the applicant feel prepared and more condent. (See Common interview questions, page 1017.)

After the Interview

After an interview, the applicant should always send a thank-you note to the person who conducted the interview.

Doing so displays courtesy and professionalism and makes an added positive impression. In addition, it reminds the employer of the applicants sincere interest in the job. However, the applicant should take care to ensure that the note is written neatly and free of spelling or grammatical errors. Depending on when the employer stated a decision would be made, it is generally considered appropriate to call a week later to inquire whether the position has been lled. If it has not, the applicant should politely relate her continued interest in the position. Continued inquiries should not be made more than once or twice per week. The person in charge of hiring may perceive an applicant who calls more frequently as too aggressive and annoying. Conversely, that person may perceive an applicant who does not call at all as too passive or lacking sincere interest in the job.

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Karen Stephens 233 Apple Road Fruitdale, CT 06101 Home: (860) 123-3344 Cell: (861) 453-6798 E-mail: bdbud@fruit.com OBJECTIVE To obtain a position as an administrative Medical Assistant EDUCATION 2008 Certificate, Fruitdale Community College, Fruitdale, CT Major: Medical Assisting

4Professional communication skills with clients in person and on the 4Detail-oriented and organized 4Strong multi-tasking skills 4Double-entry bookkeeping 4Typing: 65 wpm
RELEVANT EXPERIENCE Medical Assisting Externship (160 hrs), Eastside Medical Clinic Duties: prepared patients for examinations and procedures, medication administration, phlebotomy, EKGs, medical asepsis, WAIVE testing, data entry, reception, appointment scheduling, filing, coding, inventoried and ordered supplies 42006 present Receptionist, Fruitdale Family Dental Clinic Homemaker 42000 2006 41995 2000 Stephens Chiropractic Center, Secretary/Bookkeeper telephone

STRENGTHS AND ABILITIES

42008

4American Red Cross volunteer 4Eastside Daycare Cooperative President 4Eastside Community Church Secretary 4Fruitdale Business and Professional Womens Organization 4Crested County Chapter of Medical Assistants 4Connecticut Society of Medical Assistants
AFFILIATIONS

COMMUNITY ACTIVITIES

FIG 49-2 Sample functional resume.

Career Advancement
Most employers will place a new employee on a probationary period for up to the rst 90 days after beginning a new job. A performance that does not meet employer expectations may result in termination during this time. This time is also an opportunity for the employee and staff to become acquainted. An employee has only one chance to make a rst impression, so the newly hired medical assistant should take care to be punctual, arriving a few minutes early, and never try to leave early. She should avoid taking time off for any reason other than signicant illness or extreme emergency. Even legitimate absences will make a poor impression if they occur too frequently. A new employee should focus her

energy on learning the routine and rhythm of the ofce, adapting to the various personalities of staff members, and learning the details of the new job. An employee who brings extensive experience to her new job may be tempted to make suggestions about different, more efcient ways of carrying out day-to-day duties. However, she should wait to make such suggestions until after she has earned the trust and respect of other staff members and gains an understanding of the rationale for current practices. The keys to keeping a new job and advancing in a career revolve around maintaining a professional attitude. (For more information, see Chapter 3, Professionalism, page 19.) In addition, the professional medical assistant can demonstrate a strong work ethic with her punctuality, consistent

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Brenda Williams
Objective: Summary:

2321 Grant Road Fruitdale, CT (860) 123-8976 bwill@anyserve.com

Full-time Medical Assistant position in a primary care practice Seven years experience in emergency and primary health care

Skills and Abilities Administrative Skills Reception and appointment scheduling ICD-9-CM and CPT coding Clinical Skills First-aid and CPR Phlebotomy Electrocardiography Medication administration Preparation and assistance with sterile procedures General Skills Strong work ethic Effective written and verbal communication ability Detail-oriented, yet good at multitasking Fluent in Spanish Achievements Helped organize new local chapter of AAMA Organized and managed childrens booth at local health fair Taught first-aid course to seventh-grade students at summer camp Earned CPR and CMA credential Education 2008 present 2003 2001 Fruitdale Community College, Fruitdale, CT Major: Nursing Certificate, Fruitdale Community College, Fruitdale, CT Major: Medical Assisting Certificate, Fruitdale Community College, Fruitdale, CT Major: Emergency Medical Technician

Employment History 2006 2008 Fruitdale Family Medicine, Fruitdale, CT Clinical Medical Assistant 2003 2006 Hartell Memorial Hospital, Blueville, CT Administrative Medical Assistant 2001 2003 Gibbons Ambulance Service, Fruitdale, CT Emergency Medical Technician References: Furnished upon request

FIG 49-3 Sample targeted resume.

attendance, good organizational skills, willingness to stay late if needed, thoroughness, accuracy, and general willingness to help others. A positive, solution-focused attitude and avoiding gossip or other negative behaviors will earn the medical assistant the respect and trust of coworkers. Effectively handling responsibility and tactful, professional communication skills are keys to career advancement.

Performance Evaluation
A medical assistant will typically undergo a performance evaluation at the end of the probationary period and each year thereafter. This process involves evaluation of the medical assistant by the manager and, possibly, the medical assistants peers as well as herself. Although many people feel uncomfortable under such close scrutiny, the medical assistant should welcome it as an opportunity to identify

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October 13, 2008 Brenda Williams 2321 Grant Road Fruitdale, CT

Marcie Cross, Office Manager 1400 Peach Avenue Fruitdale, CT 06101 Dear Ms. Cross, I am interested in a position as a medical assistant for your family practice office. I have worked as a medical assistant for the past five years and very much enjoy helping people with their health care needs. I am currently enrolled in the nursing program at FCC and am excited about a continuing career as a health care professional. I believe my varied experience and skills will enable me to be a versatile, valuable member of your health care team. As you can see from my enclosed resume, I have experience in clinical and administrative medical assisting. I would be happy to work in whatever capacity you may need. However, I would especially enjoy working in both areas if possible, as doing so will enable me to continue to develop and maintain my knowledge and skills in both areas. Please call me at (860) 123-8976 so that we may schedule an interview and further discuss your needs and my qualifications. I can be contacted during the week after 3:00 p.m. and on weekends. I also have voicemail and respond to all messages promptly. I look forward to hearing from you. Sincerely,

Brenda Williams
Brenda Williams, CMA (AAMA) enclosure: resume

FIG 49-4 Sample cover letter.

strengths as well as areas of desired growth. One result of such evaluations should be a plan for professional development to guide future growth and learning. These evaluations are also an opportunity for the medical assistant to share with her manager specic goals for career development. Employers do not approve of job-hopping, a practice in which a person moves from position to position without staying in one position for an appropriate length of time. However, after a respectable length of time on the job, a

medical assistant may wish to change jobs for personal reasons or for career advancement. Whatever the reason, the medical assistant should leave her current position on a positive, professional note. She should give a minimum of 2 weeks notice and take care to keep her work effort at a high level through the last minute on the job. The medical assistant will leave a bad impression if she develops short-timers syndrome, the tendency of an employee to reduce the quality, quantity, and interest in work after giving notice of the intent to leave.

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Interviewing tips
Here are some key dos and donts to help the medical assistant make the best possible impression during a job interview and to avoid unwittingly making a poor impression. Smoke before or during the interview Chew gum Overdo makeup Wear too much jewelry (multiple earrings, dangly earrings, bracelets, necklaces, and so forth) Forget to shower or bathe (including hair) Let hair hang limp or loose over shoulders or face Appear sleepy or bored Emphasize or ask about money Use poor grammar, pronunciation, or diction Talk disrespectfully of past employers Keep eyes on the oor Use a handshake that is limp or too lengthy Arrive late Act like a know-it-all Make excuses for poor past performance Act in an indecisive manner Turn in a sloppy application form Ask for a temporary position unless it is advertised as such Discuss personal life or personal problems Wear long or acrylic nails in bold colors Say or do anything that might convey intolerance, prejudice, sexism, and so forth Act too aggressive Wear perfume or cologne Take anyone else with you.

Dos
Complete and turn in a neat application form. Make frequent direct eye contact. Appear alert, yet relaxed. Remember to smile. Keep makeup minimal and conservative. Wear minimal jewelry, such as a watch, wedding band, and one pair of stud-type earrings. Wear professional dress, such as a suit and closed-toe shoes. Be prepared with identied personal goals (that are also in the best interest of the organization). Use a rm, brief handshake. Be early. Prepare questions to ask at the end of the interview. Have a plan for self-improvement and professional growth. Demonstrate interest in the organization. Save money-related questions for later. Speak clearly, using good diction and proper grammar. Use good hygiene (body, hair, mouth and teeth, nails). Keep nails short and smooth with clear, neutral polish or no polish. Have a small note pad or planner and pen to take notes.

Donts
Fidget, bite nails, or use other nervous mannerisms Keep hands tightly clasped

Because the medical assistant will want to add the position to her resume and allow the prospective employer to contact her former supervisor for a job reference, she will want to be sure to carry out her duties well to the end of her employment. A positive recommendation from a previous employer can open the door to a new, desirable position.

Assistant (RMA). These credentials are not legally required for employment as a medical assistant. However, employers seek out medical assistants with these credentials because they understand that these individuals have demonstrated a specic level of competence in educational knowledge as well as in clinical and administrative skills.

Credentialing
There are two credentials for medical assistants: the Certied Medical Assistant (CMA) and the Registered Medical

Certied Medical Assistant

A medical assistant earns the Certied Medical Assistant (CMA) credential by passing an examination offered by the American Association of Medical Assistants (AAMA). To be eligible for the examination, the person must have

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Common interview questions

This table lists some common job interview questions with examples and tips for how the applicant might respond.

Type of Question
The interviewer wants to know what motivates the applicant and whether she will stick around for the long term. The interviewer wants to see if the applicant feels condent and competent and wants to know how the organization will benet by bringing her on board. Interviewer wants to know if the applicant has enough humility and insight to identify her own aws.

Example
What are your long-range goals? Where do you see yourself in 5 years? Why did you choose a career as a medical assistant? Why should we hire you? How will you contribute to this organization? What are your greatest strengths?

Response
The applicant should identify reasons that will be of interest to the employer (such as an interest in health care, a desire to help others, a desire to make a difference, and enjoyment of challenging, stimulating work environments). She should not mention money. The applicant should share what she will contribute to the organization in a condent manner that is not boastful.

What are your greatest weaknesses?

The applicant should be careful to avoid the potential trap in this type of question. Rather than discussing her aws at length, which might give a negative impression, she should briey mention goals she has identied for personal improvement or professional growth and then describe her current plan to achieve these goals.

The interviewer wants to know how the applicant responds to authority.

Describe an experience in which you had a major conict with a manager and describe how you handled it. Describe a time when you felt you were unfairly criticized by your boss. How did you respond?

The applicant should be careful to avoid the potential trap in this type of question. She should avoid speaking in a disrespectful or disparaging manner about previous managers, as the prospective employer might wonder if she has difculty working cooperatively with persons of authority. Rather she should share an example of a time when she used a positive, professional approach to resolve an issue in a manner that achieved a win-win result for everyone.

Interviewer wants to know how the applicant deals with conict and whether she uses effective communication and problem-solving skills. Interviewer wants to know if the applicant is a team player.

Describe an experience in which you had a conict with a coworker. How did you deal with it?

The applicant should share an example of a time when she was able to professionally resolve a conict with a coworker or at least found a way to work professionally together, despite what may have been a personality conict.

Describe a previous situation in which you worked as part of a team. What was your role and how did you contribute?

The applicants answer should stress her willingness to work cooperatively for the good of the team, the patients, and the employernot to achieve personal goals to the detriment of others. The applicant should be careful to avoid the potential trap in this type of question. She must avoid complaining about previous work experiences, which conveys to the employer that she might be an employee who complains and harbors resentment. Rather, she should describe a situation in which she rose to the challenge and found creative, cooperative ways to achieve work goals.

Interviewer wants to know how the applicant responds to stress.

Describe a time when you had too much work to get done with pressing deadlines. How did you cope with this?

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graduated from a program of medical assisting accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) or by the Accreditation Bureau of Health Education Schools (ABHES). Students who wish to take the AAMA certication examination can sit for the examination within a three-month period after applying for the examination. Upon successful completion of the examination, the medical assistant earns the privilege of using the credential CMA after her name on her name badge and on all ofcial documents. She must recertify her credentials every 5 years by undergoing continuing education or reexamination.

medical services program of the U.S. Armed Forces; or she must have been employed in the profession of medical assisting for at least 5 years. RMA examinations are offered every week at testing center locations throughout the United States. Upon successful completion of the examination, the medical assistant earns the privilege of using the title RMA after her name on her name badge and on all ofcial documents.

Preparing for the Credentialing Examination

The medical assistant can employ a number of strategies when preparing for the credentialing examination. The AAMA will send each medical assistant a copy of the Curriculum Content Outline along with the application form for the CMA examination. The medical assistant can obtain a similar outline and application for the RMA examination on the AMT website. The medical assistant should review this outline carefully when creating her study plan, paying special attention to any areas in which she feels decient. The content for the CMA and RMA examinations is similar. (See Credentialing examination content.)

Registered Medical Assistant

A medical assistant earns the Registered Medical Assistant (RMA) credential by passing an examination offered by the American Medical Technologists (AMT), a national certifying organization for laboratory professionals. There are three ways that a medical assistant can qualify for the examination: She must graduate from an ABHES-accredited medical assisting program or an organization approved by the U.S. Department of Education; she must graduate from a formal

Credentialing examination content

The Certied Medical Assistant (CMA) and the Registered Medical Assistant (RMA) credentialing examinations are similar. Here are basic outlines of the content for each. ofce policies and procedures practice nances.

Clinical
principles of infection control treatment area patient preparation and assisting the physician patient history interview collecting and processing specimens; diagnostic testing preparing and administering medications emergencies rst aid nutrition.

CMA Examination
The CMA examination includes 100 questions in each of three areas: general, administrative, and clinical.

General
medical terminology anatomy and physiology psychology professionalism communication medicolegal guidelines and requirements.

Administrative
data entry equipment computer concepts records management screening and processing mail scheduling and monitoring appointments resource information and community services maintaining the ofce environment

RMA Examination
The RMA certication examination includes 200 to 210 multiple-choice questions that require the test-taker to recall facts, interpret graphic illustrations, analyze and apply data pertaining to case studies, and perform general problem solving. The examination covers three areas: general (41% of the examination), administrative (24%), and clinical (35%).

General
anatomy and physiology medical terminology

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Credentialing examination contentcontd

medical law medical ethics human relations patient education. instruments vital signs and mensurations physical examinations clinical pharmacology minor surgery therapeutic modalities laboratory procedures electrocardiography rst aid.

Administrative
insurance nancial and bookkeeping medical receptionist/secretarial/clerical.

Clinical
asepsis sterilization

In order to get the greatest value from her time and effort, the medical assistant should adapt study strategies to her learning style. (For more information on learning styles, see Chapter 1, page 3.) For example, a social learner may wish to organize a study group that meets regularly to discuss specic topics. Such a group can help the medical assistant process information and clarify her understanding of concepts. However, the temptation to socialize can distract members from their main purpose, so adhering to the agenda should be a top priority. To review subject matter that may be included in either examination, the medical assistant may wish to review current publications and text books that include clinical and administrative content as well as anatomy and physiology, medical terminology, and laboratory procedures. In addition, the medical assistant can take several measures on the day of the examination to help her remain relaxed and focused for the examination. (See Tips for examination day.)

Recertication
CMAs must recertify their credentials every 5 years by one of two methods:

retaking the certication examination earning continuing education units (CEUs) by attending appropriate educational offerings.

Some CMAs retake the examination, but most CMAs prefer to recertify through continuing education. A CMA must accumulate a total of 60 CEUs in 5 years, 30 of which must be AAMA-approved CEUs. The other 30 may be from other programs and events. It is the responsibility of the medical assistant to determine whether the programs are appropriate for continuing education. The AMT recently announced a certication continuation program (CCP), which is a program that documents ongoing professional activities that can earn an RMA

Tips for examination day

Here are some tips for the medical assistant to follow before and during the examination to help her relax and remain focused. plan relaxing activities the night before, such as a nice meal, pleasant music, and perhaps a movie eat a nutritious breakfast, including complex carbohydrates and proteineven if she does not usually eat breakfastso her blood sugar does not uctuate widely and her energy level remains constant consider drinking a small caffeinated beverage to boost mental alertness (However, she should avoid excessive amounts of caffeine as this will make her feel anxious and edgy. Caffeine also has a diuretic effect, so too much may result in the frequent need to empty her bladder.)

Before the Examination

Before the examination, the medical assistant should: refrain from traveling or lodging with anyone whose behavior increases her own feelings of anxiety get an adequate amount of sleep the night before and avoid studying or other late-night activities physically locate the testing center the day before and stay nearby so that she has a short drive the next morning

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Tips for examination daycontd

use anxiety reduction exercises trust in herself and use positive self-talk to boost her feelings of condence and competence. cover up all areas of a written examination below the test question she is reading until she has read it twice, then uncover each potential answer one at a time and read it twice before moving on read all options even if she thinks she has already identied the correct one and then go back and read the question one more time before selecting her answer to avoid missing key words and important clues so that she is more likely to select the correct answer avoid overanalyzing the questions and, instead, select the best answer from the choices available, based on the data at hand, and then move on trust her rst inclination and avoid going back to change her answer unless she has an extremely good reason for doing so, because she is more likely to change a correct response to an incorrect one than vice versa.

During the Examination

During the examination, the medical assistant should: try to sit near the front of the room or in a corner so that the activities of others are less visible and, thus, less distracting ask permission to wear ear plugs if room noise distracts her perform an information dump if the test administrator permits writing on the examination or a blank piece of paper by writing memorized facts on paperfor example, formulas, laboratory values, and normal vital signs for various age groups

continued certication. This program applies to members certied or reinstated since January 2006. The AMT does not require those certied before that date to participate in the CCP, but strongly urges them to do so. The RMA may earn points toward continuing certication through a variety of activities, including continuous employment, continuing education, employer evaluations, instructional presentations, and authoring written works. Proof of compliance is required every 3 years.

Chapter Summary

Externship is a scheduled work experience that helps the medical assisting student bridge the gap between the classroom and workplace. A program coordinator arranges the externship and places the student in a medical office with a preceptor, who works closely with her. Externship provides the medical assistant with opportunities to learn by observation and hands-on experience. The program coordinator carefully selects externship sites to create the best possible experience for the student. Ideal placement allows a student to get experience in clinical, administrative, and general areas with staff who are interested in supporting her learning. The medical assisting student who works hard and seeks opportunities to learn and help others will quickly earn the trust and respect of the ofce staff and may even receive a job offer at her externship site.

Because job markets change over time and demand for medical assistants may uctuate, a medical assisting student should never assume that she will obtain her dream job right after graduation. Therefore, she must know how to conduct an effective job search. Job-search strategies include networking, looking online, searching the newspaper classied advertisements, and working with employment agencies. The most effective strategy is making personal contact with a prospective employer by visiting in person with a professional resume and cover letter. The job applicant should be prepared to interview with the ofce manager, a physician, or someone in the human resources ofce. A resume is a document that lists contact information, such as address, phone number, and e-mail address, and summarizes the applicants experiences, qualications, and education. The purpose of a resume is to obtain an interview for the applicant. An applicant should resist the temptation to embellish her resume by including untrue information. Such practices reect dishonesty and a lack of integrity and create unrealistic expectations from employers. There are many types of resume, including the chronological resume, functional resume, and targeted resume. An applicant should design a personalized resume that best highlights her strengths and minimizes her weaknesses. A cover letter highlights the applicants best qualications and requests a job interview. The applicants goal in an interview should be to convince the prospective employer that she would make a valuable

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contribution to the organization. She must do this in a way that demonstrates a positive, professional demeanor, without appearing overly condent or aggressive. The applicant should always send a thank-you note to the person who conducted the interview. Doing so displays courtesy and professionalism and makes an added positive impression. In addition, it reminds the employer of the applicants sincere interest in the job. Most employers will place a new employee on a probationary period for up to the rst 90 days of the job. A performance that does not meet employer expectations may result in termination during this time. Therefore, the newly hired medical assistant must take care to make a good impression. Employers do not approve of job-hopping, a practice in which a person moves from position to position without staying in one position for an appropriate length of time. However, after a respectable length of time on the job, a medical assistant may wish to change jobs for personal reasons or for career advancement. Whatever the reason, the medical assistant should leave her current position on a positive, professional note, because a previous employer can open the door to a new, desirable position. There are two credentials for medical assistants: the Certied Medical Assistant (CMA) and the Registered Medical Assistant (RMA). These credentials are not legally required for employment as a medical assistant. However, employers seek out medical assistants with these credentials because they understand that these individuals have demonstrated a specic level of competence in educational knowledge as well as in clinical and administrative skills. Medical assistants earn the certied medical assistant (CMA) credential by passing an examination offered by the American Association of Medical Assistants (AAMA). Medical assistants earn the registered medical assistant (RMA) credential by passing an examination offered by the American Medical Technologists (AMT), a national certifying organization for laboratory professionals. The medical assistant can employ a number of strategies to prepare for the credentialing examination, including obtaining copies of the examination content outlines from the certifying organizations and carefully reviewing the content. She should pay close attention to any areas in which she feels decient. CMAs must recertify their credentials every 5 years by retaking the certication examination or earning continuing education units. RMAs can take part in the certication continuation program (CCP), which allows recertication activities every 3 years.

Team Work Exercises

1. Divide into small groups of four to six students. Randomly assign two students to the role of interviewers. The

other students must be job applicants. The interviewers must meet alone and identify a list of 5 to 10 interview questions they would like to ask. The interviewers (together) will then interview each applicant, asking exactly the same questions of each. The interviewers may take notes. When the interviewers have interviewed all applicants, they may take only 10 minutes to decide whom they wish to hire. When they have made a decision, they must provide feedback to the entire group about whom they decided to hire and why. They should give each applicant feedback about her strengths and positive qualities as well as any weakness identied. If time allows, students can reverse the roles and repeat the process. 2. Organize a Career Day for your program. This event can be imaginary or actual, depending on the instructor. Divide into teams and select the following assignments: a. Team 1 must organize a Graduate Panel for Career Day by identifying working medical assistants in the community and inviting them to be part of a guest panel. Activities might include asking guest panel members to introduce themselves and talk about the jobs they have held since graduation, how they landed their current job, what they like most about being a medical assistant, what they like least, and any advice they have to offer. After each member of the panel has spoken for a few minutes, provide time for questions and answers. b. Team 2 must organize an Employer Panel for Career Day by identifying health care employers in the community who hire medical assistants and inviting them to be part of a guest panel. Activities might include asking guest panel members to introduce themselves and talk about their current job and what qualities they look for when interviewing and hiring medical assistants. After each member of the panel has spoken for a few minutes, provide time for questions and answers. c. Team 3 must design a mock interview for Career Day. Job applicants can be members of the team or other volunteers whom the team recruits. Let the applicants interview as a group so that no one individual is put on the spot. Give them permission to demonstrate some interviewing donts as well as dos so that it can be a fun, informative event. Designate who the interviewers are and provide them with a list of questions. During the interview, each member of the applicant panel will have an opportunity to answer the question. Provide members of the audience with some type of score sheet on which they can make notes and possibly score each applicant on her answers and behaviors. At the conclusion, the audience may vote on whom they would hire. d. Team 4 must organize a resume review session in which members of the class may bring drafts of their resumes

1022

UNIT 3

Clinical

and cover letters for review. Reviewers might be medical assistant program instructors, English professors, or other on-campus and health care employers. This session should be a nonthreatening opportunity for students to get honest, helpful feedback on resume preparation. e. Team 5 must organize a Dress for Success session, including advice about how to dress for the job interview and possibly even a fashion show. Be sure to address business fashion dos and donts. Include information about community resources that can help the new medical assistant obtain professional attire. For example, the YWCA commonly maintains a clothing bank with free business attire for homeless or low-income women who need clothing for interviews or new jobs.

unemployment, then 2 years as a handyman doing yard cleanup and maintenance. He was then hired at the local aluminum plant, where he worked for 5 years before he lost that job due to downsizing. After 1 year on unemployment, he decided to go back to school to become a medical assistant. Gary must prepare a resume and cover letter. What type of resume would best suit Garys needs and why? What skills and abilities in his former jobs will be useful in his career as a medical assistant? Draft a cover letter for Gary to accompany his resume.

Resources

Job searches, resumes, interviewing Career and job-search information: www.ajb.org Extensive information on searching for a job, resume preparation, and so forth: www.monster.com Information about different types of interview questions: www.jobinterviewquestions.org YWCA clothing services: www.ywca.org

Case Studies
1. Marci is a medical assisting student in her fourth and nal quarter. She and one of her classmates, Lisa, have been placed in a family practice ofce to complete their externship hours. Marci has arrived a few minutes late on several occasions and has called in sick twice. She does everything she is asked but rarely volunteers to do anything extra. She usually seems eager to leave at the end of the day to go home or to go to her real job. Out of concern one day, Lisa commented on some of these behaviors. Marci responded by saying Its not like this is a real job. When Im hired and paid to be a medical assistant, then Ill do great work. What comments might Marcis preceptor have about her level of professionalism? How might Marcis performance impact her future efforts to get a job as a medical assistant? What feedback and suggestions might the externship coordinator have for Marci? 2. Gary is a medical assisting student who will be graduating soon. He is interested in applying for work as a CMA at a local medical center and would very much like to work in the urgent care clinic. Garys work history includes 3 years in construction, followed by 9 months of

Medical assisting and examination review and preparation Elsevier, Inc.: www.us.elsevierhealth.com/specialty.jsp ?lid=3&sid=441 F.A. Davis Company: www.fadavis.com/prof_aisle/ profdetail.cfm?catid=28&disccode=HP 1915 Lippincott Williams & Wilkins: www.lww.com/ browsemediaspec/Book/0,0,129,00.html Thomson Delmar Learning: http://www.healthcare .delmar.cengage.com/Medical_Assisting/

Credentialing An application form and other information regarding the CMA credentialing examination, continuing education, and recertication: www.aama-ntl.org An application and further information about the RMA credentialing examination and the AMTs CCP: www.amt1.com

APPENDIX

Glossary
A
Abandonment Failure to make arrangements for a patients continued medical care Abduction Motion away from the midline of the body Ablation Therapeutic destruction of a part, pathway, or function using surgery, chemicals, electrocautery, or radiofrequency Abortion Spontaneous or induced termination of pregnancy before the fetus reaches a viable age Absorption Process of transferring nutrients from the digestive tract into the bloodstream; passage of a drug into the bodys bloodstream through the digestive system, mucous membranes, or skin Acceptance Stage of grief and loss when a person acknowledges the reality and permanence of life changes Accessibility Degree of a persons ability to gain entrance to a facility when using a wheelchair or other assistive device Accession record Record of numbers assigned to each new patient medical record Accommodation Ability of the eye to see objects in the distance and then adjust to focus on a close object Accountable Willingness to account for or be responsible for ones own actions Accounts payable Amount of money a practice owes to outside vendors, rent or mortgage, supplies, salaries, and so forth Accounts receivable Amount of money owed to a practice for patient services performed Accounts receivable ratio Comparison of the amount of money charged to a practice and the amount collected by the practice Accredit To certify as meeting specic standards set by regional or national organizations Acronym Word created from the rst letters of a series of words Action Ability of a drug to act on body processes at the cellular level Active les Medical les of patients who are currently seen in the ofce Active listening Nonverbal communication method used to indicate that the listener has heard the message and concerns of the patient Acute care Setting in which short-term health care is delivered to patients who are experiencing sudden illness or injury Additive Substance, such as an anticoagulant or preservative, that may be added to an evacuated blood collection tube Adduction Motion toward the midline of the body Adenomyosis Benign invasive growth of endometrial tissue into the myometrium Adenosine triphosphate Usable energy of cells Administer To give a medication to a patient as directed by a physician Administrative medical assistant Person who works in a medical ofce primarily in the front ofce areas performing clerical, reception, or medical records duties Adolescent Person from approximately age 12 to age 18 Adverse effect Nontherapeutic result of drug administration that may also be unpleasant or harmful Affect Emotional state or mood Affective domain Thought processes involving emotions, values, and attitudes Against medical advice Designation for a patient who leaves the hospital despite his doctors recommendation to remain Age of majority Legal status of adulthood as recognized by the state Ageism Form of prejudice and discrimination against individuals because of their age Agenda Items of business to be addressed at a staff meeting Agent Representative of a facility, hospital, or doctors ofce who represents the supervising physician in word and action Agglutination Type of antibodyantigen reaction in which a solid antigen clumps with a soluble antibody Aggressive Quality of striving to meet ones own needs while disregarding the rights and needs of others Aging accounts Method used to identify how long an account has been overdue Alimentary canal Route of digestion that includes all structures from the

A
mouth to the anus, excluding the accessory organs of digestion; also known as the digestive tract or gastrointestinal tract Allergen Substance that produces a hypersensitivity reaction Allergy Immune response to a medication that results in inammation and organ dysfunction Alphabetical ling Organizing system based on the alphabet, usually using the patients last name Ambiguity State of uncertainty or vagueness Ambulation Action of walking Ambulatory care Facility, such as a medical clinic, that provides medical care to nonresidential patients, who arrive and leave on the same day Analgesic Medication that relieves pain Analyte Measurable chemical substance Analyzer Automated instrument used to test blood and other body uids for various substances Anaphylaxis Severe allergic reaction Anatomical laboratory Section of the laboratory that includes histology and cytology Anemia Condition marked by a decrease in the number of red blood cells or the amount of hemoglobin Anesthesia Absence of sensation Anger Stage of grief and loss when a person experiences feelings of rage Angiogram Diagnostic radiograph of the blood vessels using a contrast medium Angioplasty Endovascular procedure that reopens narrowed blood vessels Antecubital space Space inside the arm at the bend of the elbow that is the best site for routine venipuncture Antibody Immunoglobulin produced by white blood cells in response to a specic antigen Anticoagulant Substance that inhibits blood clotting Antigen Marker that identies a cell as being part of the body (self ) or not part of the body (nonself ); substance that, when introduced into the body, elicits an immune response Antimicrobial agent Any chemical substance that has the ability to kill or stop the growth of microorganisms

1023

1024

APPENDIX A

Antipyretic Medication that lowers fever Antitussive Medication that suppresses the cough reex Anuria Absence of urine production Apical pulse Pulse felt or heard over the apex of the heart Apnea Temporary absence of breathing Aponeurosis Flat, brous sheet of connective tissue that attaches muscle to bone or other tissues Apothecary System of weights and measures based on the yard Appointment matrix Grid or schedule (computerized or manual) that shows the times available for scheduling patients and the days and hours the practice is open (excluding lunches and breaks) Approximation Bringing wound edges together closely and evenly Archives Storage place for records that are no longer in use but are kept for legal purposes Articulate To verbally express oneself clearly and easily Articulation Juncture between two or more bones; also called a joint Artifact Signal interference on an ECG caused by patient movement, faulty equipment, or other factors Asepsis State of cleanliness that is free from disease-causing microorganisms or the practice of maintaining such an environment Aspiration Unintentional inhalation of any substance other than air Assault Threat or perceived threat to do bodily harm to another person Assertive Quality of advocating for ones own rights while respecting the rights of others Assets Property owned by a business, such as equipment, supplies, and accounts receivable Assisted living Residential facilities with minimal health care, common dining and social activities, and usually transportation assistance Associate practice Sole proprietors who share resources, such as ofce space, equipment, and employees Astigmatism Abnormality of the eye in which the refraction of a ray of light is spread over a diffuse area rather than sharply focused on the retina Atherosclerosis Thickening and hardening of the walls of the arteries; also called arteriosclerosis Atopic Type of allergic reaction for which there is a genetic predisposition Atrophy Decrease in mass of a muscle or organ; also called wasting

Audiometer Instrument used to measure hearing Aura Subjective sensation that occurs prior to and signals the onset of a migraine headache or a seizure Auscultation Method of listening to body sounds with a stethoscope Auscultatory gap Disappearance of tapping sounds during phase II of a blood pressure measurement Authorization Written permission to disclose protected health information (PHI) when a consent form does not apply or another exception is evident Automated external debrillator Small, automated device used to deliver an electrical shock to a patient suffering from a life-threatening cardiac arrhythmia Automated method Laboratory test performed on an automated instrument or machine Autonomy Right to self-determination

B
Bacilli Rod-shaped bacteria Bacteria One-celled organism, some of which are capable of producing disease Balance sheet Statement of nancial condition that contains itemized assets, liabilities, and owners equity Bandage Nonsterile material applied over the top of dressings to secure them Bargaining Stage of grief and loss when a person makes irrational attempts to negotiate for unlikely or impossible changes Bartholin glands Two small glands located at the opening of the vagina Battery Intentional act of touching another person in a socially unacceptable manner without her consent Benecence Duty to provide good or benet Beneciary Recipient of insurance coverage Benet year 12-month period starting with the date of initial insurance coverage Bias Unfair or incorrect belief that stems from prejudice and inhibits impartial judgment or action Bilingual Capable of conversing in two languages Bioethics Study of the ethical implications of discoveries and advances in modern medicine and health care Biopsy Procedure in which a representative sample of tissue is obtained for microscopic examination Bioterrorism Intentional or threatened use of biological agents or toxins to

produce death, disease, or fear in an individual or a population Bioterrorism agent Any substance, such as a bacteria, virus, or other germ released during a bioterrorism attack Birthday rule Insurance regulation that uses the subscribers dates of birth to determine primary and secondary coverage for dependents Blastocyte Group of cells in early gestation that will form an embryo Blood pressure Tension exerted by blood against the arterial walls during ventricular contraction and relaxation Body mechanics Conscious coordination of the nervous and musculoskeletal systems to preserve and protect posture, balance, and body alignment while bending, lifting, and performing activities of daily living Bolus Mass of masticated (chewed) food Bone Individual unit of osseous tissue that is part of the framework of the body Boundary Physical or psychological space that indicates the limit of appropriate versus inappropriate behavior Bradykinesia Extreme slowness in movement Bradypnea Abnormally slow breathing Brainstorming Process in which individuals in a group offer ideas to solve a specied problem Breach of contract Failure to comply with an established agreement as specied in a written contract Bronchoscopy Examination of the bronchi through a specialized instrument called a bronchoscope Brudzinski sign Patient response in which neck exion causes exion of the hips when the patient is lying in a supine position Buccal Route of administration that involves placement of a drug between the cheek and gum Buffy coat Middle layer of a whole blood tube that has been allowed to settle or has been centrifuged and contains leukocytes and platelets Burnout Decreased physical, emotional, or mental energy caused by ongoing intensive demands without sufcient physical or emotional rest Business associate Person who, on behalf of the covered entity, performs or assists in the performance of a function or activity involving the use of individually identiable health information (IIHI) Business associate contract Document that describes the obligation of an

APPENDIX A

1025

outside entity that uses PHI to protect the privacy of the PHI as an extension of the physicians ofce (also called data use agreement) Business letter Formal document sent by mail that contains information related to business, rather than personal, affairs

C
Caduceus Ancient symbol of the Greek god Hermes that consists of a staff with two serpents entwined around it, surmounted by two wings, and used today by some medical groups to symbolize medical care Call forwarding Technology that enables a telephone call to reach a specic person, department, or desk Calorie Unit by which food energy is measured Capillary puncture Process of performing a skin puncture to obtain blood Capitation System of payment in which physicians are paid a at rate per patient Capsule Special container made of gelatin sized to contain a single dose of an oral medication Carbohydrate Compound containing carbon, hydrogen, and oxygen atoms Cardiac cycle One complete contraction and relaxation cycle of the heart Cardiac sphincter Circular muscle at the top of the stomach that allows food from the esophagus to enter the stomach Cardioversion Restoration of normal sinus rhythm by chemical or electrical means Cash ow Amount of available cash that a business maintains to cover expenses Catabolism Body process that converts large structures into smaller ones Cataract Opacity (clouding) of the lens of the eye Catch-up time Time in the schedule that is not booked with appointments to let doctors and staff catch up on paperwork, return phone calls, or catch up with appointments if patient visits take longer than anticipated Central nervous system Nerve tissue that comprises the brain and spinal cord Cerebral concussion Brief loss of consciousness or brief episode of disorientation or confusion following a head injury Cerebral contusion Injury involving bruising of brain tissue Certication Issuance of a certicate by a professional organization to an individual who has met a specied

standard of education or training and has, therefore, earned the right to exercise certain skills Certication continuation program Program of documenting ongoing professional activities whereby registered medical assistants (RMAs) may earn continued certication Cerumen Yellow or brown waxy substance produced in the ceruminous glands of the ear Channel Mode of conveying a message, including vision, hearing, and touch Chemical peel Destruction of supercial layers of the skin using a chemical application in order to remove scars, tattoos, or abnormal pigmentation Chest physiotherapy Type of therapy that includes percussion (clapping) over the thorax or vibration and positioning to facilitate loosening and removal of respiratory secretions Child Person from age 1 to around age 12 Cholecystogram Radiograph of the gallbladder Cholesterol Multiringed, waxy lipid found in all body cells Chronological resum Resum that lists work experience and education in chronological order, with the most recent rst Chyme Mixture of partially digested food and saliva Circumcision Surgical removal of the prepuce Circumduction Circular motion of a body part Circumoral cyanosis Blue coloring around the mouth due to inadequate oxygenation Civil law Branch of private law that deals with accidental, rather than intentional, injury to a person or personal property Claustrophobia Fear of closed spaces Clinical diagnosis Diagnosis based on actual observations, diagnostic results, and symptoms Clinical medical assistant Person who works in a medical ofce primarily in the back ofce areas assisting the physician with patient care, procedures, and diagnostic testing Cloning Creation of cells, tissue, or an embryo without the fertilization of an egg Closed question Question that can be answered with one word Closed records Medical records of patients who no longer seek treatment in the ofce Cluster booking Scheduling technique that involves consecutive booking of

patients who have similar problems or are undergoing similar procedures Cocci Round or spherical bacteria that can arrange themselves in chains, clusters, or tetrads Cognitive domain Thought processes that involve the intellect and include thinking on several levels Coitus Sexual intercourse Collection agency Business that recovers bad debts for a percentage of the debt or a xed fee Collection ratio Comparison of outstanding debt amount and amount collected Color coding Alphabetical ling system that adds colored stickers to the open end of a le to facilitate visual maintenance of les Color deciency Genetic or acquired abnormality in color perception Colposcope Instrument used to examine the tissues of the vagina and cervix Colposcopy Examination of vaginal and cervical tissues by means of a colposcope Combining form Word element created by joining a word root with a combining vowel Combining vowel Vowel placed between word parts to link them together and make the term easier to pronounce Communication Process of sending and receiving information between two or more individuals Compensation Psychological response in which a person offsets feelings of inadequacy in one aspect of that persons life by achievement in another aspect Compliance Patients adherence to the plan of care as instructed by the health care provider Computed tomography Computerized procedure that views the target organ or body area from different angles in a three-dimensional view Conception Time at which an ovum is fertilized Condentiality Principle of keeping personal medical and nancial information private and avoiding divulgence of such information to any unapproved party Congruent Consistent or matching Conjunctivitis Inammation of the conjunctiva caused by bacteria or a virus Consecutive ling Filing system that uses sequential numbers to order medical records Consent To agree or give permission Constructive criticism Method of instruction that focuses on actions that can improve an employees job performance, rather than focusing on the negative aspects of the persons performance

1026

APPENDIX A

Contagious Easily spread from one person to another Continuing education units Credits awarded for the attendance of classes, workshops, or seminars Contrecoup Rapid accelerationdeceleration injury of the brain that bruises the front and back of the brain Contracture Movement that shortens or tightens a muscle Contraindication Condition under which a drug should never be used Contrast medium Radiopaque substance that enhances an image Coordination of benets Insurance carriers explanation of how it will pay benets if a patient has more than one insurance plan Copayment Patients share of the cost of an ofce visit Core temperature Temperature within the bodys deep internal structures Corneal abrasion Injury to the translucent anterior structure of the eye Corporation Organization that is granted legal status with rights, privileges, and liabilities separate from those of its members Corpuscallosotomy Surgical procedure in which the central part of the brain is partially divided in two Corticosteroids Medications that suppress the immune response and decrease inammation Cost ratio Comparison of total expenses to number of procedures Courteous Behavior that is polite, considerate, and helpful Cover letter Letter that accompanies a resum to highlight the applicants qualications and request a job interview Covert event Unannounced event that involves the release of an agent or toxin without any advanced warning Crackles Abnormal crackly lung sound heard with a stethoscope Crash cart Wheeled supply cabinet that contains emergency equipment and supplies Criminal law Branch of public law that deals with the rights and responsibilities of the government to maintain public order Cross-reference Guide placed where a medical record could be misled to indicate the correct location of the le Cryosurgery Technique that destroys tissue by subjecting it to very cold temperatures; also called cryotherapy Cryotherapy Removal of heat from a body part to decrease cellular metabolism and swelling

Culture Growth of microorganisms in a laboratory-prepared medium Cumulative medication action Action of repeated doses of a medication that are not immediately eliminated from the body Current Procedural Terminology, 4th ed. Coding manual used to identify the procedures performed by physicians and their staff; also called CPT-4 Cycle billing Method of billing that divides patients into groups that are mailed billing statements at various times throughout the month Cystoscopy Visual examination of the bladder

D
Damages Monetary award paid by the physician to the patient as directed by the court Debrief Discussion of events, thoughts, and feelings among persons who have experienced an important or stressful event Decoding Process by which the receiver of a message extracts its meaning Defamation Providing false information (written or spoken) that causes harm to the reputation of another Defecation Passage of feces from the bowels Defense mechanism Unhealthy coping strategy that a person may employ when feeling emotionally threatened in some way Debrillator Specialized device used to deliver an electrical shock to a patient suffering from a life-threatening cardiac arrhythmia Deglutition Swallowing Dehydration Condition in which body water output exceeds water input De-identied information Health information data set from which all personal identiers are removed Delegation Act of assigning tasks to another person who then legally acts as the assigners representative Demographics Personal information used to identify a patient Denial Psychological response by which a person refuses to acknowledge the validity or reality of something that is obvious to others; stage of grief and loss when a person refuses to accept the reality of a situation Deontology Ethical philosophy concerned with duties and rights Dependable Characteristic of being reliable and trustworthy

Depolarization Electrical change in cells in which the inside becomes positive in relation to the outside Deposition Formal method of gathering information in which a person testies to the actions of herself and coworkers Dermabrasion Procedure in which outer layers of the skin are removed by abrasion with a wire brush or other device Dermaplaning Procedure in which a dermatome is used to skim off surface layers of the skin to remove scars, tattoos, and ne wrinkles Dermatome Band or region of skin supplied by a single sensory nerve; instrument used to cut thin slices of skin Diascopy Procedure in which a glass plate is held against the skin to observe changes related to pressure application Diastole Period of cardiac muscle relaxation when blood is lling the chambers of the heart and blood pressure is lowest Diastolic pressure Blood pressure between heart contractions Dictation Creation of a tape or computer voice le to be transcribed Digestion Chemical and physical breakdown of food in the gastrointestinal tract Digital radiographic imaging Radiography using computer imaging instead of conventional lm or screen imaging Dilation Increase in size Directional term Term used to indicate specic areas on the body Directive statement Statement that guides the listener in discussing topics as directed Disability Deciency, especially physical, that prevents or restricts normal performance Disclosure Process of releasing, transferring, providing access to, or divulging information in any manner to a second party Disease Any condition characterized by subjective complaints, a specic history, clinical signs or symptoms, and laboratory or radiographic ndings Disinfection Application of a substance to materials and surfaces to destroy pathogens Dispense To prepare or deliver medicines Displacement Psychological response by which a person expresses anger or another emotion at a person or object that is not the cause of those feelings Dissection Separation and delineation of animal or human tissues for study

APPENDIX A

1027

Distribution Transport of a drug to body uids, tissues, and cells Distributive justice Principle regarding the fair distribution of scarce resources Diurnal rhythm Normal daily cyclic uctuation in body temperature Dorsal recumbent position Position in which the patient is lying at with knees bent and feet on the examination table Dosage Physicians indication of how much and how often a patient should take a drug Dose Amount of a drug a patient takes each time Dosimeter Device that monitors the quantity of x-ray exposure to health care workers Double booking Scheduling technique in which several patients are scheduled for the same appointment time and are attended to at the same time in different rooms Dressing Material placed in or on a wound Drug Any substance that, when taken into a living organism, may modify one or more of its functions Drug class Grouping of drugs by their therapeutic effect, the body system affected, or their action Durable power of attorney Written legal designation of a person to make medical decisions on behalf of another person Dyspnea Labored or difcult breathing Dysuria Painful or difcult urination

E
Effacement Thinning of the cervix during labor Efcacy Ability of a medication to produce a desired effect Electrocardiogram Record or tracing of electrical activity of the heart Electrocardiograph Instrument used to record an electrocardiogram Electrocardiography Process of recording the electrical activity of the heart Electrodesiccation Destructive drying of cells by applying electrical energy Electrosurgery Use of high-frequency electric current to cut, remove, or destroy tissue; also called electrocautery Emancipated minor Person under the age of majority who has been declared by a court to be independent and responsible for his own debts Embolic Caused by a moving mass in a blood vessel (embolus) Empathy Understanding of the emotions and thoughts of another

Emulsication Process of making an emulsion, allowing fat and water to mix Endocrinologist Medical doctor who specializes in the diagnosis and treatment of endocrine diseases and disorders Endocrinology Study of the structures and functions of the endocrine system Endometrium Mucous membrane that lines the uterus Endoscopy Use of a specialized scope to visually examine a structure Enema Introduction of a solution into the rectum to stimulate bowel activity Enteric-coated Drug formulation in which tablets or capsules are coated with a compound that does not dissolve until exposed to the uids of the small intestine Enunciation Act of pronouncing words distinctly Environment Setting in which a communication experience occurs Epiglottis Uppermost cartilage of the larynx Episiotomy Incision made into the perineum to facilitate delivery of a baby Equilibrium State of balance, which is controlled by structures of the inner ear Ergonomics Science of equipment or workplace design that aims to minimize operator fatigue Erythema Redness of the skin Erythrocyte Red blood cell responsible for carrying oxygen to all cells and tissues in the body Established patient Patient who has previously received care at the ofce Ether Organic compound once used for anesthesia; also called diethyl ether Ethics Study of human behavior and moral choices based on a set of principles; rules or standards governing professional conduct Etiquette Rules for socially acceptable behavior Evacuated tube Plastic tube that contains a vacuum, which draws blood from the vein into the tube through a dual needle system Eversion Movement of a body part outward Excretion Process of eliminating waste products of digestion Exhalation Act of breathing out; also called expiration Exophthalmos Symptom of protruding eyeballs, usually caused by a severe form of hyperthyroidism called Graves disease Expectorant Medication that liquees and loosens respiratory secretions to aid in expelling them Expert witness Person who is called to testify in court due to her status as an

expert on a given subject or in a specialty Expiration Act of exhaling Extension Movement that straightens a body part External marketing Methods of informing people who have not been patients of the practice about the practice and its services External respiration Movement of air into and out of the lungs Externship Scheduled, on-the-job experience that helps a student bridge the gap between the classroom and workplace

F
Fascia Sheet of brous connective tissue that covers, separates, or supports muscle Fasciculation Visible involuntary muscle twitching Fasting Practice of denying the body all food or nutrition, usually for a specied period of time before laboratory tests or surgical procedures Fatty acid Long, unbranched fat used by the body to manufacture various lipoproteins Febrile Fever causing Fee for service Payment method based on each item billed to the insurance company Feedback Message returned by a receiver as a response to the senders message Felony Serious crime against the public that is punishable by serving time in prison Fetus Term used to describe a developing human in utero from 9 weeks gestation (after the embryonic stage) until birth Fibrillation Spontaneous muscle contraction or quivering Fidelity Concept of loyalty or faithfulness Film-screen radiography Radiography using special photographic lm that blackens in response to the light from intensifying screens Filtrate Mixture of water, electrolytes, urea, and other small molecules rst ltered in the glomerulus Financial accounting Process of tracking monetary expenditures and income for outside entities, such as the federal government Fixed costs Expenses that do not depend on the number of patients being seen in a practice Flexible Adaptable to change; able to bend without breaking

1028

APPENDIX A

Flexion Movement that bends a body part Float Ability to fulll a temporary assignment to work in a different area from the one in which an individual usually works Fluent Ability to speak and write well in a given language Fluoroscopy Radiographic imaging that can be viewed as a moving picture Fomite Any object that adheres to and transmits infectious material (such as a comb, countertop, or drinking glass) Forced vital capacity Test that measures the amount of air that can be maximally exhaled after a maximum inspiration and the time required for that expiration Fowler position Position in which the patient sits with his head as close to 90 degrees as possible and his legs resting outstretched on the examination table Fraud Intentional misrepresentation of a situation for nancial gain Frequency Need for frequent urination Functional resum Resum that emphasizes specic skill sets and describes the most valuable experiences and abilities of the applicant Fundus Area of the uterus above the openings to the fallopian tubes Fungi Kingdom of organisms that includes yeasts, molds, and mushrooms and is usually not pathogenic to humans

Goiter Enlarged thyroid gland Goniometry Process of measuring joint movements and angles Gravidity Total number of pregnancies Gross negligence Intentional failure to provide care or the commission of an act by an individual with reckless disregard for consequences that endanger a patient Group practice Medical group with three or more licensed, full-time physicians Growth hormone Hormone secreted by the pituitary gland to stimulate growth of bones and tissues; also called somatotropin Gustation Sense of taste

H
Health care operations Business activities of the practice, including employee training, marketing, fundraising, licensing, and quality assessments Hematocrit Volume of packed red blood cells Hematology Study of blood and bloodforming tissues Hematoma Discoloration of the area around a puncture site caused by an accumulation of blood around the site; also called bruise Hematopoiesis Production and development of blood cells Hematuria Presence of blood in the urine Hemiplegia Paralysis of one side of the body Hemoconcentration Accumulation of blood caused by leaving the tourniquet on the venipuncture arm longer than one minute, causing an increase in red blood cells and a decrease in plasma volume Hemodialysis Articial means of removing urea, wastes, toxins, and excess uid from the blood Hemoglobin Iron-containing protein found in red blood cells that is responsible for transporting oxygen to cells and carbon dioxide to the lungs Hemolysis Destruction or breakdown of red blood cells, causing a red tinge in serum Hemoptysis Coughing up blood Hemostasis Blood clotting process Hippocratic Oath Oath of medical ethics created by Hippocrates Histologist Specialist in the study of cells and microscopic tissues Home care Health care assistance for a person living in his own home Home health care agency Private company that employs nursing

G
Gait Manner of walking Gastroenterologist Physician who diagnoses and treats disorders of the gastrointestinal tract Gastroenterology Study of the gastrointestinal tract Genome Complete set of chromosomes and, thus, the complete genetic information present in a cell Gestation Time from conception to birth Glaucoma Disorder that involves increased intraocular pressure, resulting in atrophy of the optic nerve and, possibly, blindness Glucagon Hormone that cleaves bonds in glycogen to release glucose Glucometer Instrument used to measure glucose levels in the blood Glucose Monosaccharide used by the brain and tissues for fuel Glucosuria Presence of glucose in the urine Glycemic index Scale that lists the amount of time it takes for a food to raise blood glucose levels

assistants and nurses who make home visits to provide patients with limited nursing services Homeostasis State of equilibrium in the body Hormone Chemical substance released from a gland or organ Hospice Program that provides special end-of-life care for the terminally ill Hospital privileges Permission granted by a hospital that allows a physician to see patients and practice medicine within that hospital Household System of volume measurement using the teaspoon and tablespoon Human resources department Ofce or department that advertises job vacancies, accepts applications, arranges interviews, and manages documentation of employee benets Humor Term created by Claudius Galen that refers to any uid or semiuid substance in the body Hyperextension Position of maximum extension, or extending a body part beyond its normal limits Hyperglycemia Abnormally high blood glucose level Hyperopia Error of refraction in which affected individuals can see distant objects clearly but cannot see near objects; also called farsightedness Hypersecretion Increased amount or excessive secretion Hyperthyroidism Condition of having excessive levels of thyroid hormone in the body Hypertrophy Excessive growth of tissue Hyperventilation Increased ventilation resulting in a higher blood pH Hypoglycemia Abnormally low blood glucose levels Hypoglycemic Drug that lowers blood glucose levels Hyposecretion Decreased secretion Hypothyroidism Condition of inadequate levels of thyroid hormone in the body Hypoxia Decient level of oxygen Hypoxic drive Backup system of respiration that stimulates breathing in a patient who is retaining carbon dioxide

I
Implied consent Acceptance of treatment expressed through a patients actions, such as rolling up his sleeve for blood pressure measurement Inactive records Records of patients who have not been seen for an extended period of time (usually 1 to 6 years) but who may return for care

APPENDIX A

1029

Incentive spirometer Handheld device used by the patient to inhale a maximal breath to keep lungs expanded and functional Income statement Report of itemized monthly expenses and prots Incubation Interval between exposure to infection and the appearance of the first symptoms; period of time it takes for a microbiological culture to grow and multiply before actual bacterial colonies are visible on the medium Indication Approved use of a drug, as approved by the Food and Drug Administration Individually identiable health information Medical information contained in a patients record that could be used to identify the patient Infant Child between ages 1 month and 1 year Infectious disease Any disease caused by a microorganism that may be directly or indirectly transmitted between individuals, causing infection Inuenza Highly infectious acute respiratory infection that is characterized by a sudden onset of fever, chills, body aches, and cough Informational interview Interview conducted to gain information about an organization to determine whether a person is interested in applying to work there Informed consent Document that a patient signs, which is a written agreement for treatment Inhalation Act of breathing in; also called inspiration In-home care Care provided in the home by spouses, family, close friends, or paid, live-in caregivers Insoluble ber Indigestible food components that do not dissolve in water Inspection Process of gathering information about the patient through observation Inspiration Act of inhaling; also called inhalation Insulin Hormone that binds to glucose allowing its transport from the bloodstream to the tissues Interaction Effect in the body as the result of a combination of a drug with food or another drug Internal marketing Method used to stimulate business with existing patients through mailings and other means Interpersonal variables Factors that impact a receivers interpretation of a message

Intradermal Route of administration that involves injection of a drug just under the epidermis Intramuscular Route of administration that involves injection of a drug into the muscle Intravenous Route of administration that involves injection of a drug into a vein Intravenous pyelogram Radiographic view of the kidneys using contrast medium injected intravenously Inversion Movement of a body part inward Ionization Process of gaining or losing an electron from an atom

J
Jack-knife position Position in which the patient sits on a special examination table in a semisitting position with the thighs exed to 90 degrees Jargon Abbreviations or technical, specialized language used by professionals that is generally confusing to other people Job description Written description of the qualications and duties of a position Justice Concept of fairness or equity

K
Kernig sign Reflexive hamstring contraction and pain when attempting to extend the leg after flexing the hip Ketonuria Presence of ketones in the urine Knee-chest position Position in which the patient sits on her knees with her chest and face and arms resting forward and her buttocks in the air Korotkoff sounds Sounds heard when auscultating the blood pressure

L
Lactation Process by which a mothers body produces milk for her newborn infant Lancet Capillary puncture device that usually contains a retractable blade Laser resurfacing Use of short pulses of light to treat some skin conditions Laser surgery Treatment of tissue by means of colored light beams Layperson Nonmedical person Learning domains Modes of learning conducted by different parts of the brain Learning objectives Goals or outcomes to be achieved in the learning process Learning style Manner in which a person most effectively learns

Leukocyte White blood cell responsible for ghting off infection and producing antibodies Leukocytosis Abnormal increase in circulatory white blood cells Leukopenia Abnormal decrease in circulatory white blood cells Liability Money owed to a creditor Libel Dishonoring or defaming a person through written documents Licensure Designation signifying that a person has met standards and requirements of her profession and is legally able to offer specic services for monetary reimbursement Ligament Band or sheet of brous tissue that connects two or more bones or cartilage Ligation Application of a band, thread, or wire to tie a blood vessel or other structure in order to constrict or fasten it Lipid Family of compounds that are insoluble in water, including fatty acids, triglycerides, phospholipids, and sterols; also called fat Lithotomy position Position in which the patient reclines face up, with legs apart and feet in stirrups Lithotripsy Treatment that uses shock or sound waves to crush stones in the kidneys or urinary tract Litigation In medicine, a legal action that determines the rights and remedies a patient can pursue in the event of suspected medical malpractice Living will Written directions to a physician that instruct the physician about whether or not to maintain lifesupport systems in the event of a patients terminal illness Lobectomy Surgical removal of a lobe of a lung Local effect Impact of a medication that is specic only to a certain part of the body Locus of control Persons belief about the degree of control that he has over events in his life Lower gastrointestinal series Radiographic examination of the lower intestinal tract during and after introduction of barium, which acts as the contrast medium Lumen Space within a vessel or other tubelike structure Lymph Clear, colorless, alkaline uid found within lymph vessels made up of water, protein, salts, urea, fats, and white blood cells Lymphadenopathy Swollen, tender cervical lymph nodes

1030

APPENDIX A

M
Macrophage Type of white blood cell that destroys cellular debris and foreign invaders within tissues and organs Magnetic resonance imaging Procedure in which a strong magnetic eld and radio waves are used to produce images to view body structures Malfeasance Unlawful act that causes harm Malnutrition Condition caused by insufcient intake of nutrients Malpractice Action by a health care professional that injures a patient and fails to meet reasonable standards of professional care Mammary glands Milk-producing glands in a female Mammography Radiographic imaging of the breast to screen for breast cancer Managerial accounting Process of tracking monetary expenditures and income for a practices managers or physician owners Manipulation Application of touch to assess joint symmetry and passive range of motion, or the therapeutic application of force to increase mobility and realign dislocated joints Mantoux test Test to identify tuberculosis exposure Manual method Test method in which the steps of testing are done by hand instead of by an automated instrument Marketing Process of letting customers or potential customers know of a product or service Mastication Process of chewing food Medical asepsis Practice that frees a specic environment from microorganisms that might cause disease Medical jargon Terminology and abbreviations used in medicine that are not readily understood by laypersons Melanocyte Melanin-forming skin cell Menarche Age of rst menstruation or onset of menstruation Mnire disease Syndrome characterized by recurring episodes of hearing loss, tinnitus, and vertigo that can progressively lead to deafness Meniscus Curved upper surface of a liquid in a container Menopause Permanent cessation of menstruation, usually occurring between ages 38 and 58 Menstruation Female cycle of producing and expelling the unfertilized ovum Mensuration Measurements of body parts, including height, length, and circumference

Message Content of a communication, including verbal, nonverbal, and symbolic language Metabolism All physical and chemical changes within the body that build and break down substances; change to a medication by the body, which converts it to an inactive water-soluble compound for excretion Metered dose inhaler Handheld device used to inhale medication into the lungs Methodology System of principles and procedures used in scientic testing Metric System of weights and measures based on the meter Microdermabrasion Gentle abrasion of the skin to reduce ne lines, age spots, and acne scars and stimulate growth of new skin cells and collagen Microorganism Living organism too small to be seen with the naked eye Microsample Very small amount of a specimen Microsurgery Any procedure completed with the use of a special operating microscope Micturition reex Bladder reex that creates the urge to urinate Middle digit ling Numeric system that uses the middle digits of an identication number as the primary indexing unit Mineral Inorganic element Mnemonic Technique used to enhance memory, such as creating a word from the rst letters of a series of words Mock code Practice drill for responding to a medical emergency Modality Method of applying a therapy, usually a physical device Modied wave Scheduling technique in which two or three patients are scheduled at the beginning of each hour and then one patient is scheduled every 10 to 20 minutes into the hour Modier Two-digit number added to the end of a procedure code that changes and further denes the procedure Monthly billing Method of billing in which all patients are mailed billing statements on the same date, usually the rst of the month Morals Judgment regarding the value of certain behaviors based on personal belief Motor nerves Nerves involved in movement Multilingual Procient in several languages Muscle Tissue made up of contractile bers that produce movement Muscle testing Process of evaluating muscle strength and range of motion

Myelin Layer of phospholipids and protein that forms the myelin sheath of neurons and acts as electrical insulation Myofascia Tissue consisting of muscle and underlying fascia Myopia Error of refraction in which light rays are focused in front of the retina, enabling the person to see distinctly for only a short distance; also called nearsightedness

N
Nasal cannula Oxygen tubing designed to deliver oxygen into a patients nose Nebulizer Device that produces a ne spray or mist to deliver medication to the air passages and lungs Negative feedback system Control system in which an increase or decrease in a substance stimulates an opposite response by a hormone Negligence Unintentional failure of a health care professional to meet his responsibilities to a patient, resulting in injury to the patient Neonate Newborn baby to age 28 days Networking Exchange of information related to a persons profession with coworkers, friends, and acquaintances Neuritic plaque Accumulation of bundled bers surrounding normal and damaged nerve cells in the brain Neurobrillary tangles Tangles of neurobrils that make up part of the nerve cell body Neuron Nerve cell Neurotransmitter Chemical that plays an important role in nerve impulse transmission New patient Patient who has not previously received care at the ofce Nocturia Excessive urination during the night Noncompliance Failure of a patient to follow his physicians treatment plan Nonconsecutive ling Numeric system that does not use consecutive ordering for medical records Nonfeasance Failure of a health care professional or organization to perform a task or deliver a service, resulting in harm or injury to a patient Nonmalecence Duty to do no harm Normal ora Organisms found on and in a persons body that do not cause disease and are sometimes benecial Normal range Range of values in which a test result should fall for most healthy individuals Norms Unwritten rules of socially acceptable behavior

APPENDIX A

1031

No-show Patient who has a scheduled appointment but fails to appear Notice of Privacy Practices Document that describes the use of protected health information for carrying out treatment, payment, or health care operations Nuchal rigidity Condition that involves pain and stiffness of the neck and a resulting reluctance to ex the head forward Nuclear medicine Techniques that use radioactive material for the diagnosis and treatment of patients Numeric ling System that assigns an identication number to each patient le Nursing center Facility in which custodial and nursing care are provided to individuals who need assistance with activities of daily living; also called a skilled nursing facility or nursing home Nutrient Chemical substance obtained from food and used in the body to provide energy, build structural materials, support growth and maintenance, or repair body tissues

Over-the-counter Type of drug that can be obtained without a prescription Owners equity Amount that business assets exceed business liabilities; also called net worth

P
Palpation Examination of the patients body by touching it with the hands and pads of the ngers Palpitation Sensation of rapid or irregular beating of the heart sometimes described as a thudding or uttering sensation Palliative care Medical care aimed at alleviating disease symptoms, rather than providing a cure Pandemic Occurrence of a disease that has reached epidemic proportions in many different parts of the world at the same time Pandemic u Virulent human u that causes a global outbreak, or pandemic, of serious illness Panel Group of blood tests that evaluate the function of a particular body system; also called prole Papanicolaou test Test used to detect cancer of cervical cells Parasite Pathogen requiring another living organism in order to survive Paresthesia Abnormal sensation Partnership Creation of a legal agreement between two or more licensed physicians that species the rights, obligations, and responsibilities of each Passive Quality of submitting or yielding without offering resistance Passive-aggressive Manipulative behavior that appears initially passive but seeks to control by retaliation in the form of procrastination, stubbornness, and forgetfulness Pasteurization Process of heating a uid to a moderate temperature to destroy bacteria without changing the chemical composition of the uid Patch test Skin test in which a low concentration of a presumed allergen is applied to the skin beneath an occlusive dressing to see if a reaction occurs Paternalism Practice of providing for people without giving them rights or responsibilities Pathogen Disease-producing microorganism Pathogenic Causing disease Pathological term Term that refers to a disease or disorder of the body Peak ow meter Handheld device used to measure an individuals lung capacity

O
Olfaction Sense of smell Oliguria Deciency of urine production Open hours Block of time in which patients are seen by the physician on a rst-come, rst-served basis Open MRI Imaging table with more open space than a traditional MRI tube Open-ended question Question that requires more than a one-word answer Ophthalmoscope Handheld instrument used to view the internal structures of the eye, including the retina, optic nerve, and blood vessels Opiate Class of analgesic drugs that depress the central nervous system; also called narcotic Oral route Route of administration of a medication through the mouth and into the GI tract Otitis Inammation of the ear Otoscope Handheld instrument used to visualize the internal structures of the ear, ear canal, and eardrum Out guide Marker used to indicate that a medical record has been taken from the ling system Ovaries Glands that produces ova, the cells from the female necessary for procreation Overnutrition Condition caused by excess intake of nutrients Overt event Attack that is announced prior to or after the release of the bioterrorism agent

Pediatrician Specialist in the treatment of childrens diseases Pediatrics Medical science relating to the care of children Percussion Tapping on the body surface with the ngers or a small hammer and noting the sound elicited to determine the position, size, or density of underlying structures Performance evaluation Assessment of an employees performance conducted at the end of a probationary period and annually thereafter Perfusion Circulation of blood, nutrients, and oxygen through tissues and organs Perineum Area between the vaginal opening and anus Peripheral Away from the trunk of the body; in the extremities Peripheral nervous system Portion of the nervous system outside the central nervous system that conveys sensory and motor impulses Peristalsis Wavelike muscular contractions that move food down the esophagus Peritoneal dialysis Dialysis in which the lining of the peritoneal cavity is used as the dialyzing membrane Perjury Act of lying in court, despite taking an oath to tell the truth pH scale Scale used to measure acidity or alkalinity of a substance Phagocytosis Process in which specialized white blood cells (phagocytes) engulf and destroy microorganisms, foreign antigens, and cellular debris Pharmacodynamics Study of the bodys biochemical and physiological response to drugs Pharmacokinetics Study of the action of drugs as they move through the body, including absorption, distribution, metabolism, and excretion Pharmacology Study of drugs and their origin, nature, properties, and effects on living organisms Pharmacotherapeutics Study of the use and effect of drugs in the treatment and prevention of disease Phlebotomy Process of collecting blood for analysis Photometric reectance Measurement of the amount of light reected by a specimen Physicians ofce laboratory Laboratory within the medical ofce Placenta Uterine structure that is connected to the fetus by the umbilical cord and from which the fetus obtains nourishment and oxygen

1032

APPENDIX A

Plaintiff Person bringing charges in court Plasma Liquid portion of blood that contains clotting factors Pleural membranes Double membranes that cover the lungs and line the thoracic cavity Pneumonectomy Surgical removal of an entire lung Point of maximal impulse Point on the chest wall at which cardiac contractions are best seen or felt Policies and procedures manual Handbook that provides detailed information about regulations regarding tasks and how to perform the tasks Policyholder Person who purchases an insurance policy Polycythemia Abnormal increase in the amount of red blood cells Polydipsia Increased thirst Polyphagia Increased appetite Polypharmacy High-risk situation in which a patient is taking multiple medications, thus increasing the risk of adverse effects Polyuria Increase in the amount of urine formation and excretion Positron emission tomography Procedure in which the brain is viewed using positron-emitting radionuclides Postmenopausal Period occurring after permanent cessation of menstruation Postpartum Time from birth up to 6 weeks Postural vital signs Vital signs performed to test for orthostatic hypotension Practice-based Scheduling technique that designates special days for common treatments based on time limits and staff and equipment availability Preceptor Experienced medical assistant or other health care provider who agrees to work closely with a student in the medical ofce Preferred provider organization Managed care plan that contracts with physicians to furnish services to its members Prex Word element placed at the beginning of a word that modies the words meaning Premium Money paid to an insurer to obtain insurance Prenatal Time of gestation before birth Presbyopia Permanent loss of accommodation of the crystalline lens that occurs in people over age 40 Prescribe To indicate a drug to be administered Pressure point Point at which an artery may be compressed to decrease blood ow in the event of hemorrhage

Prion Proteinaceous infectious particle that can cause a spongiform encephalopathy Privacy standard Policies and procedures in a facility that determine who has access to protected health information Problem-oriented medical record System of documentation that includes the database, problem list, plan, and progress notes Prodromal Interval between earliest symptoms and appearance of a rash or fever Productivity Extent of a persons ability to perform a job function Prociency testing Tests on unknown specimens provided by an external monitoring agency, such as the state health department and the College of American Pathologists, to meet quality control requirements Program coordinator Medical assistant program staff member who arranges externship placement and monitors progress Projection Psychological response in which a person accuses others of that persons own feelings, attitudes, or behaviors Prolactin Hormone that stimulates breast development and production of milk Pronation Movement of the arm so the palm is down or movement of the foot outward and up Pronunciation Generally accepted sound of a spoken word Proofread Check of a written document for accuracy in spelling, punctuation, grammar, word choice, and sentence structure Protected health information Information from a patients record that contains details that could be used to identify the patient Protein Dietary source of amino acids used to build various body tissues, hormones, and antibodies Proteinuria Presence of protein in the urine Prothrombin time Blood test that determines how long it takes for blood to clot and monitors warfarin (Coumadin) therapy Protocol Expected behavior during a given situation Protozoa Unicellular, animal-like organism mainly found in soil that is capable of producing disease Proxemics Study of how much personal space people prefer and how it relates to culture and environment Pruritus Feeling of itchiness

Psychomotor domain Processes that involve physical activity and the senses (sight, sound, touch, smell, and taste) Pulmonary function test Measurement of air ow and lung volumes; also called spirometry Pulmonologist Physician who specializes in the diagnosis and treatment of respiratory disorders Pulmonology Field of medicine that studies and treats respiratory disorders Pulse decit Difference between the apical pulse and radial pulse Pulse pressure Difference between systolic and diastolic pressures Purge Permanent removal of medical records that are no longer in use Purulent Consisting of or containing pus

Q
Qualitative result Laboratory result that is descriptive, rather than providing a numerical value Quality control Methods used to monitor the accuracy of laboratory results Quantitative result Laboratory result that includes a numerical value

R
Radioallergosorbent test Blood test for allergy that measures small quantities of immunoglobulin E in blood Radiograph Image produced on radiosensitive lm by x-rays passed through an object Radiography Process of producing an image for diagnosis using a radiographic modality Radiology Branch of medicine concerned with radioactive substances, including x-rays or other sources of ionizing radiation used to assist in diagnosis and treatment Radiolucent Penetrable by x-rays Radiopaque Impenetrable to x-rays or other forms of radiation Range of motion Outer limit of joint movement Rapport Empathetic relationship Rationalization Psychological response in which a person makes excuses to justify inappropriate behaviors Reactive Responding without considering the situation at hand Reagent Substance used in a chemical reaction Receiver Person who receives a message and decodes it Recorder Person designated to document a medical emergency Redirecting Guiding the patient back to relevant subject matter

APPENDIX A

1033

Reduction Manual manipulation of a bone to return it to its normal position Reference laboratory Independent laboratory used by physician ofce and hospital laboratories to perform specialized testing Referent Stimulation or motivation to communicate Referral Request by a physician to have another physician examine a patient Reecting Validating the patients feelings and concerns Registration Process of collecting patient demographic and insurance information when the patient begins care Regression Psychological response in which a person reverts to behaviors associated with earlier (younger) developmental stages Renal colic Pain that radiates from the ank into the abdomen or groin area Renal threshold Concentration at which substances in the blood not normally excreted by the kidneys begin to appear in the urine Repetitive motion injury Physical injury caused by a specic repeated motion Repression Psychological response in which a person eliminates from conscious thought traumatic experiences or certain impulses that the person believes are unacceptable Requisition slip Form used to order laboratory tests Reservoir host Organism that provides a hospitable environment in which pathogens can grow res ipsa loquitur Latin phrase, which means the thing speaks for itself and is used in legal situations when negligence is clearly evident Resident Physician who obtains further medical training after internship, usually as a member of the house staff of a hospital Resistance Microorganisms ability to withstand the effects of an antimicrobial agent Resolution Stage of grief and loss when a person expresses emotions more freely and begins to identify changes in life caused by the loss Respectful Behavior that treats a person or object with honor or esteem respondeat superior Latin phrase, which means let the master answer and is a legal doctrine that places responsibility on a physician for the actions of her employee Restating Rewording a statement to check for accuracy Restitution Monetary compensation for loss or injury

Resum Document that summarizes a job applicants experiences, qualications, and education Rickettsia Genus of bacteria that are intracellular parasites Risk management Proactive management that seeks to reduce potential risks of a lawsuit before it occurs Roentgenography Practice of using radiation technology to examine the bones and other dense structures of a patients body; also called radiology and x-ray Rhonchi Coarse gurgling sound heard on auscultation that is caused by secretions in the air passages Rotation Movement that turns a body part around its axis Route of administration Way in which medication is introduced into the body Routine test Laboratory test ordered as part of a regular ofce visit Rugae Folds on the internal surface of the stomach

S
Saliva Oral secretions that moisten food for tasting, chewing, and swallowing Sanitize Remove microorganisms from reusable equipment and surfaces by using chemicals, heat, or ionizing radiation Scope of practice Legal description of professional responsibilities and duties that may be performed by a licensed or certied individual Scratch test Test in which a dilution of a potential allergen is placed in a lightly scratched area of the skin Security standard Policy that protects the condentiality, integrity, and availability of protected health information Self-care Activity that supports and nurtures an individuals physical, mental, spiritual, or emotional health and well-being Self-efcacy Persons perception of how capable and condent he feels about being able to make a specied change or accomplish a goal Semi-Fowler position Position in which the patient reclines at 45 degrees with legs outstretched Sender Person who delivers a message Sensory nerves Nerves that convey sensory information Serum Liquid portion of blood that does not contain clotting factors Short timers syndrome Tendency of an employee to demonstrate a reduction in

the quality and quantity of and interest in work after giving notice of the intent to leave the position Silence Communication strategy that allows the patient time to process information and formulate a response Sims position Position in which the patient lies on his side with the upper arm forward on the table, lower leg exed slightly, and upper leg exed sharply Sinusitis Inammation of the sinuses, which can be caused by a virus, bacteria, or an allergy Skill set Group of related work abilities Skin turgor Resistance of the skin to deformation when grasped between the ngers that is used to assess the state of hydration Slander Dishonoring or defaming a person through verbal attacks Slang Unconventional word or phrase used in place of a conventional word that is commonly clinical or complex in some way Sleep apnea Temporary cessation of breathing during sleep Smear Bacterial growth sample that is spread onto a microscope slide for staining purposes Sole proprietor Physician in a solo practice Soluble ber Indigestible food component that dissolves in water to form a gel Source-oriented medical record System of documentation that includes a note for each patient visit, arranged in reverse chronological order Specic gravity Weight of a substance compared with an equal amount of water Specimen Blood, other body uid, or body tissue submitted for laboratory analysis Sphygmomanometer Blood pressure cuff Spinal fusion Surgical immobilization of adjacent vertebrae Spores Bacterial or fungal cells that are resistant to temperature extremes Staff of Asclepius Ancient symbol of the Greek god Asclepius that consists of a staff with a single serpent entwined around it and used today as a symbol of medical care Statute Law Statute of limitations Law that sets a time limit within which a person can bring a lawsuit Stent Device that holds tissue in place and maintains an opening Sterile technique Method that involves performing invasive procedures in a manner that protects patients from pathogens

1034

APPENDIX A

Sterile toss Technique for placing sterile items on the sterile eld without contaminating either one Stream Most common scheduling technique in which patients are seen in a steady stream at set appointment times of 15-, 30-, 45-, or 60-minute intervals Subacute care Health care setting in which temporary care is provided with the goal of helping the patient to regain strength, mobility, and function in order to return home or to an assisted-living setting Subcutaneous Route of administration that involves injection of a drug into the fatty layer under the skin Sublingual Route of administration that involves placement of a drug under the tongue Subpoena Legal document that noties a person that he is required to appear in court or be available for deposition subpoena ducas tecum Latin phrase that means bring with you under penalty of punishment and is a legal document that requires a person to appear in court with specied documents, such as patient records Sufx Word element placed at the end of a word that modies the words meaning Summarizing Clarifying the patients key issues Summary of care Written description of assessment, services (procedures), and outcomes of care provided to a patient Superbill Document used in a medical ofce to indicate the services provided by a physician to a patient during an ofce visit Supination Movement of the arm so the palm is up or movement of the foot inward and up Supine position Position in which the patient is lying at, face up toward the ceiling Surgical asepsis Destruction of all pathogenic organisms before they enter the body Susceptibility Degree to which a microorganisms growth can be inhibited by an antimicrobial agent Suspension Solid particles mixed in a liquid but not dissolved Suture Material used to sew wound edges together or the act of sewing wound edges together Swage To fuse a suture to a needle Symptomatic Having symptoms, such as fever, sore throat, nausea, and vomiting Syrup Concentrated solution of sugar and water to which medicine is added and taken orally

Systemic circulation Circulation throughout the entire body Systemic effect Impact of a medication throughout the body Systole Period during contraction of chambers of the heart when blood pressure is the highest Systolic pressure Tension exerted against arterial walls during ventricular contraction and represented by the top number in a blood pressure reading

T
Tablet Small, disklike mass of medicine in compressed powder form taken orally Tachycardia Abnormally rapid heart rate Tachypnea Abnormally rapid breathing Tactful Displaying sensitivity and courtesy in behavior and comments to avoid offending others Targeted resum Document that identies the position desired and summarizes specic experiences and abilities that are relevant to the job for which the person is applying Teaching hospital Hospital that is afliated with a medical school where residents provide much of the physician-related care under the supervision of licensed physicians Team captain Person designated to coordinate activities of all team members during a medical emergency Teleological philosophies Philosophies that focus on consequences or the end, more than on actions or the means, in determining value Tendon Band of dense brous tissue that attaches muscle to bone Teratogenic effect Adverse effect of a drug on a developing embryo or fetus Terminal digit ling System that uses the last digits of an identication number as the primary indexing unit Termination policy Written policy that mandates termination of an employee who fails to comply with internal privacy policies and procedures Therapeutic effect Desired response in the body from a prescribed drug Thermotherapy Therapeutic application of heat used to treat various muscle injuries Thoracentesis Surgical puncture of the chest wall into the pleural space to obtain a uid specimen for testing Thrombocytes Platelets responsible for clot formation Thrombocytopenia Abnormal decrease in platelets Thrombotic Caused by a blood clot

Tickler le Reminder le used to prompt such activities as supply orders and equipment inspection Tinnitus Ringing in the ears Tolerance Need for increased dose of a drug to produce the same effect Tomography Radiographic technique that selects a level in the body and blurs out structures above and below that plane, leaving a clear image of the selected anatomy Tort Wrongful act committed by a person that causes harm to another person or property Tourniquet Device used to aid vein protrusion Toxic Poisonous or harmful Toxicology Division of medical and biological science concerned with toxic substances Tracer Radioactive isotope that can identify a specic portion of a molecule to follow its course Transaction Exchange of information between two parties to carry out nancial or administrative activities related to health care Transaction code sets Standardized codes used to represent health care concepts and procedures for healthcare-related nancial and administrative procedures Transcription Creation of a written document from dictated tapes or computer voice les Transducer Device that moves over the skin to record sound waves Transection Cutting Trendelenburg position Position in which the patient lies with her head approximately 30 degrees lower than her outstretched legs and feet Triage Process of screening patients to determine which need immediate medical treatment and in what order each patient must be seen, and which patients must go to the emergency room or if they can be worked into the physicians schedule for the day Troponin Protein that is released into the blood by damaged heart muscle and, therefore, a highly sensitive and specic indicator of recent myocardial infarction Turbid Thick or opaque

U
Ultrasonography Use of high-frequency sound waves to produce an image of an organ or tissue Ultrasound Application of highfrequency sound waves to warm tissues,

APPENDIX A

1035

increasing tissue extensibility and improving local blood ow Undernutrition Condition caused by insufcient intake of calories and, sometimes, nutrients Unit Each part of a patients name or identication number used in a ling system Upcode Illegal practice of using a procedure code that yields higher reimbursement than the procedure that is actually performed Upper gastrointestinal series Radiographic examination of the esophagus, stomach, and upper small intestine during and after the introduction of barium as a contrast medium; also called upper GI series or barium swallow Urgency Sudden, nearly uncontrollable need to urinate Urinalysis Laboratory analysis of urine Urinary catheterization Procedure that involves insertion of a sterile drainage tube into the bladder to drain or withdraw urine Urine culture Growth and study of microorganisms isolated from a urine specimen Utilitarianism Ethical philosophy concerned with achieving the greatest good for the greatest number of people Utilization review Determination by a managed care organization of the medical necessity of a procedure or service Uvula Soft tissue hanging from the upper mouth that prevents food from entering the nasal cavity

Variable costs Expenses that increase with an increase in the number of patients seen Vasectomy Procedure that involves removal of a segment of the vas deferens to achieve male sterilization Vasoconstriction Decrease in diameter of blood vessels, which decreases blood ow and raises blood pressure Vasodilation Dilation or enlargement of blood vessels, especially small arteries and arterioles Vector Carrier, usually an insect, that transmits a disease from an infected person to a noninfected person Venipuncture Process of puncturing a vein with a needle to obtain blood Venous Pertaining to the veins or the blood in the veins Veracity Quality of truthfulness Verication Process of conrming insurance benets with the patients insurance carrier Vicarious liability Liability of an employer for the wrongdoing of an employee while on the job Villi Projections of the small intestines that absorb water and nutrients Virus Pathogen that can grow and reproduce only after infecting a host cell Visual acuity Ability to see at different distances Vitamin Organic molecule that contains carbon and several different elements needed by the body to support chemical reactions Voice mail System that enables a caller to leave a recorded message for the recipient

Wedge resection Surgical removal of a small part of a lung Wheeze Somewhat musical sound heard in the lungs, usually with a stethoscope, that is caused by partial airway obstruction White space Blank space on a document to create a more organized, less cluttered presentation Whole blood Blood composed of formed elements (cells) and plasma Word root Main stem of a word that conveys the words meaning Workow Physical space that facilitates accomplishment of work-related duties Write-off Difference in the amount charged for a service and the amount contractually allowed by an insurance company

X, Y
X-ray lm Special photographic lm that blackens on exposure to light X-ray tube Vacuum tube that creates electromagnetic radiation with a wavelength between 0.1 and 100 angstrom units

Z
Z-track injection Intramuscular injection technique where the skin is pulled to one side to prevent medication from leaking into the subcutaneous tissues Zygote Fertilized ovum

W
Wave Scheduling technique in which patients are scheduled in the rst halfhour of each hour

V
Vaccine Preparation used to improve immunity to a particular disease

APPENDIX

Abbreviations
This appendix includes two lists of abbreviations. The rst includes commonly used abbreviations and the second lists discontinued abbreviations. Even so, the medical assistant should always check her facilitys policy on the appropriate use of abbreviations. Commonly Used Abbreviations The table below lists abbreviations commonly used in the medical ofce and other health care settings along with their spelled-out terms.

B
C
C&S C c c/o Ca Ca, CA CABG CAD cap CBC CK CKD Cl cm CNS CO2 COPD CPAP CPR CRF C-section CSF CT CVA culture and sensitivity Celsius with complaint of calcium cancer coronary artery bypass graft coronary artery disease capsule complete blood count conductive keratoplasty, creatine kinase chronic kidney disease chloride centimeter central nervous system carbon dioxide chronic obstructive pulmonary disease continuous positive airway pressure cardiopulmonary resuscitation chronic renal failure cesarean section cerebrospinal uid computed tomography cerebrovascular accident (stroke)

A
a ABGs ac, AC AC ACL ACTH AD ad lib ADD ADH ADHD ADL AGA AIDS AK ALS ALT AMD, ARMD APGAR aq ARDS ARF AS ASHD AST before arterial blood gases before meals air conduction anterior cruciate ligament adrenocorticotropic hormone Alzheimer disease as desired attention decit disorder antidiuretic hormone attention decit hyperactivity disorder activities of daily living appropriate for gestational age acquired immune deciency syndrome above the knee amyotrophic lateral sclerosis alanine aminotransferase age-related macular degeneration activity, pulse, grimace, appearance, respiration water acute respiratory distress syndrome acute renal failure ankylosing spondylitis arteriosclerotic heart disease aspartate aminotransferase

D
D&C DDH decub. disc DJD DM DNR DPT DRE DTR DVT Dx dilatation and curettage developmental dysplasia of the hip decubitus (ulcer) discontinue degenerative joint disease diabetes mellitus do not resuscitate diphtheria, pertussis, and tetanus digital rectal examination deep tendon reexes deep vein thrombosis diagnosis

B
BaE, BE BC BG bid BK BM BMG BOM BP BPH BS BSA BUN Bx barium enema bone conduction blood glucose twice a day below the knee bowel movement bone mineral density bilateral otitis media blood pressure benign prostatic hypertrophy blood sugar body surface area blood urea nitrogen biopsy

E
EAC EC external auditory canal enteric coated

1037

1038

APPENDIX B

ED EEG EMG ENT EOM ERCP ESR ESRD

erectile dysfunction; emergency department electroencephalography electromyogram ears, nose, and throat extraocular movement endoscopic retrograde cholangiopancreatography erythrocyte sedimentation rate end-stage renal disease

IV IVC IVF IVP IVPB

intravenous intravenous cholangiogram in vitro fertilization intravenous pyelogram intravenous piggy back

J, K
JRA K kg, Kg KUB juvenile rheumatoid arthritis potassium kilogram kidney, ureter, bladder

F
FBG FBS Fe FH , d fsbs FSH fasting blood glucose fasting blood sugar iron family history uid nger stick blood sugar follicle-stimulating hormone

L
L LA LASIK LD LDL LFT LH LLE LMP LP LTC LTK LUE LV lytes liter left atrium laser-assisted keratomileusis lactate dehydrogenase low-density lipoprotein liver function test leuteinizing hormone left lower extremity last menstrual period lumbar puncture long-term care laser thermal keratoplasty left upper extremity left ventricle electrolytes

G
g, G, Gm GERD GFR GGT GH GI gr gtt GYN gram gastroesophageal reux disease glomerular ltration rate gamma-glutamyl transferase growth hormone gastrointestinal grain drop gynecology

M
mcg MD mEq Mg mg ml, mL mm MMR MRI MS MVA microgram muscular dystrophy; medical doctor milliequivalent magnesium milligram milliliter millimeter measles, mumps, and rubella magnetic resonance imaging multiple sclerosis motor vehicle accident

H
H&H h, hr HCT HDL HEENT Hep B Hgb Hgb A1C HiB HIV HPV HSV-1 HSV-2 HTN Hx hemoglobin and hematocrit hour hematocrit high-density lipoprotein head, eyes, ears, nose, and throat hepatitis B vaccination hemoglobin glycosylated hemoglobin Haemophilus inuenzae type B vaccine human immunodeciency virus human papillomavirus herpes simplex virus type 1 herpes simplex virus type 2 hypertension history

N
N&V Na NaCl NG NIDDM NIHL noc, noct, n NPC NPO, npo NSAID nausea and vomiting sodium sodium chloride nasogastric non-insulin-dependent diabetes mellitus noise-induced hearing loss night nonproductive cough nothing by mouth (nil per os) nonsteroidal anti-inammatory drug

I
I&D IBD IBS ICP ID IDDM IM INR IOL IOP IPV IUD incision and drainage inammatory bowel disease irritable bowel syndrome intracranial pressure intradermal insulin dependent diabetes mellitus intramuscular International Normalized Ratio intraocular lens intraocular pressure inactivated poliovirus vaccine intrauterine device

O
O2 OA OB-GYN OC oxygen osteoarthritis obstetrics and gynecology oral contraceptive

APPENDIX B

1039

ORIF OT OTC oz

open reduction and internal xation occupational therapy over-the-counter ounce

RP RR RUE RV Rx

P
P p PAC Pap test pc PCP PCV PDA PE PE tube Peds PERRLA pH PID PKD Plt PM, pm PMH PND PNS PO, po PR PRN, prn PSA PT PTCA PTH PTT PUD PVC pulse after premature atrial contraction Papanicolaou test after meals Pneumocystis pneumonia pneumococcal conjugate vaccine patent ductus arteriosis physical examination pressure-equalizing tube pediatric pupils equal, round, and reactive to light and accommodation parts hydrogen pelvic inammatory disease polycystic kidney disease platelets afternoon prior medical history paroxysmal nocturnal dyspnea; postnasal drip; postnasal drainage peripheral nervous system by mouth, orally (per os) per rectum whenever necessary (pro re nata) prostatic-specic antigen prothrombin time; physical therapy percutaneous transluminal coronary angioplasty parathormone, parathyroid hormone partial thromboplastin time peptic ulcer disease premature ventricular contraction

retrograde pyelogram; retinitis pigmentosa respiratory rate right upper extremity right ventricle prescription

S
s SARS SBO SubQ, subcu, or subq sed rate SIDS SL SLE SOB sol SOM SR stat STD STI supp Sx syr without sudden acute respiratory syndrome small bowel obstruction subcutaneous erythrocyte sedimentation rate sudden infant death syndrome sublingual systemic lupus erythematosus shortness of breath solution serous otitis media sustained release immediately sexually transmitted disease sexually transmitted infection suppository symptom syrup

T
T T, Tbsp, Tbs t, tsp, Tsp T&A T3 T4 tab TAH TAH-BSO TB TC TENS TIA tid tinct, tr TM TMJ TO TPR TSE TSH TURP Tx temperature tablespoon teaspoon tonsillectomy and adenoidectomy triiodothyronine thyroxine tablet total abdominal hysterectomy total abdominal hysterectomy with bilateral salpingo-oophorectomy tuberculosis total cholesterol transcutaneous electrical nerve stimulation transient ischemic attack three times a day tincture tympanic membrane temporomandibular joint telephone order temperature, pulse, respiration testicular self-examination thyroid stimulating hormone transurethral resection of the prostate treatment

Q
q q2h q3h qam qh qhs qid QNS QS, qs every every 2 hours every 3 hours every morning every hour every day at bed time (or each evening) four times a day quantity not sufcient quantity sufcient

R
R RA RAST RBC RK RLE ROM ROP respiration; rectal right atrium; rheumatoid arthritis radioallergosorbent test red blood cell radial keratotomy right lower extremity range of motion retinopathy of prematurity

U
UA ung URI US UTI urinalysis ointment upper respiratory infection ultrasound urinary tract infection

1040

APPENDIX B

V
VA vag VC VF VLDL VO visual acuity vaginal vital capacity visual eld very-low-density lipoprotein verbal order

W, X, Y, Z
WBC WNL white blood cell within normal limits

Discontinued Abbreviations The abbreviations below, although commonly used in the past, have been identied as the cause of many errors and much confusion. Thus, the medical assistant should refrain from using these abbreviations. Even so, many of these abbreviations will appear in medical records; thus, medical assistants should know the abbreviated and spelled-out forms for each. AD AS AU cc DC, dc hs, HS OD OS, os right ear (auris dextra) left ear (auris sinistra) both ears (auris utraque) cubic centimeter discharge (confused with discontinue) bedtime right eye (oculus dexter), overdose left eye (oculus sinister) OU IU g qd qod SC, SQ U both eyes together (oculus uterque) International Unit microgram every day every other day subcutaneous unit

APPENDIX

Index of Competencies
Below are lists of competencies as determined by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and Accrediting Bureau of Health Education Schools (ABHES). Each list includes the individual competency and every chapter in which it appears. The CAAHEP list also includes a column to indicate those competencies that require a work product. CAAHEP Competencies

C
Chapter
11, 12

Competency
Administrative Competencies Perform Clerical Functions Schedule and manage appointments

Work Product

Schedule inpatient and outpatient admissions and procedures Organize a patients medical record File medical records Perform Bookkeeping Procedures Prepare a bank deposit Post entries on a day sheet Perform accounts receivable procedures Perform billing and collection procedures Post adjustments Process a credit balance Process refunds Post nonsufcient fund (NSF) checks Post collection agency payments Process Insurance Claims Apply managed care policies and procedures Apply third party guidelines Perform procedural coding Perform diagnostic coding Complete insurance claim forms Clinical Competencies Fundamental Principles Perform hand washing Wrap items for autoclaving Perform sterilization techniques Dispose of biohazardous materials Practice standard precautions

Appointment schedule Appointment schedule showing changes, such as rescheduling and no-shows Completed referral forms for each of the four components None required None required Completed bank deposit slip Completed day sheet Completed day sheet Completed billing form Documentation of collection activity Completed day sheet or ledger including adjustments Completed day sheet or ledger including credit balance Completed day sheet or ledger including refund or indication of refund issued Completed day sheet or ledger including NSF check Completed day sheet or ledger including collection agency payment

12 7, 14 14 18 18 17, 18 17, 18 18 18 18 18 18

None required None required Completed CMS 1500 Completed CMS 1500 Completed CMS 1500

7, 16 7, 16 16 25, 28, 29, 16 16

None None None None None

required required required required required

19 19 19 19, 30, 38, 40, 41, 46 19, 22, 30, 40, 41, 46

Continued

1041

1042

APPENDIX C

Competency
Clinical Competencies Specimen Collection Perform venipuncture Perform capillary puncture Obtain specimens for microbiological testing Instruct patients in the collection of a clean-catch, midstream urine specimen Instruct patients in the collection of a fecal specimen Diagnostic Testing Perform electrocardiography Perform respiratory testing CLIA-Waived Tests Perform urinalysis Perform hematology testing Perform chemistry testing Perform immunology testing Perform microbiology testing Patient Care Perform telephone and in-person screening

Work Product

Chapter

None None None None

required required required required

41 41 40, 45, 46 44 30

None required

ECG tracing to accompany the checklist as evidence of the achievement Results of the testing attached with the checklist or recorded on the checklist Reporting of the results of the with or on the checklist Reporting of the results of the test with or on the checklist Reporting of the results of the test with or on the checklist Reporting of the results of the test with or on the checklist Reporting of the results of the test with or on the checklist urinalysis hematology chemistry immunology microbiology

27 28 25, 32, 40, 42, 43, 44, 45, 40, 44 40, 42 40, 43 25, 40, 43 40, 45

Obtain vital signs

Obtain and record patient history Prepare and maintain examination and treatment areas Prepare patients for and assist with routine and specialty examinations Prepare patients for and assist with procedures, treatments, and minor ofce surgeries Apply pharmacology principles to prepare and administer oral and parenteral (excluding IV) medications Maintain medication and immunization records

Chart notes referring to the screening process between the medical assistant and the patient Charting examples on a medical record or the checklist that demonstrates the student has recorded her results A patient history form completed by the student None required None required None required Documentation of the administration of the oral and parenteral medications in the chart or on the checklist Documentation in a patients chart or on a medication log showing both medications and immunizations (could be separate logs for different patients) Documentation of calling or writing the patient to follow up on the test results

12, 48

21, 33

20 22, 27, 30, 32, 33, 48 22, 25, 26, 27, 28, 29, 30, 31, 32, 33, 36, 48 22, 24, 25, 26, 28, 29, 30, 31, 33, 35 36, 38, 39

33, 39

Screen and follow up test results General Competencies* Professional Communications Respond to and initiate written communications

40, 48

Recognize and respond to verbal communication Recognize and respond to nonverbal communications

Sample of the written communication used to document the achievement of this competency (for example, a letter or memorandum) None required None required

13, 23

12, 15, 20, 23, 34 3, 5, 6, 9, 10, 11, 34, 48, 49

APPENDIX C

1043

Competency
General Competencies* Professional Communications Demonstrate telephone techniques Legal Concepts Identify and respond to issues of condentiality Perform within legal and ethical boundaries Establish and maintain the medical record Document appropriately

Work Product

Chapter

None required None required None required None required Sample of documentation associated with the procedure used to document achievement of this competency (For example, if Obtain vital signs was the basis for achievement of this competency, then the sheet used to record vitals signs should be attached.) None required

11, 12 6, 6, 6, 6, 7, 7, 7, 7, 8, 11, 10, 13, 15, 34, 48 8, 11, 13, 15, 39 13, 20, 32 11, 20, 22, 26, 32, 38, 39, 40, 41

Demonstrate knowledge of federal and state health care legislation and regulations Patient Instruction Explain general ofce policies Instruct individuals according to their needs Provide instruction for health maintenance and disease prevention Identify community resources Operational Functions Perform an inventory of supplies and equipment

6, 7, 38, 39,

None required None required None required None required Completed inventory sheet showing status of supplies Completed inventory sheet showing status of equipment Sample of routine maintenance log for the administrative equipment used to document achievement of this competency Sample of routine maintenance log for the clinical equipment used to document achievement of this competency Printed sample from the computer software used to document achievement of this competency (for example, a letter for word processing, an insurance form or report for medical ofce software, sent e-mail message for e-mail software, and a printout of a website page for research) Sample of quality control log for the test performed to document achievement of this competency

10, 11, 17 1, 9, 10, 11, 23, 25, 26, 27, 28, 29, 30, 32, 34, 35, 36, 37, 38, 39, 47, 48 9, 10, 19, 22, 23, 25, 27, 28, 29, 31, 32, 34, 35, 37 4, 10, 32, 34, 37 15

Perform routine maintenance of administrative and clinical equipment

15, 40

Utilize computer software to maintain ofce systems

15, 12, 16, 18

Use methods of quality control

40, 42, 43, 44

*Documentation of achievement of General Competencies may include materials other than checklists.

ABHES Competencies
Competency
Professionalism Project a positive attitude Maintain condentiality at all times Be a team player Be cognizant of ethical boundaries Exhibit initiative 3, 7, 3, 7, 3, 10, 15, 49 8, 10, 34, 48 15 8, 10, 49 15, 49

Chapter

Continued

1044

APPENDIX C

Competency
Professionalism Adapt to change Evidence a responsible attitude Be courteous and diplomatic Conduct work within scope of education, training, and ability Communication Be attentive, listen, and learn Be impartial and show empathy when dealing with patients Adapt what is said to the recipients level of comprehension Serve as a liaison between the physician and others Use proper telephone techniques Interview effectively Use appropriate medical terminology Receive, organize, prioritize, and transmit information expediently Recognize and respond to verbal and nonverbal communication (and recognition and response to verbal and nonverbal communication) Use correct grammar, spelling, and formatting techniques in written works Principles of verbal and nonverbal communication Adaptation for individualized needs Application of electronic technology Fundamental writing skills Professional components Allied health professions and credentialing Administrative Duties Perform basic secretarial skills Prepare and maintain medical records Schedule and monitor appointments Apply computer concepts for ofce procedures Locate resources and information for patients and employers Manage physicians professional schedule and travel Schedule inpatient and outpatient admissions File medical records Prepare a bank statement and deposit record Reconcile a bank statement Post entries on a day sheet Perform billing and collection procedures Prepare a check Establish and maintain a petty cash fund Post adjustments Process credit balance Process refunds Post NSF funds Post collection agency payments Apply managed care policies and procedures Obtain managed care referrals and precertication Perform diagnostic coding Complete insurance claim forms Use physician fee schedule Clinical Duties Interview and record patient history Prepare patients for procedures Apply principles of aseptic technique and infection control Take vital signs Recognize emergencies Perform rst aid and CPR Prepare and maintain examination and treatment areas

Chapter
3 3, 8, 10, 15, 39 3, 5, 8, 10, 20 6, 7, 39, 48

5, 10, 11, 15, 20 5, 7, 10, 32 7, 10, 11, 20, 32, 34, 38, 39, 48 4, 11, 32, 38, 39, 48 11, 12 12, 15, 20 10, 12, 23, 25, 26, 30 11, 13, 20 3, 5, 10, 12, 20, 30, 41, 48, 49

10, 13, 49 5, 10, 20 9, 20, 34, 48 13, 48 6, 13 3 3

13 20 11, 12 12, 18 7, 13, 34 15 12 14 18 18 18 17, 18 18 18 18 18 18 18 18 16 16 16, 25, 26, 29 16 16

20, 22, 19, 21, 47 47 30,

31, 25, 24, 32,

32, 33 26, 27, 28, 29, 30, 31, 32, 33, 35, 36, 48 32, 36, 39, 41 33

32, 33, 35, 36, 48

APPENDIX C

1045

Competency
Clinical Duties Prepare patient for and assist physician with routine and specialty examinations and treatments and minor ofce surgeries Use quality control Collect and process specimens Perform selected CLIA-waived tests that assist with diagnosis and treatment Screen and follow up patient test results Prepare and administer oral and parenteral medications as directed by the physician Maintain medication and immunization records Wrap items for autoclaving Perform sterilization techniques Dispose of biohazardous materials Practice standard precautions Perform venipuncture Perform capillary puncture Obtain throat specimen for microbiological testing Perform wound collection procedure for microbiological testing Instruct patients in the collection of a clean-catch, midstream urine specimen Instruct patient in the collection of fecal specimen Perform urinalysis Perform hematology testing Perform chemistry testing Perform immunology testing Perform microbiology testing Perform electrocardiograms Perform respiratory testing Perform telephone and in-person screening Legal Concepts Determine needs for documentation and reporting Document accurately Use appropriate guidelines when releasing records or information Follow established policy in initiating or terminating medical treatment Dispose of controlled substances in compliance with government regulations Maintain licenses and accreditation Monitor legislation related to current health care issues and practices Perform risk management procedures Ofce Management Maintain physical plant Operate and maintain facilities and equipment safely Inventory equipment and supplies Evaluate and recommend equipment and supplies for practice Maintain liability coverage Exercise efcient time management Instruction Orient patients to ofce policies and procedures Instruct patients with special needs Teach patients methods of health promotion and disease prevention Orient and train personnel Financial Management Use manual and computerized bookkeeping systems Implement current procedural terminology and ICD-9-CM coding Analyze and use current third-party guidelines for reimbursement Manage accounts payable and receivable Maintain records for accounting and banking purposes Process employee payroll

Chapter
22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 35, 36, 48 40, 41, 42, 43, 44 25, 26, 31, 32, 40, 41, 42, 43, 44, 46 32, 40 40, 41 39 33 19 19 30, 32, 41 33, 33, 45 44

32, 39, 41, 42, 43, 44, 45 39, 41, 42, 43, 44, 45 41 45

30 33, 44 41, 42 43 25, 43 45 27 28 11

6, 7, 32, 48 6, 7, 20, 30, 32, 35, 48 6, 9, 14 6, 9, 13 38, 39 6 6, 38 6

15 15 15 15 15 15

17 1, 9, 32, 34, 35, 36, 37 1, 9, 25, 26, 27, 29, 32, 34, 35, 36, 37, 38, 47 15

18 16 16 18 18 18

APPENDIX

Commonly Prescribed Drugs

This table includes a list of many of the most commonly prescribed medications in the United States. They are alphabetized according to the generic names with some of the common trade names listed in the second column. Because of the extent of trade name drugs for some generic forms, the list of trade names is not comprehensive in every case.

Generic name
acetaminophen acyclovir albuterol alendronate allopurinol alprazolam amiodarone amitriptyline amlodipine amlodipine and atorvastatin* amlodipine and benazepril* amoxicillin amoxicillin clavulanate amphetamine ampicillin aripiprazole aspirin atenolol atomoxetine atorvastin atropine azithromycin baclofen bupropion bupropion hydrochloride buspirone butalbital, acetaminophen, and caffeine* butalbital sodium calcium carbonate calcium chloride, calcium gluceptate, or calcium gluconate candesartan cilexetil captopril carbamazepine carbidopa-levodopa carisoprodol carvedilol cefdinir celecoxib cephalexin cetirizine ciprooxacin citalopram clarithromycin clindamycin
*combination product

Trade name(s)
Tylenol, APAP, Abenol, Acephen, Panadol Zovirax, Acycloguanosine Proventil, Ventolin, Salbutamol, Volmax Fosamax Zyloprim, Aloprim, Lopurin Xanax, Niravam Cordarone, Pacerone Elavil, Endep Norvasc Caduet* Lotrel* Amoxil, Trimox, Wymox Augmentin Adderall, Racemic Amphetamine, Sulfate Principen, Polycillin, Totacillin, Marcillin, Omnipen Abilify Bayer, ASA, Acuprin, Artria, Ecotrin, Empirin Tenormin Strattera Lipitor Atropen, Sal-Tropine Zithromax, Zmax Lioresal Wellbutrin, Budeprion SR, Zyban Budeprion, Wellbutrin, Zyban BuSpar Fioricet*, Dolmar*, Medigesic* Butisol, Barbased, Butalan, Sarisol No2 Caltrate 600, Chooz, Os-Cal 500, Titralac, Tums Kalcinate Atacand Capoten Tegretol, Atretol, Carbatrol, Epitol, Equetro, Teril Sinemet, Atamet, Parcopa Soma, Rela, Vanadom Coreg Omnicef Celebrex Cefanex, Keex, Keftab, Ceporex, Novolexin-A Zyrtec Cipro, Proquin Celexa Biaxin Cleocin

Continued

1047

1048

APPENDIX D

Generic name
clonazepam clonidine clopidogrel codeine colchicine conjugated estrogen cyclobenzaprine desloratidine dexamethasone diazepam diclofenac dicyclomine digoxin diltiazem diphenhydramine divalproex sodium (valproic acid) donepezil hydrochloride dopamine doxazosin doxepin doxycycline duloxetine enalapril enoxaparin erythromycin escitalopram oxalate esomeprazole estradiol eszopiclone etanercept ethinyl estradiol and drospirenone* ethinyl estradiol and norelgestromin etodolac exenatide ezetimibe ezetimibe and simvastatin* famotidine fenobrate fentanyl fexofenadine nasteride ucanazole uoxetine uticasone furosemide gabapentin glimepiride glipizide glyburide haloperidol heparin hydralazine hydrochlorothiazide hydrocodone bitartrate hydrocodone bitartrate and acetaminophen hydrocortisone hydromorphone hydroxyzine ibandronate sodium
*combination product

Trade name(s)
Klonopin Catapres, Duraclon, Dixaril Plavix Codeine Colchicine Premarin, Congest Cycloex, Flexeril Cymbalta Decadron, Dexon, Hexadrol, Mymethasone Valium, Diastat, Valrelease Cataam, Volatren, Solaraze Bentyl, Antispas, Byclomine, Dibent, Nospaz Lanoxicaps, Lanoxin Cardizem, Dilacor XR, Tiazac, Tiamate Benadryl, Benylin, Compoz, Diphon Depakote, Depacon, Depakene, Zalkote Aricept Intropin, Dopastat Cardura Doxepin, Sinequan Adoxa, Doxy, Monodox, Vibramycin, Vibra-Tabs, Vivox Cymbalta Vasotec Lovenox E-Mycin, Ery-Tab, Erythrocin Lexapro Nexium Estrace, Estraderm, Alora, Climara Lunesta Enbrel Yasmin*, Yaz28* Ortho Evra Lodine Byetta Zetia Vytorin* Mylanta AR, Pepcid Tricor, Antara, Lobra, Triglide Actiq, Sublimaze, Duragesic (transdermal), Oralet Allegra Proscar, Propexia Diucan Prozac, Sarafem Flovent, Butivate, Flonase, Cutivate Lasix Neurontin, Gabarone Amaryl Glucotrol DiaBeta, Glynase, Micronase Haldol Lipo-Hepin, Liquaemin Sodium Apresoline Esidrix, HCTC, Hydro-Chlor, HydroDIURIL Hycodan, Robidone Vicodin, Norco, Zydone, Lortab Cortef, Cortifoam, Hydrocortone, SoluCortef Dilaudid , Hydrostat Atarax, Hyzine-50, Vistacon, Visteril Boniva

APPENDIX D

1049

Generic name
ibuprofen indomethacin insulins: Rapid Acting: lispro Short Acting: regular Intermediate Acting: isophane suspension (NPH) Long Acting: glargine Mixtures: isophane suspension and regular* ipratropium irbesartan isosorbide dinitrate ketorolac lamotrigine lansoprazole leuprolide levetiracetam levooxacin levothyroxine lidocaine lisinopril lithium loratadine lorazepam losartan losartan potassium and hydrochlorothiazide* lovastatin magnesium hydroxide meclizine medroxyprogesterone meloxicam memantine meperidine metaxalone metformin methadone methocarbamol methotrexate methylphenidate methylprednisolone metoclopramide metoprolol metronidazole midazolam mirtazapine modanil mometasone montelukast morphine moxioxacin Hcl nabumetone naproxen niacin nifedipine nitrofurantoin nystatin olanzapine olmesartan medoxomil omeprazole ondansetron oseltamivir
*combination product

Trade name(s)
Advil, Excedrin IB, Motrin, Nuprin Indocin Humalog Humulin R, Novolin R Humulin N, Novolin N, Lantus Humulin 70/30*, Novolin 70/30* Atrovent Avapro Iso-Bid, Isorbid, Isordil, Sorbitrate, Imdur, Monoket Toradol Lamictal Prevacid Lupron, Eligard, Viadur Keppra Levaquin, Iquiz, Quixin Levoxyl, Levo-T, Levothyroid, Synthroid Xylocaine, Anestacon, Dilocaine, Lidoderm Prinivil, Zestril Eskalith, Lithonate, Lithotabs Claritin, Dimetapp, Tavist ND Ativan Cozaar Hyzaar* Mevacor, Altoprev, Mevinolin Phillips Magnesia Tablets, Phillips Milk of Magnesia, MOM Antivert, Antrizine, Bonine, Meni-D, Vergon Provera, Amen, Curretab, Cycrin, Depr-Provera Mobic Namenda Demerol, Pethidine Skelaxin Fortamet, Glucophage, Glumetza, Riomet Dolophine, Methadose Carbacot, Robaxin Rheumatrex, Amethopterin, Trexall Ritalin, Concerta, Daytrana, Methylin, Methidate Medrol, A-Methapred, Solu-Medrol, Duralone Metoclopramide Octamide, Reglan Sensamide IV Lopressor, Toprol-XL Flagyl, Protostat, Metizol Versed Remeron Provigil Nasonex, Asthmanex Twisthaler, Elocon Singulair Duramorph, Roxanol, MS-Contin Avelox, Vigamox Relafen Naprosyn, Aleve, Anaprox, Midol ER Niaspan, Nia-Bid, Niac, Niacor Adalat, Procardia Macrobid, Furadantin, Macrodantin Mycostatin, Nilstat, Nystex, OV Statin Zyprexa Benicar Prilosec, Zegerid Zofran Tamiu

Continued

1050

APPENDIX D

Generic name
oxcarbazepine oxybutynin oxycodone oxycodone and acetaminophen pantoprazole paroxetine penicillins (many variations) phentermine phenylephrine, phenylpropanolamine, and guaifenesin* phenytoin pioglitazone hydrochloride piroxicam potassium pravastatin prednisolone prednisone pregabalin prochlorperazine promethazine promethazine propoxyphene propoxyphene and acetaminophen* propranolol propranolol pseudoephedrine quetiapine quinapril quinine rabeprazole raloxifene ramelteon ramipril ranitidine risedronate risperidone ropinirole rosiglitazone maleate rosuvastatin sertraline sildenal simvastatin spironolactone sumatriptan tadalal tamsulosin tegaserod mesylate temazepam terazosin terbinane tetracycline thyroid tiotroppium tizanidine tolterodine topiramate tramadol tramadol and acetaminophen* trazodone triamcinolone triamterene
*combination product

Trade name(s)
Trileptal Ditropan, Oxytrol Roxicodone, Endocodone, Oxycontin, M-Oxy Percocet, Endocet, Roxicet, Tylox Protonix Paxil, Asimia Pentids, Bicillin, Permapen, Wycillin, Veetids, Penacillin VK Adipex-P, Fstin, ObeNix-30, Zantryl Entex Dilantin Actos Feldene K-Lyte, K-Dur, Micro-K, SlowK Pravachol Delta-Cortef, Key-Pred, Predalone, Prelone Deltasone, Meticorten, Orasone, Panasol Lyrica Compazine, Ultrazine, Chlorpazine Phenergan, Phenadoz Phenergan, Phenadoz Darvon, Darvon-N, Dolene Darvocet* Inderal, InnoPran XL Inderal, InnoPran LX Halofed, Sudafed, Triaminic AM Decongestant Formula Seroquel Accupril Quinamm, Quiphile Aciphex Evista Rozerem Altace Zantac Actonel Risperdal Requip Avandia Crestor Zoloft Viagra, Revatio Zocor Aldactone Imitrex Cialis Flomax Zelnorm Restoril, Razepam Hytrin Lamisil Panmycin, Robitet, Sumycin, Teline, Tetracap, Tetracyn Amour, Thyrar Spiriva Zanaex Detrol Topamax Ultram, Zydol Ultracet* Desyrel Amcort, Aristocort, Azmacort, Kenacort, Kenalog Dyrenium

APPENDIX D

1051

Generic name
trimethoprim and sulfamethoxazole valacyclovir valsartan vancomycin vardenal venlafaxine verapamil warfarin ziprasidone zolpidem
*combination product

Trade name(s)
Bactrim, Septra, Cotrim, Co-Rimoxazole Valtrex Diovan Lyphocin, Vancocin, Vancoled Levitra Effexor Calan, Covera-HS, Isoptin, Verelan PM Coumadin, Panwarfarin Geodon Ambien

APPENDIX

Certication Examination Content Outlines

This appendix provides detailed information about the content students can expect on the medical assistant certication examinations. Students may use this as a study guide along with other examination preparation materials when preparing to take the certied medical assistant (CMA) or registered medical assistant (RMA) examination. However, because examination content is revised annually, students should check with the certifying organization for updates after 2009.

CMA (AAMA) Certication-Recertication Examination

I. AF General A. Medical Terminology 1. Word building and denitions a. Basic structure 1. roots or stems 2. prexes 3. sufxes 4. abbreviations b. Surgical procedures c. Diagnostic procedures d. Medical specialties 2. Uses of terminology a. Spelling b. Selection and use (e.g., data entry, reports, records, documents, patient education, correspondence, medicolegal documentation, letters, memos, messages, facsimiles) c. Reference sources B. Anatomy and Physiology 1. Body as a whole, including multiple systems a. Structural units b. Anatomical divisions c. Positions and directions d. Body planes e. Common diseases and pathology 2. Systems, including structure, function, related conditions and diseases, and their interrelationships a. Integumentary b. Musculoskeletal c. Nervous d. Cardiovascular, hematopoietic, and lymphatic e. Respiratory f. Digestive g. Urinary h. Reproductive i. Endocrine j. Sensory

C. Psychology 1. Basic principles a. Understanding human behavior 1. Behavioral theories 2. Death and dying 2. Developmental stages of the life cycle a. Developmental theories used to explain behavior and development b. Human growth and development 3. Defense mechanisms a. Recognition b. Management D. Professionalism 1. Displaying professional attitude a. Supporting professional organization b. Accepting responsibility for own action 2. Job readiness and seeking employment a. Resum and cover letter b. Methods of job searching c. Interviewing as a job candidate 3. Working as a team member to achieve goals a. Member responsibility b. Promoting competent patient care c. Utilizing principles of group dynamics E. Communication 1. Adapting communication according to an individuals needs a. Blind b. Deaf c. Elderly d. Children e. Seriously ill f. Mentally impaired g. Illiterate h. Non-English-speaking i. Anxious j. Angry/distraught k. Culturally different

1053

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APPENDIX E

2. Recognizing and responding to verbal and nonverbal communication a. Body language b. Listening skills c. Eye contact d. Barriers to communication e. Identifying needs of others 3. Professional communication and behavior a. Professional situations 1. Tact 2. Diplomacy 3. Courtesy 4. Responsibility/integrity b. Therapeutic relationships 1. Impartial behavior 2. Empathy/sympathy 3. Understanding emotional behavior 4. Patient interviewing techniques a. Types of questions 1. Exploratory 2. Open-ended 3. Direct b. Evaluating effectiveness 1. Observation 2. Active listening 3. Feedback c. Legal restrictions 5. Receiving, organizing, prioritizing, and transmitting information a. Modalities for incoming and outgoing data (e.g., mail, fax telephone, computer) b. Prioritizing incoming and outgoing data (e.g. importance, urgency, recipient availability) 6. Telephone techniques a. Incoming calls management criteria 1. Screening 2. Maintaining condentiality 3. Gathering data 4. Multiple-line competency 5. Transferring appropriate calls 6. Identifying caller, ofce, and self 7. Taking messages 8. Ending calls b. Monitoring special calls 1. Problem calls (e.g., unidentied caller, angry patient, family member) 2. Emergency calls 7. Fundamental writing skills a. Sentence structure b. Grammar c. Punctuation F. Medicolegal Guidelines and Requirements 1. Licenses a. Medical practice acts b. Revocations/suspension of license 1. Criminal/unprofessional conduct 2. Professional/personal incapacity 2. Legislation a. Advanced directives

b. Anatomical gifts c. Reportable incidences 1. Public health statutes (e.g., communicable diseases, vital statistics, substance abuse/chemical dependency, abuse against persons) 2. Wounds of violence d. Occupational Safety and Health Act (OSHA) e. Food and Drug Administration (FDA) f. Clinical Laboratory Improvement Act (CLIA 88) g. Americans with Disabilities Act (ADA) h. Health Insurance Portability and Accountability Act (HIPPA) 3. Documentation/reporting a. Sources of information b. Drug Enforcement Administration (DEA) c. Internal Revenue Service (e.g., personnel forms) d. Employment laws e. Personal injury occurrences f. Workers compensation g. Medical records 1. Patient activity 2. Patient care 3. Patient condentiality 4. Ownership h. Personnel records 1. Performance evaluation 2. Privacy 4. Releasing medical information a. Consent 1. Patient written authorization 2. Federal codes (1) Right to privacy (2) Drug and alcohol rehabilitation records (3) Public health and welfare disclosures (4) HIV-related issues (5) Subpoena duces tecum 3. Rescinding authorization for release 5. Physician-patient relationship a. Contract 1. Legal obligations 2. Consequences for noncompliance b. Responsibility and rights 1. Patient 2. Physician 3. Medical assistant c. Guidelines for third-party agreements d. Professional liability 1. Current standard of care 2. Current legal standards 3. Informed consent e. Arbitration agreements f. Afrmation defenses 1. Statue of limitations 2. Comparative/contributory negligence 3. Assumption of risk g. Termination of medical care 1. Establishing policy 2. Elements for withdrawal 3. Patient notication and documentation h. Medicolegal terms and doctrines

APPENDIX E

1055

6. Maintaining condentiality a. Agent of the physician 1. Patient rights 2. Releasing patient information b. Intentional tort 1. Invasion of privacy 2. Slander and libel 7. Performing within ethical boundaries a. Ethical standards 1. AAMA Code of Ethics 2. AMA Code of Ethics b. Patient rights c. Current issues in medical bioethics II. GQ Administrative G. Data Entry 1. Keyboard fundamentals and functions a. Alpha, numeric, and symbol keys b. Tabulation 2. Formats a. Letters b. Memos c. Reports d. Envelopes e. Chart notes 3. Proofreading a. Proofreaders marks b. Making corrections from rough draft H. Equipment 1. Equipment operations a. Calculator b. Photocopier c. Computer d. Fax machine e. Telephone services and features f. Scanners 2. Maintenance and repairs a. Contents of instruction manual b. Routine maintenance 1. Agreements 2. Warranty 3. Repair service 3. Protection and Safety I. Computer Concepts 1. Computer components a. Terminology b. Central processing unit (CPU), monitor, keyboard c. Printer d. Disk drive e. Storage devices (e.g., hard drives, magnetic tapes, CD-ROMs, ash drives) f. Operating systems g. Basic commands 2. Computer applications a. Word processing b. Database (e.g., menu, elds, records, les)

c. Spreadsheets, graphics d. Electronic mail e. Networks f. Security/password g. Medical management software 1. Patient data 2. Report generation 3. Internet services J. Records Management 1. Needs, purposes, and terminology of ling systems a. Basic ling systems 1. Alphabetic 2. Numeric/terminal digit 3. Subject b. Special ling systems 1. Color-code 2. Tickler le 3. Electronic data processing les (EDP 4. Cross-reference/master le 2. Filing guidelines a. Storing b. Protecting/safekeeping c. Transferring 3. Medical records (paper/electronic) a. Organization of patients medical record b. Types 1. Problem oriented 2. Source oriented c. Collecting information d. Making corrections e. Retaining and purging 1. Statue of limitations K. Screening and Processing Mail 1. U.S. Postal Service a. Classications b. Types of mail services 2. Postal machine/meter 3. Processing incoming mail 4. Preparing outgoing mail a. Labels b. Optical Character Reader (OCR) guidelines L. Scheduling and Monitoring Appointments 1. Utilizing appointment schedules/types a. Stream b. Wave/Modied wave c. Open booking d. Categorization 2. Appointment guidelines a. Appointment schedule matrix b. Legal aspects c. New/established patient d. Patient needs/preference e. Physician preference/habits f. Facilities/equipment requirements

1056

APPENDIX E

3. Appointment protocol a. Follow-up visits 1. Routine 2. Urgent b. Emergency/acutely ill c. Physician referrals d. Cancellations/no-shows e. Physician delay/unavailability f. Outside services (e.g., lab, x-ray, surgery) g. Reminders/recalls 1. Appointment cards 2. Phone calls M. Resource Information and Community Services 1. Patient advocate a. Services available b. Appropriate referrals c. Follow-up N. Intentionally left blank (currently there are no items for this category) O. Maintaining the Ofce Environment 1. Physical environment a. Arrangement of furniture, equipment, and supplies b. Facilities and equipment 1. Maintenance and repair 2. Safety regulations (1) Occupational Safety and Health Act (OSHA) (2) Centers for Disease Control and Prevention (CDC) guidelines (3) Americans with Disabilities Act (ADA) (4) Fire regulations (5) Security systems 2. Equipment and supply inventory a. Inventory control b. Purchasing 3. Maintaining liability coverage a. Types of coverage b. Recordkeeping 4. Time management a. Establishing priorities b. Managing routine duties P. Ofce Policies and Procedures 1. Patient information booklet 2. Personnel manual 3. Policy and procedures manuals/protocols Q. Practice Finances 1. Bookkeeping principles a. Daily reports, charges slips, receipts, ledgers, etc. 1. Charges, payments, and adjustments 2. Identifying and correcting errors b. Petty cash 2. Coding systems a. Types 1. Current Procedural Terminology (CPT) 2. International Classication of Diseases, Clinical Modications (ICD-CM) (current schedule)

3. Healthcare Financing Common Procedural Coding System (HCPCS Level II) b. Relationship between procedures and diagnosis codes 3. Third-party billing a. Types 1. Capitated plans 2. Commercial carriers 3. Government plans (1) Medicare (2) Medicaid (3) Tricare (4) CHAMPVA 4. Prepaid HMO, PPO, POS 5. Workers compensation b. Processing claims 1. Manual and electronic preparation of claims 2. Tracing claims 3. Sequence of ling (e.g., primary versus secondary) 4. Reconciling payments/rejections 5. Inquiry and appeal process c. Applying managed care policies and procedures 1. Referrals 2. Precertication d. Fee schedules 1. Methods for establishing fees (1) Relative Value Studies (2) Resource-Based Relative Value Scale (RBRVS) (3) Diagnosis Related Groups (DRGs) 2. Contracted fees 4. Accounting and banking procedures a. Accounts receivable 1. Billing procedures (1) Itemization (2) Billing cycles 2. Aging/collection procedures (1) Collection agencies (2) Consumer protection acts b. Accounts payable 1. Ordering goods and services 2. Monitoring invoices 3. Tracking merchandise c. Banking procedures 1. Processing accounts receivable 2. Preparing bank deposit 5. Employee payroll a. Calculating wages b. Payroll forms III. RZ Clinical R. Principles of Infection Control 1. Principles of asepsis 2. Aseptic technique a. Medical asepsis 1. Handwashing 2. Sanitization 3. Chemical disinfection b. Surgical asepsis 1. Scrubbing 2. Gowning 3. Gloving

APPENDIX E

1057

4. Surgical assisting 5. Preparing equipment 6. Preparing items for autoclave 7. Performing sterilization techniques 3. Disposal of biohazardous material 4. Standard precautions S. Treatment Area 1. Principles of equipment operation a. Autoclave/sterilizer b. Cast equipment/materials c. Electrocardiograph d. Examination tables e. Microscope f. Ophthalmoscope/otoscope/stethoscope g. Oxygen h. Physical therapy modalities i. Endoscopes j. Scales k. Sphygmomanometers l. Spirometer m. Thermometers n. Nebulizers o. Mobility assistive devices p. Oximeter 2. Restocking supplies 3. Preparing/maintaining treatment areas 4. Safety precautions T. Patient Preparation and Assisting the Physician 1. Vital signs a. Performing b. Recording 2. Examinations a. Types b. Body positions c. Body mechanics 3. Procedures a. Instruments, supplies, and equipment b. Explanation and instructions 4. Providing education for health maintenance and disease prevention U. Patient History Interview 1. Components of patient history a. Personal data b. Chief complaint c. Past, present, family, and social history d. Review of systems 2. Documentation guidelines V. Collecting and Processing Specimens; Diagnostic Testing 1. Methods of collection a. Blood 1. Vein 2. Capillary b. Urine

c. Stool d. Sputum e. Cultures 1. Throat 2. Vaginal 3. Wounds 4. Urine 5. Blood 2. Processing specimens a. Centers for Disease Control and Prevention (CDC) guidelines b. Proper labeling c. Contamination d. Specimen preservation e. Recordkeeping 3. Quality control 4. Performing selected tests a. Urinalysis 1. Physical 2. Chemical 3. Microscopic b. Hematology 1. Hematocrit 2. Hemoglobin 3. Erythrocyte sedimentation rate 4. Automated cell counts (1) Red blood cell (RBC) (2) White blood cell (WBC) (3) Platelet 5. Coagulation testing c. Blood chemistry 1. Glucose 2. Kidney function tests 3. Liver function tests 4. Lipid prole 5. Hemoglobin A1c d. Immunology 1. Mono test 2. Strep test 3. C-reactive protein (CRP) 4. Pregnancy testing e. Microbiology 1. Theory/terminology (1) Bacteria i. Grams staining (2) Virus (3) Fungus (4) Parasites (5) Protozoa f. Tuberculosis testing g. Guaiac testing 5. Electrocardiography (EKG/ECG) 6. Vision testing 7. Hearing testing 8. Respiratory testing a. Pulmonary function b. Spirometry c. Pulse oximetry d. Nebulizer treatment

1058

APPENDIX E

9. Medical imaging a. Safety principles b. Patient preparation c. Patient instruction W. Preparing and Administering Medications 1. Pharmacology a. Classes of drugs b. Drug forms c. Drug actions/uses d. Side effects/adverse reactions e. Emergency use f. Substance abuse 2. Preparing and administering oral and parenteral medications a. Calculation of dosage b. Routes of administration c. Types of injections d. Injection sites 3. Prescriptions a. Safekeeping b. Medication recordkeeping c. Controlled substance guidelines 4. Immunizations a. Childhood b. Adult vaccines c. Storage d. Recordkeeping 5. Principles of IV therapy a. Terminology b. Theory (excludes administration of IV medications) X. Emergencies 1. Preplanned action a. Policies and procedures b. Legal implications and action documentation c. Equipment 1. Crash cart 2. Automated external debrillator 2. Assessment and triage 3. Emergency preparedness Y. First Aid 1. Identifying and responding to a. Bleeding/pressure points b. Burns

c. Cardiac and respiratory arrest/CPR d. Choking/Heimlich maneuver e. Diabetic coma/insulin shock f. Fractures g. Poisoning h. Seizures i. Shock j. Stroke k. Syncope l. Wounds Z. Nutrition 1. Basic principles a. Dietary guidelines b. Food nutrients (e.g., vitamins, minerals) 2. Special needs a. Diets b. Restrictions

Registered Medical Assistant Examination

General Medical Assisting Knowledge41%* Anatomy and physiology Medical terminology Medical law Medical ethics Human relations Patient education

Administrative Medical Assisting24%* Insurance Financial and bookkeeping Medical receptionist/secretarial/clerical

Clinical Medical Assisting35%* Asepsis Sterilization Instruments Vital signs and mensurations Physical examinations Clinical pharmacology Minor surgery Therapeutic modalities Laboratory procedures Electrocardiography First aid

* Approximate percentages of questions in content areas

Index
AAA. See Abdominal aortic aneurysm AAMA. See American Association of Medical Assistants AAP. See American Academy of Pediatrics AAPC. See American Academy of Professional Coders Abandonment, 55, 61 AB blood type, 914 Abbreviations, 374377, 379 cardiovascular and lymphatic systems, 471472 common, 375 discontinued, 377 endocrinology, 527 gastroenterology, 544 geriatrics, 690 hematology, 898 integumentary system, 417 for laboratory tests, 851 in medication orders, 830 miscommunication and, 376 neurology, 444 obstetrics and gynecology, 610 ophthalmology and otolaryngology, 754 orthopedics, 716 pediatrics, 645 pulmonology system, 501 urology and the male reproductive system, 575576 ABCD system, warning signs of malignant melanoma, 428 ABCs of rst-aid (airway, breathing, circulation), 969 Abdominal aortic aneurysm (AAA), 476477 Abdominal hernia, (ICD-9-CM code: 553.9), 548549 Abdominal pain, 978980 Abduction, 726 ABHES. See Accreditation Bureau of Health Education Schools Ablation, 477 A blood type, 914 Abortion (ICD-9-CM code: 632), 86, 618619 Abruptio placentae (ICD-9-CM code: 641.20), 618 Absorption, drugs and, 808 Abstinence, 630 Abuse, 6367 child abuse, 6465, 67 claims and, 241, 246, 247 elder abuse, 67 emotional abuse, 65 neglect, 674

physical abuse, 65, 674 reporting child abuse, 673674 sexual abuse, 65 Abusive phone calls, 130 Acceptance stage of grief and loss, 101 Accessibility, 112 Accession log ling, 179180 Accountability, 22 Accounting, 260282 accounts payable, 263, 267271 accounts receivable ratio, 267 adjustments, 263267 balance sheet, 261, 263 bookkeeping, 261267 collection ratio, 267 cost ratio, 260-261, 262 day sheets, 264265 nancial, 260 xed and variable costs, 260 income statement, 261262 ledger cards, 263, 264 managerial, 260 non sufcient funds (NSF) checks, 263 payroll, 268 writing checks, 268269 See also Banking Accounts receivable ratio, 267 Accreditation, 15 organizations for, 15-16 See also Credentialing Accreditation Bureau of Health Education Schools (ABHES), 15, 16, 10181019 Accuracy, 20 Acid-fast bacillus stain, 945 ACLS. See Advanced cardiac life support Acne (ICD-9-CM code: 706.1), 420421 Acquired immune deciency syndrome (AIDS) (ICD-9-CM code: 042), 480481, 613 nutrition and, 795796 Activated partial thromboplastin time, 900 Active articial immunity, 295 Active listening, 4647, 309 Active natural immunity, 295 Activities of daily living (ADLs), 8, 33, 445 Acupuncture, 29 Acute abdominal pain, 978980 Acute care, 33 Acute infections, 291 Acute lymphocytic leukemia, 479 Acute myelogenous leukemia, 479 Acute pancreatitis (ICD-9-CM code: 577.0), 553 Acute renal failure (ICD-9-CM code: 584), 573, 575, 580582

Acute stage, 292 ADA. See Americans with Disabilities Act ADD. See Attention decit disorder Adduction, 726 Adenopathy, 467 Adenosine triphosphate (ATP), 779 ADHD. See Attention decit hyperactivity disorder Adjustments, 263 ADLs. See Activities of daily living Administrative medical assistants, 12 interviewing patients, 307316 medical coding specialist, 4041 medical transcriptionist, 41 skills of, 13 See also Front ofce-back ofce connection; Front ofce medical assistants; Health care team; Medical assisting Administrative specialists, 4041 Adolescents interviewing, 313 nutrition and, 794795 Adrenal cortex, 520, 523 Adrenal glands, 520, 522, 524 Adrenalin (epinephrine), 522 Adrenal medulla, 520 Adrenocorticotropic hormone, 522 Adult-onset diabetes (type II), 528529 Advanced cardiac life support (ACLS), 40, 968 AEDs. See Automated external debrillators Affective domain, 97 Against medical advice, 59 Age blood pressure and, 336 respiratory rates by, 335 Ageism, 684685 See also Geriatrics Agent, 55 Age of majority, 55 Age-related teaching considerations, 102, 104 Agglutination, 913 Aggressive pattern of communication, 4748 Aging myths, 685 Aging of accounts, 249250 Aging population, 684 See also Geriatrics Agranulocytes, 892 AHIMA. See American Health Information Association AIDS. See Acquired immune deciency syndrome Airway, breathing, circulation. See ABCs of rst-aid

1059

1060

INDEX

Alcohol-based hand sanitizer, 298, 300 Alcohol consumption, 87 pregnancy and, 628 Alcoholics Anonymous, 817 Aldosterone, 522 Alimentary canal, 538541 Allergic reactions to drugs, 814 Allergic rhinitis (ICD-9-CM codes: 477.0, 477.1, 477.2, 477.8), 500, 502 Allergies (ICD-9-CM code: 995.3), 653654 Allergy skin testing, 429432 guidelines for, 432 intradermal test, 417, 429, 430 patch test, 429432 radioallergosorbent test, 417432 scratch test, 429 Alphabetical ling system, 176177, 182 Alpha-Z color-coding system, 177 Altered consciousness (ICD-9-CM code: 780.09), 974, 977 Alzheimer disease (ICD-9-CM code: 331.0), 689, 690692, 694695, 696 diagnosing, 690 life expectancy, 692 stages of, 690 Ambiguity, 89 Ambulation, 727 See also Orthopedics Ambulatory care, 33 Amenorrhea (ICD-9-CM code: 626.0), 614 American Academy of Pediatrics (AAP), 679680 American Academy of Professional Coders (AAPC), 41 American Association of Medical Assistants (AAMA), 15 Code of Ethics and Medical Assistants Creed, 9091 continuing education units (CEUs) for certied medical assistants, 1019 externships and, 10081009 American Cancer Society, 621 American Diabetes Association, 796 American Health Information Association (AHIMA), 4041 American Health Information Management Association, 183 American Medical Association, 205 American Medical Technologists (AMT), 1516 certication continuation program (CCP) for registered medical assistants, 1018 American National Standards Institute (ANSI), 75 American Society for Clinical Pathology (ASCP), 38 Americans with Disabilities Act (ADA), 112, 190 Amino acids (essential and nonessential), 782783 Amniocentesis, 636 Amphiarthrosis, 710 Amplied DNA probe test, 637638 Ampule preparation for injections, 832, 836837

AMT. See American Medical Technologists Amylopectin starch, 780 Amylose starch, 780 Amyotrophic lateral sclerosis (Lou Gehrigs disease) (ICD-9-CM code: 335.20), 443444, 451452 Analogy, 105 Analyte, 905 Analyzers chemistry, 905906 urine, 925926 Anaphylactic shock, 654 Anatomical laboratory, 852 Ancient health care, 2930 Androgens, 522 Anemia (ICD-9-CM codes: 280289), 478479, 898 Anesthetics, 407 Aneurysm (ICD-9-CM code: 442.9), 476477 Anger, 101 Anger stage of grief and loss, 101102 Angina, (ICD-9-CM code: 413.9), 469, 473, 979 Angioplasty, 472, 473, 474 Antigensantibodies, reactions, 913 Animal bite (ICD-9-CM code: 879.8), 981 Anorexia nervosa (ICD-9-CM code: 307.1), 554, 659 Anoscope, 385 ANS. See Autonomic nervous system ANSI. See American National Standards Institute Answering machines, 130131 Answering services, 130131 Antacids, 545 Antagonistic drug effect, 815816 Antecubital space, 876877 Anterior cruciate ligament tear (ICD-9-CM code: 717.83), 721 Antibiotic overuse, 775 Antibiotics, 652 antimicrobial susceptibility testing, 947949 Antibodies, 295, 786, 913 Antibodiesantigens reactions, 913914 Anticoagulants, 445, 877 Antidiuretic hormone, 522, 523, 527 Antigens, 294, 913 red blood cell antigens, 915 Antigensantibodies reactions, 913914 Antimicrobial agent, 947 Antimicrobial susceptibility testing, 947949, 951 Antiseptics, 407 Antitussive medication, 505 Anuria, 572, 581 Aortic aneurysm, 476 APACHE II (for pancreatitis), 553 Apex, 463 Apgar score, 670671 Apgar, Virginia, 671 Apical pulse, 331, 462 Apnea, 335 Aponeurosis, 709 Apothecary system, 826

Appearance, professional, 2223 Appendicitis (ICD-9-CM code: 540), 549, 983 Appointment cards, 137, 138 Appointment scheduling, 133149 appointment analysis, 137, 140 appointment cards, 137138 appointment matrix, 137141 catch-up time, 135 changes and cancellations, 140, 144 charging for cancelled visits or denying future visits, 140 cluster booking, 135 computerized, 137, 139 daily worksheet, 140, 142143 diagnostic imaging procedures, 1009, 1005 double booking, 135 established patients, 136 hospital precertication for admission, 146 informational ofce brochure, 136 at in-ofce checkout, 137 manual, 140, 141 new patients, 135 open hours, 135 by phone, 135136 physical examinations, 346 practice-based scheduling, 134 referral procedures, 144 scheduling inpatient and outpatient procedures, 145149 stream scheduling, 134135 termination of services, 147 triage and, 138139, 140, 142, 144145 wave scheduling, 135 Aqueous humor, 30, 747, 750 Archives, 184 Arm sling, 735, 740 Arrhythmias, 474 Arterioles, 465 Arteriosclerosis, 473 Arthritic knee, 694 Arthritis, rheumatoid, 718719 Arthroscope, 385 Articulation, 710 Artifacts, 486, 490491 Articial sweeteners, 799 Articial cardiac pacemaker, 486 ASCP. See American Society for Clinical Pathology Asepsis, 117, 298304 disinfection, 298, 300 medical, 303, 305 sanitization, 298300 sterilization, 300303 surgical, 303305 See also Surgical asepsis Aseptic technique. See Sterile technique; Surgical asepsis Asian u, 964 Aspiration, 503 Assault, 58 Assertive pattern of communication, 47 Assets, 261, 263 Assisted living, 700, 703

INDEX

1061

Associate practices, 34 Association of Public Health Laboratories, Laboratory Response Network (LRN) for Bioterrorism, 962 Asthma (ICD-9-CM codes: 493.90, 493.20), 505506, 655656 Astigmatism (ICD-9-CM code: 367.20), 755 Asymptomatic infected hosts, 291 Atelectasis, 513 Atherosclerosis, 444, 473476, 908, 909 ATP. See Adenosine triphosphate Atrial brillation (arrhythmias) (ICD-9-CM code: 427), 331, 477 Atrophy, 711713 Attention decit disorder (ADD) (ICD-9-CM code: 314.00), 7, 656 Attention decit hyperactivity disorder (ADHD) (ICD-9-CM code: 314.01), 7, 656 Attire, 2223 Attitude, positive, 22 Attorneys, letters to, 156, 160, 161 Audiometric testing, 770 Auditory learners, 56 Aura, 446 Auscultation, 347348 Authorization to release health care information, 63, 64 Autism (ICD-9-CM code: 299.0), 656657 Autoantigens, 295 Autoclaves, 301303 Automated analyzers, 863 Automated external debrillators (AEDs), 971 Automated routing units, 130 Automated urine dipstick reader, 863 Autonomic dysreexia, 449 Autonomic nervous system (ANS), 439 Autonomy, 88, 89 Avian u, 964 Axillary crutches, 730, 734 Axillary temperature measurement (with digital thermometer), 321323 Axons, 436, 439

Bacilli bacteria, 289, 939941 Back ofce medical assistants, 1214 See also Clinical medical assistants; Front ofce-back ofce connection; Medical assisting Bacteria, 289, 939941, 944, 945 bacilli, 939940, 942 cocci, 934, 940, 941 gram staining, 940 normal ora, 936938 spiral, 941, 943 Bacteria culture, 945947 Bacterial cystitis and urethritis (ICD-9-CM codes: 595.9, 597.80), 573, 576577 Bacterial skin infections, 417422 Bad habits, 24 Balance sheet, 261, 263 Balanoposthitis (ICD-9-CM code: 607.1), 586

Bandages, 405407 Bandage scissors (dressing scissors), 383 Banking practices, 271282 bank deposits, 271, 274 petty cash, 282 reconciling bank statements, 276278 See also Accounting Bank statement, 277278 Bargaining stage of grief and loss, 101102 Barriers, to professionalism, 24 Bartholin gland cyst (ICD-9-CM code: 616.3), 613 Bartholin glands, 601 Basal cell carcinoma (ICD-9-CM code: M809013), 428 Basal ganglia, 437, 439 Basement membrane, 412 Basic cardiac life support (BCLS), 968 Basophils, 892 Battery, 59 B blood type, 914 BCLS. See Basic cardiac life support Bee stings, 654 Behavioral disorders (ADD, ICD-9-CM code: 314.00), (ADHD, ICD-9-CM code: 314.01), 656 Bell palsy (ICD-9-CM code: 351.0), 452 Benecence, 8788 Beneciaries, 204 Benign prostatic hypertrophy (ICD-9-CM code: 600.2), 582583 Bentham, Jeremy, 89 Beriberi (ICD-9-CM code: 265.0), 801802 Bias, 90 Bile, 541 Bilingual speakers, 123124 Bilirubin, 541, 927 Billing, 248252 aging of accounts, 249250 computerized billing and account transactions, 250251 cycle billing, 251252 explaining fees and billing, 250253 monthly billing, 251 See also Credit and collections Bimanual pelvic examination, 633 Binaurals, 334 Bioemergencies. See Bioterrorism; Pandemic inuenza Bioethics, 9092 AAMA Code of Ethics and Medical Assistants Creed, 9091 controversy and, 87 dened, 87 ethical behavior in the medical ofce, 9091 See also Ethics Biofeedback, 7 Biohazardous waste biohazard spill, 297298 disposal of, 296297 Biopsy, 424, 852 with colposcopy, 638 endometrial, 638639

Biopsy equipment, 386, 387 Biosafety levels, 962963 Bioterrorism, 960965 agents of, 960961 categories of, 961 covert event, 960 dened, 960 laboratory biosafety levels, 962963 laboratory response network, 962 medical assistant response role and, 963 overt event, 960 specimen collection and submission, 963964 Birthday marketing, 164, 166 Birthday rule, 230 Birth process, 606607 See also Labor Black bile, 30 Blackwell, Elizabeth, 30, 31 Bladder cancer (ICD-9-CM code: 239.4), 578 Bladder infection, 576 Bland diet, 796 Blastocyte, 603 Bleeding, pulse points to control, 330 Bleeding time, 900 Blepharitis (ICD-9-CM code: 373.0), 755 Blood, 30 capillary blood composition, 882, 884 common tests of, 905 phlebotomists, 40 plasma, 868869, 890 platelets (thrombocytes), 868, 891893 red blood cells (erythrocytes), 868, 892894 serum, 869, 891 urine and, 927 white blood cells (leukocytes), 868869, 892, 894 whole blood, 868869, 890 See also Coagulation; Hematology; Phlebotomy Bloodborne pathogen exposure, 290, 297 Blood cells. See Hematology; Blood Blood glucose, regulation of, 781 Blood glucose testing, 906909 2-hour postprandial, 906 100-gram meal, 906 fasting blood glucose, 534, 906 glucose monitors, 908909 glucose tolerance test (GTT), 534535, 906907 monitoring tips, 909 performing, 908909 See also Endocrinology Blood groups and typing, 914, 915 Blood pressure, 336340, 465 diastolic pressure, 336, 465 evaluating, 337338 factors that affect, 337 Korotkoff sounds, 337338 measuring, 338339 modifying heart rate and blood pressure, 336

1062

INDEX

nonmodiable risk factors for hypertension, 336 pediatrics, 642, 643 postural vital signs, 339 pulse pressure, 336 strategies for accurate measurement, 340 systolic pressure, 334, 465 Blood stasis, 478 Blood tests. See Physicians ofce laboratory (POL); Hematology; Phlebotomy; Blood glucose testing Blood urea nitrogen, 595 BMI. See Body mass index Body language, 46 Body mass index (BMI), 798 Body mechanics, 8 Body of patient interview, 307 Body piercing, 22 Bodys defense mechanisms, 292295 cellular, 293295 chemical, 293 immunity, 294295 inammatory response, 294 mechanical, 292293 Body surface area, 828 Bolus, 539540 Bone disorders. See Geriatrics; Orthopedics Bone health, protein and, 786787 Bone injuries. See Orthopedics Bone joints, 710, 712 Bone marrow, 710, 891892, 898 Bones, 709, 710 See also Orthopedics Bookkeeping, 261, 263267 See also Accounting Botox, 433434 Boundaries, 50 Bowel obstruction (ICD-9-CM code: 560.9), 979 Brachial pulse, 331 Bradykinesia, 450 Bradypnea, 335 Brain, 437-440 See also Neurology Brain aneurysms, 476 Brain attack, 443444 See also Stroke Brainstem, 437 Brainstorming, 90, 188 Brain tumor (ICD-9-CM code: 239.6), 451 BRAT for recovery of diarrhea, 648 Braxton Hicks contractions, 606 BRCA-1 and BRCA-2, 621, 624 Breach of contract, 55 Breast cancer (ICD-9-CM code: 174.9), 621622 therapies for, 622 Breast examinations and breast self-examinations, 632633 Breastfeeding, 603604, 629 Breasts, 602, 603 Breathing. See Respiration Breathing emergencies, 509

Bris, 671 Bronchitis (ICD-9-CM codes: 466, 491), 505 Bronchoscopy, 511512 Brudzinski sign, 448 Bruit, 477 Buffy coat, 869 Bulimia nervosa (ICD-9-CM code: 307.51), 554555, 655 Burnout, 8, 9 Burns rst-degree (ICD-9-CM codes: 940.1949.1), 983984 Rule of Nines, 983 second-degree (ICD-9-CM codes: 940.2949.2), 983985 third-degree (ICD-9-CM codes: 940.3949.3), 985 Business communications. See Business letters; Faxed documents; Internal marketing; Mail; Transcription Business letters, 152160 to attorneys, 156, 160, 161 discontinuing care, 156, 159 envelopes, 162164 full-block, 154 indented, 154, 156 initiating written communications, 160 misspelling, 160, 162 modied-block, 154155 parts of, 152153 to patients, 155156 to physicians, 156, 160 postal abbreviations, 163164 responding to written communications, 155, 157158 simplied, 154, 157 summary of care, 160, 161 Business structures, 5859 Buttery needle. See Winged infusion sets

CAAHEP. See Commission on Accreditation of Allied Health Education Programs CAD. See Coronary artery disease Caduceus, 29 Caller ID, 124, 128 Campylobacter infection (ICD-9-CM code: 005.8), 555 Cancellations, 140, 144 Cancer ABCD system (warning signs of malignant melanoma), 428 bladder, 578580 breast, 621622 cervical, 586, 623 colorectal, 557 esophageal, 557 gastric, 557 grading, 427 leukemia, 479, 898 liver, 557558 lung, 508509 neoplasms of the skin, 427

nutrition and, 796 oral, 556557 ovarian, 623624 pancreatic, 558 prostate, 583584 renal, 578579 seven warning signs of cancer, 428 skin, 428429 staging, 622 testicular, 584, 585 uterine, 623 Wilms tumor, 579 Candida albicans, 610611 Candidiasis (yeast infection) (ICD-9-CM code: 112.3, 112.0, 112.1, 553.3), 424, 610611 Canes, 723, 727728 Capillaries, 462 Capillary puncture. See Phlebotomy Capitation, 239 Carbohydrates, 778779, 781 complex, 779780 digestion of, 781 glucose regulation, 781, 783 glycemic index, 781784 simple, 779 Cardiac cycle, 465 Cardiac muscle, 709, 711712 Cardiac panel, 912 Cardiac stress test, 486 Cardiology aging population and, 686 articial cardiac pacemaker, 486 assisting with examination, 481 cardiac stress test, 486 cardiovascular system disorders, 472479 aneurysm (ICD-9-CM code: 442.9), 476477 atrial brillation (arrhythmias) (ICD-9-CM code: 427), 477 coronary artery disease (ICD-9-CM code: 414.0), 473 deep vein thrombosis (ICD-9-CM code: 451), 478 heart failure (ICD-9-CM code: 427.5), 474476 hypertension (ICD-9-CM code: 401), 472 myocardial infarction (heart attack) (ICD-9-CM code: 427.5, 410.9), 473474, 912 shock (ICD-9-CM codes: 785.50, 785.51, 785.59), 478 varicose veins (ICD-9-CM code: 454), 477478 electrocardiography (ECG), 481486 event recorder, 491 Holter monitoring, 486491 implantable cardioverter debrillator (ICD), 486 lymphatic system disorders, 472481 acquired immune deciency syndrome (AIDS) (ICD-9-CM code: 042), 480 anemia (ICD-9-CM codes: 280289), 478479

INDEX

1063

Hodgkin disease (ICD-9-CM code: 201.90), 479480 leukemia (IDC-9-CM codes: 204.0, 204.1, 205.0, 205.1), 479 non-Hodgkin lymphoma (ICD-9-CM code: 202.8), 480 structures and functions of the cardiovascular system, 462466 circulatory system, 462463, 465466 heart, 462, 463466 See also Lymphatics Cardiomegaly, 476 Cardiomyopathy, 475 Cardiopulmonary resuscitation (CPR), 40, 968 Cardiovascular system disorders. See Cardiology Cardioversion, 477 Career advancement, 1015 Career planning, 1213 Carotid pulse, 330331 Carpal tunnel syndrome (ICD-9-CM code: 354.0), 453 Cash receipt, 253 Casting, 730731, 733734 removal of, 739740 triangular arm sling, 740 CAT. See Computerized axial tomography Catabolism, 796 Cataracts (ICD-9-CM code: 366), 694695, 758 Catch-up time, 135 Category I codes (CPT-4), 205 Category II codes (CPT-4), 205, 207 Category III codes (CPT-4), 207 Catheterization, 588589, 590593 Catheterized urine testing, 921 CBC. See Complete blood count CCMS. See Clean-catch, midstream (CCMS) urine testing (clean voided midstream testing) CCP. See Certication continuing program CD-4 lymphocytes, 480481 CDC. See Centers for Disease Control and Prevention CDHPs. See Consumer-driven health plans Celiac disease (ICD-9-CM code: 579.0), 554 Cellular defenses of the body, 293294 Cellulitis (ICD-9-CM code: 682.9), 421 Celsius, vs. Fahrenheit, 329 Centers for Disease Control and Prevention (CDC), 295296 categories of bioterrorism agents, 961 Laboratory Response Network (LRN) for Bioterrorism, 962 Centers for Medicare and Medicaid (CMS), 82, 225 Central nervous system (CNS), 437, 439441 Central nervous system disorders. See Neurology Centrifuge, 862, 863 microhematocrit, 894, 897898 Cerebellum, 437 Cerebral concussion, 448449 Cerebral contusion, 448449 Cerebral cortex, 437, 439

Cerebral palsy (CP) (ICD-9-CM code: 343.9), 658 Cerebrospinal uid, 437 Cerebrovascular accident (CVA), 444 See also Stroke Cerebrum, 437 Certicate of Provider-Performed Microscopy, 855 Certication continuing program (CCP), 1019 Certied medical assistant (CMA), 1517 continuing education units (AAMA-approved), 1018 credentialing, 1417, 1016, 10181020 recertication, 1019 Certied ofce laboratory technicians (COLT), 15 Cerumen, 751 Ceruminous glands, 751 Cervical cancer (ICD-9-CM code: 180.9), 422, 623 Cervical caps, 630 Cervical effacement, 607 Cervix, 601 CEUs. See Continuing education units Chain of infection. See Infection, chain of CHAMPUS. See Civilian Health and Medical Program of the Uniformed Services CHAMPVA. See Civilian Health and Medical Program of the Department of Veterans Affairs Channels, 45 Charge policies, for no-shows, 140 Charting, dos and donts, 315 Check register, 269 Chemical defenses of the body, 293 Chemical drug names, 810 Chemical peel, 432 Chemical sterilization, 300 Chemical thermometers, 321 Chemistry tests. See Physicians ofce laboratory (POL) Chemotherapy, 622, 796 Chest pain diseases and disorders, 974, 975976 Chest physiotherapy, 505 Chicken pox, 289 Child abuse, 6465, 67 Child Abuse Prevention and Treatment Act, 673 Children dosing calculations, 828 interviewing, 310311 nutrition and, 794798 sick child area, 115 Chlamydia (ICD-9-CM code: 079.98, 553.3), 586, 611 Chlorhexidine gluconate (Hibiclens), 407 Cholecystitis (ICD-9-CM code: 575.12), 552553, 976, 979 Cholelithiasis (ICD-9-CM code: 574.20), 552553 Cholestech LDX, 863, 910, 911 Cholesterol, 788, 789, 909912 HDL and LDL, 910 lipid panel, 910912 normal ranges for, 910

Chorionic villus sampling, 637 Choroid, 746, 750 Christmas hemophilia (type B), 901 Chronic infections, 291 Chronic lymphocytic leukemia, 479 Chronic myelogenous leukemia, 479 Chronic obstructive pulmonary disease (COPD) (ICD-9-CM code: 490), 335, 504506 Chronic renal failure (ICD-9-CM code: 585), 582 Chronological resume, 1011 Chyme, 540, 647 Circadian rhythm, 521 Circulation, motion, sensation (CMS), 986 Circulatory system, 462464, 465466 Circumcision, 570, 671 Circumduction, 726, 727 Circumoral cyanosis, 506 Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), 225 Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), 224225 Civil law, 60 Claims. See Health insurance Clarity, urine and, 925926 Classic hemophilia (Type A), 901 Clean-catch, midstream (CCMS) urine testing (clean voided midstream testing), 921, 923 Cleanliness, in the medical ofce, 117118 Cleft lip (ICD-9-CM code: 749.10), 760761 Cleft palate (ICD-9-CM code: 749.00), 761 CLIA. See Clinical Laboratory Improvement Amendment Clinical (tentative) diagnosis, 857 Clinical cabinet inventory, 195 Clinical chemistry. See Physicians ofce laboratory (POL) Clinical courses, 4 Clinical laboratory. See Physicians ofce laboratory (POL); Laboratory tests Clinical Laboratory Improvement Amendment (CLIA 1988), 852855, 905 CLIA-waived hematological tests, 894, 896898 CLIA-waived mono test, 916917 CLIA-waived pregnancy tests, 928, 933 high-complexity tests, 854 measuring prothrombin time using a CLIA-waived analyzer, 899900 moderate-complexity tests, 854 provider-performed microscopy procedures, 855 See also Laboratory tests Clinical medical assistants, 1214 interviewing patients, 308314 skills of, 1314 See also Back ofce medical assistants; Front ofce-back ofce connection; Health care team; Medical assisting Clinical serology. See Physicians ofce laboratory (POL); Hematology; Phlebotomy; Blood glucose testing

1064

INDEX

Clitoris, 601602 Cloning, 32 Closed batches, 233 Closed medical record, 184 Closed questions, 309 Clostridium botulinum, 300 Clostridium tetani, 300 Cluster booking, 135 CMA. See Certied medical assistant CMA Today, 15 CMS. See Centers for Medicare and Medicaid CMS (circulation, motion, sensation), 986 CMS-1500 form, 204, 216217, 231, 233, 234, 239, 244 submitting to a third-party payor, 235236 CNS. See Central nervous system Coagulation, 899901 diseases associated with disseminated intravascular coagulation, 900 hemophilia, 901 thrombophilic disorder, 900 tests for, 893, 899900 measuring prothrombin time using a CLIAwaived analyzer, 900 therapeutic ranges for oral anticoagulant therapy, 901 See also Hematology COBRA. See Consolidated Omnibus Budget Reconciliation Act Cocci bacteria, 289, 939, 940, 941 Coccobacilli, 939, 942 Cochlea, 748 Code cart, 970971 Code of Ethics (AAMA), 9091 Coding, 204221 CMS-1500 form, 204, 216217, 263 Current Procedural Terminology, 4th edition (CPT-4), 205213 Current Procedural Terminology, 4th edition (CPT-4) modiers, 207, 208212 Current Procedural Terminology, 5th edition (CPT-5), 205 diagnostic, 208, 212219 E codes (ICD-9-CM), 213 evaluation and management (E/M) codes, 206207 health care procedural coding system (HCPCS), 208 International Classication of Diseases, 9th editionClinical Modications (ICD-9CM), 208, 212219 medical coding specialist, 4041 multiple diagnosis codes, 214, 216 procedural, 204208 procedures and diagnosis example, 221222 superbills, 216, 219 V codes (ICD-9-CM), 213214 See also International Classication of Diseases, 9th editionClinical Modications (ICD-9CM) Cognitive domain, 97 Coinsurance, 204 Cold sores, 760

Colitis, 551 Collection agencies, 252, 257 Collection agency card, 267 Collection letters, 255256 See also Credit and collections Collection ratio, 267, 268 Collections. See Credit and collections Color, urine and, 926 Color-coded alphabetical ling system, 176177 Color deciency, 750, 751 Colorectal cancer (ICD-9-CM code: 154), 557 Colorectal health, ber and, 782 Colors, in the medical ofce, 116 Colposcopy with biopsy, 638 COLT. See Certied ofce laboratory technicians Combining forms (words), 369 Combining vowel, 369 Commission on Accreditation of Allied Health Education Programs (CAAHEP), 15, 16, 1018 Common cold (ICD-9-CM code: 460), 289, 291, 502, 503, 645646 Communicable diseases, 289 See also Infectious diseases Communication, 4352 active listening, 4647 cultural variables, 5051 cycle of, 4546 defense mechanisms, 4849 rst impressions, 45 geriatric patients and, 697 giving advice, 47 nonverbal, 46 patterns of, 4748 strategies for dealing with difcult people, 4950 verbal, 46 See also Interviewing patients; Patient education Communications. See Business letters; Faxed documents; Internal marketing; Mail; Transcription Community resources, for elder care, 703 Compensation, 48 Competency assessment, 1009 Complete blood count (CBC), 893894, 895 See also Hematology Complex carbohydrates, 779781, 782 ber, 780781, 782 glycogen, 780 starch, 780 Compliance, 98 of HIPAA, 7980 Computed tomography (CT) or computerized axial tomography (CAT), 32, 457, 10021003 Computer imaging. See Radiology and diagnostic imaging Computerized appointment systems, 137, 139 Computerized axial tomography (CAT), 32, 10021003 Computerized billing and account transactions, 250251 Computerized daily worksheet, 142

Computers, condentiality and, 198 Computer software and hardware, purchasing, 195, 198 Conception, 604, 605 Condoms, 630 Cones, 750 Condentiality, 63, 64, 88, 91 computers and, 198 employees and, 192 hearing loss and, 697 pregnancy results and, 933 release of medical records and, 185 See also Disclosure; Health Information Portability and Accountability Act (HIPAA); Protected health information (PHI) Condential Patient Information, 135 Conict resolution, 50 ethics and, 90, 91 Congestive heart failure. See Heart failure Congruence, 45 Conjunctivitis (pink eye) (ICD-9-CM codes: 372.0, 372.1, 372.30), 645, 646, 755 Consecutive ling system, 178, 179, 180 Consent, 5657, 88 Consolidated Omnibus Budget Reconciliation Act (COBRA), 230 Constipation (ICD-9-CM code: 564.0), 550, 657, 658 Constructive criticism, 189 Consumer-driven health plans (CDHPs), 224225 See also Health insurance Contagious diseases, 936 See also Infectious diseases Continuing education, 168 Continuing education units (CEUs), 21, 1019 Contraception, 630631 Contraceptive patch (Ortho-Evra), 631 Contracoup, 448 Contractions, 606607 Contracture, 727 Contraindications, 817 Contrast medium, 999, 1001 Controlled substances, 817819 Controlled Substances Act, 817 Convalescent stage of disease, 292 Conversational teaching style, 105 Coordination of benets, 230 Copayment, 204 COPD. See Chronic obstructive pulmonary disease Core temperature, 320321 Cornea, 746, 749750 Corneal abrasion, 751 Coronary artery bypass grafts, 477 Coronary artery disease (CAD) (ICD-9-CM code: 414.0), 472, 473, 910 Corporations, 34, 59 Corpus albicans, 604 Corpus luteum, 604, 605 Cortex, 437 Corticosteroids, 505

INDEX

1065

Cortisol, 522 Coryza. See Upper respiratory infection Costochondritis (ICD-9-CM code: 733.6), 976 Cost ratio, 260262 Court cases, release of medical records and, 185 Courteousness, 20 Cover letters, 1010, 1011, 1012 Covert event, 960 CP. See Cerebral palsy CPR. See Cardiopulmonary resuscitation CPT-4. See Current Procedural Terminology, 4th edition Crackles, 475 Cranial nerves, 437, 440 Cranium, 437, 439 Crash cart, 970971 Creams, 407 Creatinine, 582, 594 Credentialing, 1417, 1016, 10181021 certied medical assistant (CMA), 1417, 1016, 10181021 examination content, 1018 nursing credentials, 38 preparing for the examination, 10191020 recertication, 1019 registered medical assistant (RMA), 1416, 1016, 10181020 See also Accreditation Credit and collections, 252257 collection agencies, 257 collection letter examples, 255 collection strategies, 253254 creating a collection letter, 256 extending credit, 253 past-due message on a bill, 254 policies and procedures, 252255 telephone collections, 254, 257 See also Billing Cremasters, 570 Cretinism, 530 Creutzfeldt-Jakob disease, 941 Criminal False Claims Act, 84 Criminal law, 5960 Crohn disease (ICD-9-CM code: 555.9), 550, 979 Cross-referencing medical records, 181182 Cross-training, 194 Croup (ICD-9-CM code: 646.4), 646647 Crowning, 607 Crutches, 727, 730, 736737 Cryosurgery (cryotherapy), 397, 634635, 740 CT or CAT. See Computed tomography (CT) or computerized axial tomography (CAT) CT scanning. See Computed tomography (CT) scanning Cultural variables, communication and, 5051 Culture and sensitivity test, 947 Cumulative effect of drugs, 814815 Current Procedural Terminology, 4th edition (CPT-4), 205213, 216 Category I, 205 Category II, 207 Category III, 207

CPT-5, 205 modiers, 207, 209212 Current Procedural Terminology, 5th edition (CPT-5), 205 Cycle billing, 251252 Cystoscopy, 594

D&C. See Dilatation and curettage Daily worksheets, 140, 142143 Dairy, diarrhea and, 648 Damages, 57 Database, medical history, 313 Daviss Drug Guide for Nurses, 820 Day sheet, 263265 D-dimer, 900 DDST. See Denver Developmental Screening Tool DEA. See Drug Enforcement Agency Debrieng, 970 Declining stage of disease, 292 Deductibles, 225 Deep vein thrombosis (ICD-9-CM code: 451), 478 Defamation, 59 Defense mechanisms, 4849 Debrillator, 970 Deglutition, 539 Dehydration, 792 IVs and, 841 De-identied information, 75 Delegating, 1213 Delirium, 691 Dementia Alzheimer disease, 690692 communicating with patients with, 692 conditions confused with, 691 See also Geriatrics Dendrites, 436, 439 Denial, 48 stage of grief and loss, 101102 Denial notication form, 242 Denver Developmental Screening Tool (DDST), 672 Deontological philosophies, 89 Department of Defense, Laboratory Response Network (LRN) for Bioterrorism, 962 Dependability, 2021 Depo-Provera, 631 Depositions, 5758 Deposit slip, 279 Depression, confused with dementia, 691 Dermabrasion, 421, 432 Dermal puncture. See Phlebotomy Dermaplaning, 432 Dermatology, 411434 allergy skin testing, 429431 assisting with examination, 428429 bacterial skin infections acne (ICD-9-CM code: 706.1), 417, 420421 cellulitis (ICD-9-CM code: 682.9), 421

folliculitis (ICD-9-CM code: 704.8), 421422 impetigo (ICD-9-CM code: 684), 416417, 420 culture and sensitivity testing, 432 functions of the skin, 412414 fungal skin disorders candidiasis (yeast infection) (ICD-9-CM code: 112.3, 112.0, 112.1, 553.3), 424, 610 tinea (ICD-9-CM code: 110.9, 110.0, 110.1, 110.4, 110.3), 424 geriatrics and, 685686 hypersensitivity and inammatory reactions eczema (ICD-9-CM code 690, 691, 692), 425426 psoriasis (ICD-9-CM code: 696), 426 systemic lupus erythematosus (ICD-9-CM code: 710.0), 426427 image enhancement procedures, 432433 layers and structure of the skin (integumentary system), 412, 413 malignant melanoma: ABCD system, 428 medical terminology related to the integumentary system, 414417 neoplasms basal cell carcinoma (ICD-9-CM code: M809013), 428 malignant melanoma, 428 squamous cell carcinoma (ICD-9-CM code: M807013), 428 parasitic infestations pediculosis (ICD-9-CM code: 132), 425 scabies (ICD-9-CM code: 133.0), 425 seven warning signs of cancer, 428 skin lesions, 418420 viral skin infections herpes viruses (ICD-9-CM code: 054.10 (genital herpes simplex), 054.9 (oral herpes simplex)), 422423 herpes zoster (shingles) (ICD-9-CM code: 053.9), 423 warts (ICD-9-CM code: 078.10 (for common warts), 078.11 (genital)), 422 Dermatomes, 423, 439, 441 Diabetes, 906 blood glucose testing, 906909 gestational (ICD-9-CM code: 648.80), 529530 insulin pump, 910 nutrition and, 796 type I (ICD-9-CM code: 250.90), 528 type II (ICD-9-CM code: 250.90), 528529 See also Blood glucose testing Diabetic emergencies (ICD-9-CM code: 250.90), 978 Diabetic ketoacidosis, 528 Diabetic retinopathy (ICD-9-CM code: 362.01), 755, 756 Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), 213, 656 Diagnostic coding, 208, 212216 See also Coding Diagnostic imaging. See Radiology and diagnostic imaging

1066

INDEX

Dialysis, 581 Diaphoresis, 473 Diaphragms, 630 Diarrhea (ICD-9-CM code: 787.91), 647648 Diarthosis, 710 Diastole, 462 Diastolic blood pressure, 336, 465 Dictation tapes, 168 Digestion, 539541 See also Gastroenterology Digital thermometers, 321, 323, 324326 Dignity, 9192 Dilatation and curettage (D&C), 635 Dilating instruments, 384 Dilation, 607 Diplobacilli, 939942 Diplomactic, 21 Directional terms, 377, 379 Directive statement, 309 Disabilities, 112 Disaccharides, 779, 780 Disciplinary actions, 194 Disclosure, 72 accounting of, 79 dos and donts, 7576 Disclosure rules, exceptions to, 63 Discontinuance of care. See Termination of services Diseases and disorders dened, 289 stages of, 292 See also Diseases under each medical specialty; Infectious diseases; International Classication of Diseases, 9th editionClinical Modications Disinfecting thermometers, 328 Disinfection, 300, 306 Disk-diffusion method, 947948 Dislocation (ICD-9-CM codes: 830839), 717 Displacement, 48 Dissecting aneurysm, 477 Dissection, 30 Disseminated intravascular coagulation, 900 Distribution, drugs and, 808 Distributive justice, 88 Diurnal rhythm, 321 Diverticular disease (ICD-9-CM codes: 562.10, 562.12, 562.11, 562.13), 549, 979 DNA, viruses and, 289, 941 Documentation, 62, 314317 charting dos and donts, 315 in the lab, 855 phone calls, 130131 source-oriented medical record (SOMR), 314 Dopamine, 450 Dorsalis pedis pulse, 334 Dorsal recumbent position, 355, 357 Dosage calculations, 826828 apothecary and household system, 826 dose on hand, 827 fractional equation, 827 infant and child dosages, 828 metric system, 826827

ratio and proportion, 827 using conversions, 828 See also Medication; Medication administration; Pharmacology Dose on hand calculation, 827 Dosimeter, 1005 Double booking, 135 Down syndrome (trisomy 21) (ICD-9-CM code: 758.0), 657 Dressings, 403, 405, 407 Drug abuse. See Substance abuse Drug classes, 811813 See also Pharmacology Drug Enforcement Agency (DEA), 817 Drugs. See Pharmacology; Medication administration; Dosage calculation; Medication Dry heat, 738, 740 DSM-IV. See Diagnostic and Statistical Manual of Mental Disorders, 4th edition Durable power of attorney, 63, 6567 Dysmenorrhea (ICD-9-CM code: 625.3), 614 Dysphagia, 444 Dysphasia, 444 Dyspnea, 506 Dysuria, 920

Ear disorders and diseases. See Ophthalmology and otolaryngology Eardrops, 774, 775 Ear irrigation, 772773 Early and periodic screening, diagnostic, and treatment (EPSDT) services, 226 Ears, 747748, 751 external ear, 747, 749, 751 inner ear, 748, 749, 751, 755 middle ear, 747, 749, 751, 753, 755 See also Ophthalmology and otolaryngology Eating disorders (anorexia nervosa) (ICD-9-CM code: 307.1) (bulimia nervosa) (ICD-9-CM code: 307.51), 655 ECG. See Electrocardiography Eclampsia (ICD-9-CM code: 642.60), 621 E codes (ICD-9-CM), 213 E. coli infection (ICD-9-CM code: 041.4), 555 Ectopic pregnancy (ICD-9-CM code: 633.9), 618 Eczema (dermatitis) (ICD-9-CM codes: 690, 691, 692), 426, 658, 660 ED. See Erectile dysfunction EDD. See Expected date of delivery EDI. See Electronic data interchange EDR. See Electrodermal response Educational resources, 118 EEG. See Electroencephalography EHR. See Electronic health record Elder abuse, 67 Elderly, interviewing, 313 Electrocardiography (ECG), 481486, 487490 12-lead, 492 artifacts, 486, 490491 preparing the machine, 481482

preparing the patient, 483484 rhythm interpretation, 484486, 487490 Electrocautery, 398 Electrodermal response (EDR), 7 Electroencephalography (EEG), 7, 455456 Electrolyte panel, 911 Electromyography (EMG), 7 Electronic claim submission, 233 Electronic data interchange (EDI), 75 Electronic health record (EHR), 182183, 314315 barriers to EHR conversion, 183 conversion methods to, 184 for cost reduction, 183 for increased access, 182183 reduced medical errors and, 183 Electronic medical record. See Electronic health record Electrosurgery, 398 Electrosurgical unit, 398 ELISA. See Enzyme linked immunosorbent assay E-mail guidelines, 166 Emancipated minors, 55 medical records and, 185 Embolic stroke, 444 Embolization, 637 E/M codes. See Evaluation and management (E/M) codes Emergencies, 128129 See also Bioterrorism; Ofce emergencies; Pandemic inuenza Emergency medical services (EMS), 129, 968 Emergency medical technicians (EMTs), 3940 Emergency preparedness, 960 Emesis (vomiting), 547 EMG. See Electromyography Emotional abuse, 65, 67 Emotional response to illness and disability, 101 Empathy, 101 Emphysema (ICD-9-CM code: 492.8), 506507 Employee evaluations, 192195 Employer insurance programs, 219220, 222 EMR. See Electronic health record EMS. See Emergency medical services EMTs. See Emergency medical technicians Emulsication, 787 Encephalitis (ICD-9-CM code: 323.9), 447 Endocardium, 462 Endocrinology, 520536 aging and, 687 assisting with examination, 532, 533534 diabetes, type I (ICD-9-CM code: 250.90), 528 diabetes, type II (ICD-9-CM code: 250.90), 528529 fasting blood glucose, 534 foot and skin care, 534535 gestational diabetes, 529530 glucometer testing, 535 glucose tolerance test, 534535 glycosylated hemoglobin, 535 hyperthyroidism (ICD-9-CM code: 242.0), 531532

INDEX

1067

hypoglycemia vs. hyperglycemia, 530 hypothyroidism (ICD-9-CM codes: 243, 244.9), 530531 medical terminology, 524 radioactive iodine uptake, 535536 structures and functions of the endocrine system, 520524 adrenal glands, 521522 negative feedback system, 522 ovaries, 522 pancreas, 522 pineal gland, 521 pituitary gland, 521522 testes, 522 thymus gland, 522 thyroid gland, 522 thyroid scan, 535 thyroid tests, 535 urine glucose test, 535 See also Blood glucose testing End-of-life issues, 703704 See also Geriatrics Endometrial biopsy, 638639 Endometriosis (ICD-9-CM code: 617.9), 615616 Endometrium, 601, 603, 604 Endoscopy, 398 End-stage renal disease (ESRD), 580, 582 Enunciation, 122 Envelopes, 162163 Environment, 46 Environmental contaminants, pregnancy and, 628 Environmental injuries, 981985 See also Ofce emergencies Environment sanitization, 298, 300 Enzyme linked immunosorbent assay (ELISA), 480, 913914, 916 EOB. See Explanation of benets Eosinophils, 892, 893 Epicardium, 462 Epicondylitis, medial and lateral (ICD-9-CM codes: 726.32, 726.31), 721 Epidemic, vs. pandemic, 964 Epididymitis (ICD-9-CM code: 604.90), 584 Epilepsy (ICD-9-CM code: 345.90), 446447 See also Seizures Epinephrine (adrenalin), 522 EpiPen, 654, 838, 841 Episiotomy, 607 Epistaxis (nosebleed) (ICD-9-CM code: 784.7), 980981 Epithelial tumors, 623 EPSDT. See Early and periodic screening, diagnostic, and treatment (EPSDT) services Epstein-Barr virus (ICD-9-CM code: 075), 479, 508 Equilibrium, 751 Equipment, for physical examinations, 352 Equipment maintenance, laboratory, 863, 865 Equipment sanitization, 298, 300 Erectile dysfunction (ED) (ICD-9-CM codes: 607.84, 302.72), 587588, 687

Ergonomics, 113115 Erythema, 413 Erythrocytes. See Red blood cells (RBC) Erythrocyte sedimentation rate, 893 ESRD. See End-stage renal disease Essential fatty acids, 786787 Established patients, 136137 Estrogen, 602, 603 Ether, 30 Ethical decision making, 8990 Ethical dilemma, 8990 Ethical philosophies, 8889 deontological philosophies, 89 philosophical divide, 89 teleological philosophies, 89 utilitarianism, 89 Ethical reasoning process, 90 Ethics autonomy, 88 benecence, 8788 consent and, 88 dened, 86 deliberate unethical behavior, 84 distributive justice, 88 delity, 88 law and, 8687 morals and, 86 nonmalecence, 87 paternalism, 88 veracity, 88 See also Bioethics; Ethical philosophies Ethics committee, 90 Ethmoid sinuses, 748 Evacuated tubes, 869870 Evaluation and management (E/M) codes, 206207 Evaluations, employee, 192194 Event recorder, 491492 Eversion, 726 Examination room preparation, 348, 352 Examinations, 5, 78 See also Test-taking strategies Exercise-induced asthma, 655 Exhalation, 498 Exophthalmos (ICD-9-CM code: 376.30), 532, 756 Expected date of delivery (EDD), 626 Expectorant, 505 Expert witness, 57 Expiration, 334 Explanation of benets (EOB), 239242 Excretion, drugs and, 808 Extended care. See Geriatrics Extension, 726 External ear, 747, 757 External marketing, 200 External respiration, 334 Externship (internship or practicum), 10081010 benets of, 1008 placement, 10081010 Eye disorders and diseases. See Ophthalmology and otolaryngology Eyedrops, instilling, 762, 768769

Eye injury (ICD-9-CM code: 930.9), 986 Eyes, 746747, 748, 749750, 757 choroid, 746, 750 humors (aqueous and vitreous), 747, 750, 751 other structures, 747, 751 retina, 746747, 750, 751 sclera and cornea, 746, 749750 See also Ophthalmology and otolaryngology Eyes, ears, mouth, nose, and throat. See Ophthalmology and otolaryngology

Fad diets, 797 Fahrenheit, vs. Celsius, 329 Failed appointments, 140 See also No-show patients Failure to thrive (FTT) (ICD-9-CM code: 783.41), 657658, 674 Fainting, venipuncture or capillary punctures and, 886, 977 See also Syncope Faithfulness, 88 Fallopian tubes, 601, 603 Fallopius, Gabriele, 368 False imprisonment, 59 False reassurance, 311 Family history (FH), 313 Farsightedness, 757 Fascia, 709 Fasciculations, 452 Fasteners, 175 Fasting, for tests, 859 Fasting blood sugar (FBS) test, 534, 906 Father of Bacteriology (Louis Pasteur), 30 Father of Medicine (Hippocrates), 29 Father of Modern Anatomy (Andreas Vesalius), 30 Father of Sterile Surgery ( Joseph Lister), 30 Fats, 786788, 789 cholesterol, 788, 789 digestion of, 788 fatty acids, 786787 food sources of, 787 phospholipids, 787788 triglycerides, 787 Fatty acids, 786787 Faxed documents, 160, 162 FBS. See Fasting blood sugar test FDA. See Food and Drug Administration Fecal occult blood test, 559560 Fecal occult blood test (stool card), 559560 Federal Bureau of Investigation, Laboratory Response Network (LRN) for Bioterrorism, 962 Federal laboratories, bioterrorism and, 962963 Federally qualied health-center (FQHC), 226 Federal poverty level, 226 Feedback, 45 Fee-for-service (FFS), 222, 223, 224, 228, 238, 239 See also Indemnity plans Fees. See Billing; Credit and collections Felonies, 56 Female condoms, 630 Female reproductive cycle. See Obstetrics and gynecology

1068

INDEX

Femoral pulse, 334 Ferritin, 785 Fetal ultrasound, 637 Fetus, 605, 606 See also Obstetrics and gynecology Fever, 321, 322 See also Temperature FFS. See Fee-for-service FH. See Family history Fiber, 780781, 782 Fiberglass casts, 739 Fibrillations, 452 Fibrin degradation product, 900 Fibrinogen test, 900 Fibrinolysis, 899 Fibrocystic breast disease (ICD-9-CM code: 610.1), 625 Fibromyalgia (ICD-9-CM code: 729.1), 719, 720 Fidelity, 88 Fight or ight response (sympathetic nervous system), 439 File folders, 175176, 180181 File storage, 174175 Filing systems, 176180 Fimbriae, 601 Financial accounting, 260 Financial letters to patients, 155 Financial management, 260 See also Accounting; Banking Findings, in physical examinations, 349352 Fine motor skills, 643 Fingernail clubbing, 506 First-degree burns (ICD-9-CM codes: 940.1949.1), 983984 First impressions, 45 First morning urine testing, 921 First trimester, 605606 Fixed costs, 260, 261 Flexibility, 21 Flexible sigmoidoscopy, 560, 561562 Flexible spending accounts (FSAs), 225 Flexion, 726 Floaters, 1213 Floppy baby syndrome, 658 Flora, normal, 289, 936938 Fluoroscopy, 9991000 Follicle-stimulating hormone, 522 Follicle-stimulating hormone (FSH), 604, 605 Follicular phase of menstruation, 604, 605 Folliculitis (ICD-9-CM code: 704.8), 421422 Fomites, 291 Food allergies at school, 654 Food and Drug Administration (FDA), 819 Food poisoning (ICD-9-CM code: 005.9), 555 Food pyramid, for children (MyPyramid), 680 Foods drug interactions with, 816 gout and, 718 See also Nutrition Foot care, 531, 533534 Forceps, 384 Forearm or Lofstrand crutches, 730, 736

Forebrain, 437 Foreign antigens, 295 Foreskin (prepuce), 570, 671 Fourth-degree burns, 985 Fowler and semi-Fowler position, 356, 360 FQHC. See Federally qualied health-center Fractional equation dosage calculation, 827 Fractures (ICD-9-CM codes: 800829), 714716, 985986 Fraud and abuse, 59 claims and, 241, 246 Frontal sinuses, 748 Front ofce medical assistants, 1213 See also Administrative medical assistants; Medical assisting Frostbite (ICD-9-CM code: 991.3), 982 Fructose, 779 FSAs. See Flexible spending accounts FSH. See Follicle-stimulating hormone FTT. See Failure to thrive Full-block business letters, 154 Functional resume, 10111013 Fundus, 601 Fungal culture, 945 Fungal skin disorders, 423424 Fungus, 289, 942, 944

Gait, 710 Gait belt, 727, 731732 Galactose, 779 Galen, Claudius, 30 Gallbladder, 539, 541 Gallbladder ultrasound, 564 Gardener-Wells tongs and traction, 449 Gastric bypass surgery, 799 Gastritis (ICD-9-CM code: 535.5), 546548 Gastroenteritis (ICD-9-CM code: 558.9), 979 Gastroenterology, 537565 aging population and, 690691 alimentary canal, 538, 539541 assisting with examinations, 558 cancers of the GI system, 556558 colorectal cancer (ICD-9-CM code: 154), 557 esophageal cancer (ICD-9-CM code: 150.9), 557 gastric cancer (ICD-9-CM code: 151.9), 557 liver cancer (ICD-9-CM code: 155.0), 557558 oral cancer (ICD-9-CM code: 145.9), 556 pancreatic cancer (ICD-9-CM code: 157.9), 558 cleansing enema, 560, 561 diarrhea causing disorders, 555556 Campylobacter infection (ICD-9-CM code: 005.8), 555 E. coli infection (ICD-9-CM code: 041.4), 555 food poisoning (ICD-9-CM code: 005.9), 555 Salmonella infection (ICD-9-CM code: 003.0), 556

disorders of the accessory organs of digestion, 551553 acute pancreatitis (ICD-9-CM code: 577.0), 553 cholelithiasis and cholecystitis (ICD-9-CM codes: 574.20, 575.12), 552553 viral hepatitis (ICD-9-CM codes: 070.1, 070.30, 070.51, 070.54, 070.52, 070.53), 551552 fecal occult blood test, 559, 560 exible sigmoidoscopy, 560, 561562 gallbladder, 539, 541 gallbladder ultrasound, 564 Helicobacter pylori, 561 interview questions, 558 liver, 539, 541 liver function test, 561 lower GI tract disorders, 548551 abdominal hernia, (ICD-9-CM code: 553.9), 548549 appendicitis (ICD-9-CM code: 540), 549 diverticular disease (ICD-9-CM codes: 562.10, 562.12, 562.11, 562.13), 549550 hemorrhoids (ICD-9-CM code: 455), 550 inammatory bowel disease (ICD-9-CM codes: 555.9, 556.9, 564.1), 550551 lower GI x-ray, 563564 medical terminology, 542544 nutrition disorders, 553555 anorexia nervosa (ICD-9-CM code: 307.1), 554 bulimia (ICD-9-CM code: 307.51), 554555 celiac disease (ICD-9-CM code: 579.0), 554 pancreas, 539, 541542 statin drugs and the liver, 564 stool specimen collection, 559 structures and functions of the gastrointestinal system, 538542 upper GI tract disorders, 544548 gastritis (ICD-9-CM code: 535.5), 546548 gastroesophageal reux disease (GERD) (ICD-9-CM code: 530.81), 545, 686, 976 hiatal hernia (ICD-9-CM code: 553.3), 545 peptic ulcer disease (ICD-9-CM codes: 531.90, 530.2), 545546 pyloric stenosis (ICD-9-CM codes: 537.0, 750.5), 548 upper GI x-ray, 563 Gastroesophageal reux disease (GERD) (ICD-9-CM code: 530.81), 545, 686, 976 Gastrointestinal (GI) system. See Gastroenterology Gauze pads, 403 Gender, blood pressure and, 336 Generalized seizure (ICD-9-CM code: 345.90), 977 Generic drug names, 810 Genetics, blood pressure and, 336

INDEX

1069

Genital herpes (ICD-9-CM codes: 054.10, 553.3), 586, 611 Genital syphilis (ICD-9-CM code: 091.0), 586 Genital warts (ICD-9-CM code: 553.3), 612 Genome, 32 GERD. See Gastroesophageal reux disease Geriatrics, 683706 ageism, 684685 aging myths, 685 the aging population, 684 bone disorders, 692695 osteoarthritis (ICD-9-CM code: 715.90), 693694 osteoporosis (ICD-9-CM code: 733.0), 698 communication strategies, 697 dementia, 690 Alzheimer disease (ICD-9-CM code: 331.0), 690692, 705 conditions confused with, 691 drugs and, 823 extended care assisted living, 697, 700, 703 community resources for elder care, 703 end-of-life issues, 700, 704 extended care campus, 703 hospice care, 704 in-home and home health care, 700 nursing center (nursing home; skilled nursing facility), 703 medical terminology, 688690 nutrition and, 686 pain management, 700 palliative care, 704 physiological changes of aging, 685688 cardiovascular system, 686 digestive system, 686687 endocrine system, 687 integumentary system, 685686 musculoskeletal system, 687688 nervous system, 686 reproductive system, 687 respiratory system, 686 sensory system, 688 urinary system, 687 preventing medication problems, 700 safety promotion, 692, 697698 sensory disorders cataracts (ICD-9-CM code: 366), 694695 glaucoma (ICD-9-CM codes: 365.10, 365.2), 695696 macular degeneration (ICD-9-CM code: 362.50), 696 presbycusis (ICD-9-CM code: 388.01), 696697 presbyopia (ICD-9-CM code: 367.4), 694 Germ cell tumors, 623624 Gestation, 605607 See also Obstetrics and gynecology Gestational diabetes (ICD-9-CM code: 648.8), 618619 GFR. See Glomerular ltration rate

GI system. See Gastroenterology Glass thermometer, 321 Glaucoma (ICD-9-CM codes: 365, 365.10, 365.2), 695696, 762 Glia, 437 Glomerular ltration rate (GFR), 582 Glomerulonephritis (ICD-9-CM codes: 580, 582), 503, 577578 Gloving, 394 venipuncture and, 874, 875 Glucagon, 522, 530, 536 Glucometer, 98, 534, 535 Glucose, 539, 780 urine and, 535, 926927 Glucose monitors, 907908 Glucose testing. See Blood glucose testing Glucose tolerance test (GTT), 540541, 906908 Glucosuria, 927 Glycemic index, 784785 Glycogen, 522, 541, 542, 780 Glycosylated hemoglobin, 535 GnRH. See Gonadotropin-releasing hormone Goiter, 531 Golfers elbow, 721 Gonadotropin-releasing hormone (GnRH), 604, 616 Gonads, 520 Gonad shields, 997, 998 Goniometer, 725, 726, 727, 731 Goniometry, 725 Gonorrhea (ICD-9-CM code: 098.0, 553.3), 586587, 612 Good Samaritan law, 57 Gossip, 24, 190 Gout (ICD-9-CM code: 274.0), 718 Gram staining, 939, 940 Grasping-clamping instruments, 382, 384 Graves disease (hyperthyroidism), 531 Gravidity, 625 Gray matter, 436437, 439 Greek, 368 Grief stages, 101102 Grooved director probe, 386 Gross motor skills, 672 Gross negligence, 58 Group model HMOs, 223 Group practice, 34 Groups, teaching and, 105 Growth hormone, 522 GTT. See Glucose tolerance test Guardianship, records release and, 185 Gustation, 751

HAART. See Highly active antiretroviral therapies Hair, 22, 412 Halo traction, 449 Hand sanitization, 298, 300 Hardware, purchasing, 195, 198 HAV. See Hepatitis A Hay fever, 502

HBV. See Hepatitis B HCFA. See Health Care Financing Administration HCG. See Human chorionic gonadotropin HCPCS. See Health care procedural coding system HCT. See Hematocrit HCV. See Hepatitis C HDHPs. See High-deductible health policies HDLs. See High-density lipoproteins HDV. See Hepatitis D Head circumference, 667, 668 Head injury (ICD-9-CM codes: 852, 852.4, 852.2), 978 Health Care Financing Administration (HCFA), 854 Health care practices, 72 Health care procedural coding system (HCPCS), 208 Health care settings, 33 Health care specialties, 14 Health care team administrative specialists, 4041 medical specialties, 3536 medical technologists (MTs), 3839 nonmedical health care providers, 37 nurses, 3738 physician assistants, 38 physicians, 3437 prehospital care specialists, 39 registered dieticians (RDs), 39 technicians, 40 therapists, 39 Web sites for, 42 See also Medical assisting Health Information Portability and Accountability Act (HIPAA), 7184 compliance of, 7980 creating medical records and, 179 documents, 8082 faxed referrals, 147 insurance claims and, 231 in the mail, 77 medical records, 167, 169 new patients and, 135 noncompliance of, 82, 84 Notice of Privacy Practices (NPP), 7982 ofce communications and, 152, 170171 ofce manager as compliance ofcer, 189 protected health information (PHI) outside the ofce, 77 release of medical records, 8283, 185 telephones and, 122, 124 Title I: Insurance Reform, 74 Title II: Administrative Simplication, 7475, 7779 transcription, 170 See also Protected health information (PHI) Health insurance, 204, 219245 choosing, 224 claims, 231238, 240 claim form, 218 Health Insurance Portability and Accountability Act (HIPAA) and, 231

1070

INDEX

life cycle of a claim, 231232 submitting a claim, 233234 Consolidated Omnibus Budget Reconciliation Act (COBRA), 230 consumer-driven plans, 224225 exible spending accounts (FSAs), 225 health reimbursement accounts (HRAs), 225 health savings accounts (HSAs), 225 denitions of, 204 employer programs, 219220 explanation of benets (EOB), 239242 fraud and abuse, 241, 247 government programs, 225228 Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), 228 Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), 228 Medicaid, 226, 228 Medicare, 225226 managed care, 222223 health maintenance organizations (HMOs), 222223 independent practice associations (IPAs), 222 preferred provider organizations (PPOs), 222 multiple policies, 230 payment denials and appeals process, 241245 payment processing, 239241 payment systems, 238 capitation, 238 fee-for-service, 238, 239 resource-based relative value scale (RBRVS), 239 usual, customary, and reasonable, 239 self-pay patients, 231 traditional, 223 workers compensation, 228230 Health maintenance organizations (HMOs), 34, 222223 Health reimbursement accounts (HRAs), 225 Health savings accounts (HSAs), 222, 246 Hearing loss, 696697 condentiality and, 697 See also Ophthalmology and Otolaryngology Hearing screening, 668 Heart, 462, 463465 cardiac muscle, 709, 711712 See also Cardiology Heart attack (myocardial infarction) (ICD-9CM codes: 427.5, 410.9), 473474, 474, 975 Heart failure (ICD-9-CM code: 427.5), 474476 Heart rate. See Pulse Heat exhaustion (ICD-9-CM code: 992.5), 982 Heat stroke (ICD-9-CM code: 992.0), 982 Height measurement, 362363 pediatrics, 662663 Helicobacter pylori, 561 Hematocrit (HCT), 893, 894

See also Hematology; Hemoglobin and hematocrit tests Hematocrit tests. See Hematology; Hemoglobin and hematocrit tests Hematology, 890901 abbreviations, 898 CLIA-waived hematological tests, 894, 899901 measuring hematocrit using a microhematocrit centrifuge, 894, 897 measuring hemoglobin using the HemoCue analyzer, 894, 896 diseases anemia, 898 leukemia, 898 leukocytosis, 899 leukopenia, 899 polycythemia, 898 thrombocytopenia, 899 plasma, 890 platelets (thrombocytes), 892893 red blood cells (RBCs) (erythrocytes), 891, 892 serum, 891 tests for, 893898 blood cell indices, 894 complete blood count (CBC), 893894, 895 erythrocyte sedimentation rate (ESR), 898 hemoglobin (Hgb) and hematocrit (HCT), 893 reporting critical values, 894 reticulocyte count, 898 white blood cells (WBCs) (leukocytes), 891, 892, 893 whole blood, 890 See also Coagulation; Phlebotomy; Physicians ofce laboratory (POL) Hematoma, 875, 978 Hematopoiesis, 710, 891 Hematuria, 927 Hemiplegia, 719 Hemoconcentration, 875 HemoCue analyzer, 894, 896 Hemodialysis, 581 Hemoglobin (Hgb), 785, 893, 894 Hemoglobin and hematocrit tests, 677, 893, 893894 Hemoglobin tests. See Hematology Hemophilia, 901 Hemoptysis, 507, 508 Hemorrhage, 978, 980 Hemorrhagic stroke, 444445 Hemorrhoids (ICD-9-CM code: 455), 550, 559 Hemostats, 382, 385, 400 Heparin, 899, 900 Hepatic panel, 912 Hepatitis, 289 Hepatitis A (ICD-9-CM code: 070.1), 551552 Hepatitis B (ICD-9-CM code: 070.30), 293, 552 Hepatitis C (ICD-9-CM codes: 070.51, 070.54), 291, 552 Hepatitis D (ICD-9-CM code: 070.52), 552 Hepatitis E (ICD-9-CM code: 070.53), 552

Hernias abdominal, 548549 hiatal, 545 Herniated disk (ICD-9-CM code: 722), 721 Herpes viruses (ICD-9-CM code: 054.10 (genital herpes simplex), 054.9 (oral herpes simplex)), 422, 423, 760 Herpes zoster (singles) (ICD-9-CM code: 053.9), 423 HEV. See Hepatitis E Hgb. See Hemoglobin HHS. See U.S. Department of Health and Human Services Hiatal hernia (ICD-9-CM code: 553.3), 545 High blood pressure. See Hypertension High-complexity tests, 854 High-deductible health policies (HDHPs), 224, 225 High-density lipoproteins (HDLs), 708, 910 Highly active antiretroviral therapies (HAART), 481 Hindbrain, 441 HIPAA. See Health Information Portability and Accountability Act Hippocrates (Father of Medicine), 29 Hippocratic oath, 29 Histamine, 294 Histologists, 30 Historical background, 2932 ancient health care, 2930 current medicine, 3132 early development of medicine, 3031 future of medicine, 32 HIV. See Human immunodeciency virus HMOs. See Health maintenance organizations Hodgkin disease (ICD-9-CM code: 201.90), 479480 Holiday marketing, 164, 166 Holter monitoring, 486 Home health care, 33, 700 Homeostasis, 320, 436 Home safety, geriatric patients and, 692, 698 Hong Kong u, 964 Hormone replacement therapy (HRT), 607 Hormones, 520529, 601 aging and, 687 estrogen, 614 menstruation and pregnancy, 604605 progesterone, 605 See also Endocrinology Hormone therapy (for cancer), 622 Hospice care, 704 Hospital clinical laboratories, 963 Hospital precertication for admission, 149 Hospital privileges, 33 Hospitals, 33 Household system for dosage calculations, 826 HPV. See Human papillomavirus HRAs. See Health reimbursement accounts HRT. See Hormone replacement therapy HSAs. See Health savings accounts Human chorionic gonadotropin (HCG), 604, 636, 928

INDEX

1071

Human immunodeciency virus (HIV), 289290, 297, 480481, 611612 ELISA test for, 913914, 916 nutrition and, 795 testing for, 915916 Human papillomavirus (HPV) (ICD-9-CM code: 078.1), 424, 586587, 623 Human resources department, 1010 Human resources director, 189190 Humors (black bile, yellow bile, phlegm, blood), 30 Hydrocollators, 736 Hydronephrosis (ICD-9-CM code: 591), 579580 Hygeia (Greek goddess of health), 368 Hygiene daily, 22 origin of word, 368 Hypercapnia, 505 Hyperextension, 712 Hyperglycemia, 528 vs. hypoglycemia, 530 Hyperlipidemia (ICD-9-CM code: 414), 799, 913 Hyperopia (farsightedness) (ICD-9-CM code: 367.0), 757 Hypersensitivity and inammatory reactions, 294, 417, 425 Hypertension (ICD-9-CM code: 401), 336, 472, 798799 Hypertensive retinopathy (ICD-9-CM code: 362.11), 755 Hyperthyroidism, 913 Hypertonic solutions (IVs), 841 Hypertrophy, 531 Hyperventilation, 335 Hypoglycemia, 913 vs. hyperglycemia, 530 Hypotension, 339 Hypothermia (ICD-9-CM code: 991.6), 982 Hypothyroidism (ICD-9-CM codes: 243, 244.9), 530531, 913 Hypoxia, 505 Hypoxic drive, 505 Hypotonic solutions (IVs), 841 Hysterectomy, 636 alternatives to, 637

ICD-9-CM. See International Classication of Diseases, 9th editionClinical Modications Idiosyncratic effect of drugs, 814 IIHI. See Individually identiable health information I language, 4950 Image enhancement procedures, 432433 Botox, 433 chemical peel, 432433 dermabrasion and dermaplaning, 432 laser resurfacing, 433 microdermabrasion, 43 Immunity, 294295 active articial, 295 active natural, 295

passive articial, 295 passive natural, 295 See also Lymphatics Immunizations. See Vaccinations Impetigo (ICD-9-CM code: 684), 417, 420, 648649 Implantable cardioverter debrillator (ICD), 486 Implied consent, 5657 Impotence, 587 Inactive medical record, 184 Incentive spirometry, 513514 Income statement, 261 Incubation stage of disease, 292 Incubator, 946948 Incus (anvil) bone, 747 Indemnity plans, 223 See also Fee-for-service Indented business letters, 154, 156 Independent function strategies, 725 Independent practice associations (IPAs), 223 Indigenous ora, 937 Individually identiable health information (IIHI), 77, 84 Infection, chain of, 289290 means of entry, 291 means of exit, 291 mode of transmission, 291 pathogen, 290 preventing disease transmission, 290 reservoir host, 290291 susceptible host, 291 Infection control, 295305 See also Asepsis; Surgical asepsis Infectious diseases, 289 bodys defense mechanisms, 292295 chain of infection, 289291 dened, 289, 936 microorganisms and pathogens, 289 stages of disease, 292 standard precautions, 295298 types of infection, 291 See also Bodys defense mechanisms; Microbiology Infertility (ICD-9-CM code: 628.9), 624625 Inammatory bowel disease (ICD-9-CM codes: 555.9, 556.9, 564.1), 550 Inammatory reactions. See Hypersensitivity and inammatory reactions Inuenza, pandemic, 964 Inuenza virus (ICD-9-CM code: 487), 503504, 649 Informational interviews, 1010 Informational ofce brochure, 136 Informed consent, 57 Ingrown toenails, 397 Inhalation, 498 In-home care, 33, 700 Initiation of patient interview, 308 Inner ear, 748, 751 Inpatient referrals, 149 Insect sting (ICD-9-CM code: 919.4), 983 Insoluble ber, 780 Inspection, 346

Inspiration, 334 Insulin, 528, 541, 785 Insulin-dependent diabetes mellitus (type I), 528 Insulin pump, 908, 910 Insulin resistance (ICD-9-CM code: 277.7), 798 Insurance. See Health insurance Insurance cards, 233, 242 Integumentary system. See Dermatology Intentional tort, 58 Interferons, 293 Internal marketing, 164166, 199201 birthdays and holidays, 164, 166 referrals, 164, 167168 reminder notes, 164, 165 International Classication of Diseases, 9th editionClinical Modications (ICD-9-CM), 208, 214218 cardiology, 468, 481493 changes in the new classication system, ICD-10, 216 conventions, 216, 218219 dermatology, 414, 417, 428433 endocrinology, 532, 534536 gastroenterology, 544558 geriatrics, 688, 690, 697 hematology and coagulation, 890, 893 lymphatics, 479481 neurology, 441, 455456 nutrition, 778802 obstetrics and gynecology, 610, 625639 ofce emergencies, 972986 ophthalmology and otolaryngology, 761 orthopedics, 712, 722 pediatrics, 642, 645 pulmonology, 509, 517 urology and the male reproductive system, 571, 587595 International Classication of Diseases, 10 (ICD-10), 216 International Normalized Ratio, 900 Internship. See Externship Interpersonal variables, 46 Interstitial uid (intercellular uid), 466 Interventions, for self-efcacy, 100 Interviewing for a job, 10111012, 10161017 after the interview, 1012 common questions, 1017 dos and donts, 1016 informational interview tips, 1011, 1016 manager conducting an interview, 190192 Interviewing patients, 308316 administrative medical assistant, 312 body of interview, 310 children, 312313 clinical medical assistant, 312 the elderly, 313 rst impressions, 308 GI questions, 558 initiation, 308 judgmental questions, 311

1072

INDEX

medical history, 308309 MRI scans, 993, 10021003 OB-GYN questions, 610, 625 offering false reassurance, 311 offering opinions and advice, 311 older children and adolescents, 313 quiet patients, 309 self-assessment, 310 sensitive topics and, 311312 summary of interview, 308 talkative patients, 309 talking too much, 311 techniques, 308310 using technical language, 311 See also Communication Intradermal injections, 832, 837841 Intradermal test, 429, 430 Intramuscular injections, 832, 837838, 843845 Intrauterine device (IUD), 610, 631 Intravenous injections (IVs), 830, 832833, 841 Intravenous pyelography, 589, 593594 Inventory, 195198 Inversion, 726, 729, 731 IPAs. See Independent practice associations Iris scissors, 383 Irrigating the eye, 762, 766768 Irritable bowel syndrome, 554, 551 Ischemic stroke, 443, 444445 Ishihara color vision test, 762, 765766 Islets of Langerhans, 520, 539, 541542 Isotonic solutions (IVs), 841 IUD. See Intrauterine device IVs. See Intravenous injections

King of Hearts monitor (event recorder), 491 Kinin, 294 Knee-chest position, 359, 361362 Knee joint, 710, 712 KOH stain. See Potassium hydroxide (KOH) preparation Korotkoff, Nikolai Sergeyevich, 337 Korotkoff sounds, 337339 Kuru, 941 Kwashiorkor (ICD-9-CM code: 260), 797 Kyphosis (hunchback or Potts curvature) (ICD9-CM codes: 737.0, 737.1), 717

Jack-knife position, 359 Jayne A. Veins, MD vs. Marjorie Wells, 60 Jenner, Edward, 30 Jewelry, 22 Job description, 189, 190 Job search, 10101013 applying, 1010 cover letters, 1011, 1015 interviewing, 10111012, 1016, 1017 networking, 1010 resumes, 10101011, 1012, 1013, 1014 chronological, 1011, 1012 functional, 10111013 targeted, 1011, 1014 Judgmental questions, 311 Junk food, 794 Justice, 87, 88 Juvenile rheumatoid arthritis (ICD-9-CM code: 714.30), 719

Kaiser Family Foundation, 231 Kernig sign, 448 Ketones, urine and, 926927 Kidneys, 568, 569, 687, 920, 921, 926927 Kidney stones, 572, 577, 579582, 589 Kinesthetic learners, 56

Labia majora, 601602 Labia minora, 601602 Labor stages of, 606607 See also Birth process Laboratory courses, 4 Laboratory equipment, 862865 Laboratory professions and departments, 852853 Laboratory Response Network (LRN) for Bioterrorism, 962963 Laboratory tests 850852 abbreviations for, 851 automated methods, 851 Clinical Laboratory Improvement Amendment (CLIA 1988), 852854 high-complexity tests, 854855 measuring hematocrit using the microhematocrit centrifuge, 897898 measuring hemoglobin using the HemoCue analyzer, 896 moderate-complexity tests, 854 provider-performed microscopy procedures, 855 waived tests, 854 life cycle of, 851 manual methods, 851 panel, 850 patient preparation, 859 physicians ofce laboratory (POL), 856859 laboratory report, 857859 laboratory requisition slip, 857 purpose of, 851852 quality control (QC) and, 855856 quantitative or qualitative results, 852 reference (independent) labs, 850 specimen collection, handling, and transport, 859862 See also Physicians ofce laboratory (POL) Labyrinthitis (ICD-9-CM code: 386.30), 759 Laceration (ICD-9-CM code: 879.8), 978980 Lacrimal glands, 747, 751 Lactation, 603 Lactose, 779, 780 Laennec, Rene, 29 Laminectomy, 721 Language development, 672

Laparoscopy, 635 Laryngeal mirror, 386, 387 Laryngopharynx, 746, 749750, 752 Laser resurfacing, 433 Laser surgery, 398 Latent infections, 291 See also Incubation stage Latent syphilis (ICD-9-CM code: 097.1), 586 Latex allergy, 875 Latin, 368, 377 Lawsuit process, 5763 Laypersons, 311 LDLs. See Low-density lipoproteins Lead poisoning (ICD-9-CM code: 984.9), 660661 Learning barriers to, 101103 evaluation of, 106 motivation to, 98100 See also Patient education Learning domains affective, 97 cognitive, 97 psychomotor, 97 Learning needs, assessing, 9798 Learning objectives, 98 Learning styles, 9697 auditory learners, 56 kinesthetic learners, 56 oral-dependent learners, 56 social learners, 45, 6 solitary learners, 4, 6 visual learners, 56 writing-dependent learners, 56 Ledger cards, 263, 264 LEEP (loop electrosurgical excision procedure), 638 Leeuwenhoek, Antoni van, 30, 31 Legal considerations, 5370 condentiality, 63 consent, 5657 criminal vs. civil law, 5960 documentation, 62 durable power of attorney, 63, 6567 licensure, 5556 living wills, 63, 6869 malpractice, 57 malpractice insurance, 5859 Medical Practice Act, 55 medical practice business structures, 5859 negligence, 5658 of patient education, 106 patient noncompliance, 6061 relationship of patients and physicians, 55 reporting abuse, 6365, 67 risk management, 6162 scope of practice, 56 standard of care, 5657 statute of limitations, 61 subpoenas and depositions, 5758 trial, 58 websites for, 70 Leg casts, coding options for, 205

INDEX

1073

Legislation, ethics and, 8687 Letters. See Business letters Leukemia (IDC-9-CM codes: 204.0, 204.1, 205.0, 205.1), 479, 898 Leukocytes. See White blood cells Leukocytosis, 899 Leukopenia, 899 LH. See Luteinizing hormone Liabilities, 261, 263 Libel, 59, 60 Libelous charting, 60 Licensure, 5556 Lidocaine, 407408 Lifelong learning, 21, 92 See also Continuing education units (CEUs) Lifting technique, 89 Ligaments, 709, 712 See also Orthopedics Ligation, 478 Lighting, 115116, 117 Limited liability corporation (LLC), 59 Linoleic acid, 786789 Linolenic acid, 786787 Lipid testing, 908910 cholesterol, 908910 lipid panel, 910911 Lipoproteins, 908 Listening, active, 309 Lister, Joseph (Father of Sterile Surgery), 30 Literature informational ofce brochure, 135 patient education, 101102 reading materials in the medical ofce, 116 translating, 369 Lithotomy position, 356, 358359 Lithotripsy, 579, 580 Litigation, 56 See also Legal considerations Liver, 539, 541 Liver cancer (ICD-9-CM code: 155.0), 557 Liver function test, 561, 563 Living wills, 63, 6869 LLC. See Limited liability corporation Locus of control, 99 Lofstrand crutches, 730 Long, Crawford Williamson, 30 Long-term care (LTC), 33 Lordosis (ICD-9-CM codes: 737.20, 754.2), 718 Lou Gehrigs disease, 451452 Low-density lipoproteins (LDLs), 788, 789, 910 Lower airway, 499 See also Pulmonology Lower respiratory diseases and disorders. see Pulmonology Loyalty, 91 LTC. See Long-term care Luer-Lok, 834 Lumbar puncture, 456459 Lumen, 473 Lumpectomy, 622 Lung cancer (ICD-9-CM code: 162.9), 508509 Lungs, 497, 498 See also Pulmonology

Luteal phase of menstruation, 604, 605 Luteinizing hormone (LH), 604 Lymphadeonopathy, 480 Lymphatics assisting with examinations, 481 diseases and disorders. See Cardiology spleen, 471472 structures and functions of lymphatic system, 467 thymus, 467 See also Cardiology Lymphatic system. See Lymphatics Lymphatic system disorders. See Cardiology Lymphatic vessels, 466 Lymph nodes (glands), 466467 Lymphocytes, 892, 893 Lysozyme, 293

Macronutrients, 778788, 789 carbohydrates, 786, 778781 fats, 786788, 789 proteins, 781786 See also Nutrition Macrophages, 892 Macular degeneration (ICD-9-CM code: 362.50), 696, 758 Magnetic resonance imaging (MRI), 32, 457, 459, 10021003 Mail e-mail, 166 incoming, 166168 types of, 166168 Maintenance solutions (IVs), 841 Makeup, 22 Male reproductive system. See Urology and the male reproductive system Malfeasance, 56 Malignant melanoma, 427, 428 Malleus (hammer) bone, 747 Malnutrition, 796797 Malpighi, Marcello, 30 Malpractice, 57 Malpractice insurance, 58 Maltose, 779, 780 Mammary glands, 602 Mammography, 639, 999 Managed care, 222223, 223224 See also Health insurance Management. See Ofce management Manipulation, 348 Mantoux test (puried protein derivative test), 511512 Manual appointment book system, 140 Manual daily worksheet, 140 Marasmus (ICD-9-CM code: 261), 797798 Marketing, 198201 external, 200, 202 internal, 199201 tracking, 200 Marketing materials, 118 Mastectomy, 622 Master gland (pituitary gland), 521522

Mastication, 751 Material Safety Data Sheets, 189 Maxillary sinuses, 748 Mayo scissors, 383 Mechanical defenses of the body, 292293 Mediastinum, 462 Medicaid, 226, 228 eligibility, 226, 228 federal matching funds with states, 228 Title XIX of the Social Security Act, 226 Medical alert, 654, 977 Medical asepsis, 30, 303, 305 Medical Assistants Creed (AAMA), 9091 Medical assisting, 1117 Accreditation Bureau of Health Education Schools (ABHES), 15, 16, 1018, administrative medical assistant, 1213 assistant as role model, 23 bioterrorism response, 963 cardiology and lymphatics procedures, 481 career opportunities for, 1314 certied medical assistant (CMA), 1416, 10161020 clinical medical assistant, 1214 Commission on Accreditation of Allied Health Education Programs (CAAHEP), 15, 16, 1018 common skills of, 1314 credentialing, 1416, 1016, 10181020 dermatology, 428429 endocrinology, 532 gastroenterology, 558 health care specialties that employ medical assistants, 1314 neurology, 455, 456 obstetrics and gynecology, 629, 634635, 639 ophthalmology and otolaryngology, 761770 orthopedics, 722725 pediatrics, 662 with the physical examination, 352359, 360362 professional and regulatory organizations, 1516 pulmonology, 509 radiography, 995999 registered medical assistant (RMA), 1417, 10161020 role in minor surgery, 398402 urology and the male reproductive system, 588589 See also Administrative medical assistant; Health care team; Professionalism Medical coding specialists, 40 Medical doctors (MDs), 34 See also Physicians Medical history, obtaining, 313314 Medical information letters to patients, 155, 156157 Medical jargon, 311 Medical laboratory technicians (MLTs), 16, 40, 852, 854 Medical Practice Act, 55

1074

INDEX

Medical practices corporations, 34 partnerships, 34 sole proprietorships, 3334 Medical records, 316318 problem-oriented, 315316 source-oriented, 315 Medical records management, 173186 alphabetical ling system, 176177 archives, 184 creating records, 179 cross-referencing, 181182 electronic health record (EHR), 182183 le folders, 175176, 180181 importance of, 174 moveable les, 175 numeric ling system, 177180 open-shelf lateral les, 174175 purging, 184 release of records, 185 tracking medical records, 181 vertical les, 174 Medical specialties, 3536 Medical technologists (MTs), 3839, 854 Medical terminology. See Terminology Medical transcriptionists, 41 Medicare, 225226 parts of, 225226 services not covered by, 227 Medication administration, 825847 abbreviations in medication orders, 830 inhalation (parenteral), 832 injection (parenteral), 832845 ampule preparation, 836837 intradermal, 837, 840841 intramuscular, 837838, 841845 intravenous, 841 subcutaneous, 833, 838839 vial preparation, 834835 oral (enteral) route, 831832, 833 prescription parts, 829 rectal (parenteral), 843, 846 self-administration, 846 seven rights of, 831832 sublingual and buccal (parenteral), 832 topical (parenteral), 832, 841 vaginal (parenteral), 841, 843 See also Dosage calculations; Pharmacology Medications geriatric patients and, 700, 701702 pregnancy and, 628 restrictions for lab tests, 859 See also Dosage calculations; Medication administration; Pharmacology Medigap plan, 226 Meditation, 7 Medroxyprogestone (Depo-Provera), 631 Medulla oblongata, 437 Megakaryocyte, 892 Melanoma, 428 Memorizing medical terms, 377, 378379 Menarche, 604 Mnire disease (ICD-9-CM code: 386.0), 758

Meninges, 437 Meningitis (ICD-9-CM code: 322.9), 447448 Menopause, 607 Menstrual disorders. See Obstetrics and gynecology Menstruation, 604 follicular phase, 604 luteal phase, 604 menstrual phase, 604 Mercury thermometers, 321, 323 Messages, 45 Metabolic panels, 912 Metabolism, 778 drugs and, 808 Metered-dose inhaler, 513515 Methicillin-resistant Staphylococcus aureus (MRSA), 950 Metric system, dosing calculations and, 826828 MIC. See Minimum inhibitory concentration Michelangelo, 30 Microbiology, 935958 history of, 936, 937 infection and disease dened, 936 microorganisms bacteria, 289, 939942, 943 fungus, 289, 942, 944 parasitic worms, 942, 944945 prions, 941 protozoa, 289, 942945 summary of, 942943 viruses, 289, 941, 943, 944 normal ora, 936938 proper specimen storage, 937 testing, 945957 antimicrobial susceptibility testing, 947949 bacterial culture, 945947 MRSA resistance to antibiotics, 950 rapid streptococcal test, 951, 953958 specimen rejection, 951 sputum specimen for, 952 stool specimen collection, 953 throat culture, 953, 955957 throat specimen for, 955 wound specimen for, 952953 See also Pathogens Microdermabrasion, 432 Microhematocrit centrifuge, 863, 894, 897898 Micronutrients. See Vitamins; Minerals; Water Microorganisms, 289 See also Microbiology; Pathogens Microsample, 904 Microscopes, 864 Microscopic components, of urine, 927932 Microsurgery, 397398 Micturition reex, 569 Midbrain, 437 Middle-digit ling, 179 Middle ear, 747, 751 Migraine headache (ICD-9-CM code 346.9), 445446 Mill, John Stuart, 89

Minerals, 789790, 791792 for children, 680681 Minimum inhibitory concentration (MIC), 947, 949 Minor surgical procedures, 382, 394402 anesthetics, 407 bandages, 405, 407 creams, ointments, solutions (antiseptics), 407 cryosurgery, 399 dressings, 403, 405, 406 electrosurgery (electrocautery), 398 endoscopy, 398 laser surgery, 398 medical assistants roles, 382, 398408 microsurgery, 397398 preoperative and postoperative care, 399, 402 wound care, staples, 403, 405 wound care, sutures, 403405 Miscarriage (spontaneous abortion), 618 Misspelled words, 160, 162 Mixed nerves, 439 MLTs. See Medical laboratory technicians Mnemonics, 4 Mobility aids geriatrics and, 698 See also Orthopedics Mock codes, 975 Modalities, 712 Moderate-complexity tests, 854 Modied-block business letters, 154155 Modied radical mastectomy, 622 Modied wave system, 135 Moist heat, 735736 Molds, 942 Monocytes, 892 Mononucleosis (Epstein-Barr virus) (ICD-9-CM code: 075), 508 testing for, 913, 915 Monosaccharides, 779 Mons pubis, 602 Monthly billing, 251 Monounsaturated fats, 786787 Morals dened, 86 ethics and, 86 Morbid obesity (ICD-9-CM code: 278.01), 798 Motor point of muscle, 710 Motor skill development, 643, 672 Mouth, 748749, 751752 See also Ophthalmology and otolaryngology Mouth disorders and diseases. See Ophthalmology and otolaryngology Movable shelving, 175 Moveable les, 175 MRI. See Magnetic resonance imaging MRSA. See Methicillin-resistant Staphylococcus aureus MTs. See Medical technologists Nuchal rigidity, 448 Mueller-Hinton agar medium, 947948 Multilingual callers, 123124 Multiple insurance policies, 230

INDEX

1075

Multiple sclerosis (ICD-9-CM code: 340), 450451 Muscle disorders. See Orthopedics Muscles, 709, 710712 cardiac muscle, 709, 710, 711712 skeletal muscles, 709, 710711 smooth muscles, 709, 710711 See also Orthopedics Muscle strain (ICD-9-CM codes: 840848), 986 Muscle strength scale, 725 Muscle testing, 719 Musculoskeletal disease and disorders. See Orthopedics Musculoskeletal system aging and, 687688 See also Orthopedics Music, in the medical ofce, 117 Myasthenia gravis (ICD-9-CM code: 358.0), 720 Mydriatic drops, 761, 762 Myelin sheath, 436, 439 Myocardial infarction (heart attack) (ICD-9-CM coded: 410.9, 427.5), 473474, 475, 974 Myocardium, 462 Myofascia, 709 Myoglobin, 785 Myomectomy, 637 Myometrium, 601 Myopia (nearsightedness) (ICD-9-CM code: 367.1), 756757 MyPyramid website, 793 for young children, 680 Myxedema, 530

Ngeles rule, 626 Nails, 412 Narcotics Anonymous, 817 Nasal septum, 748 Nasal specula, 384385 Nasopharynx, 749, 750 National Coalition in Healthcare, 231 National Committee for Clinical Laboratory Standards (NCCLS), 948 National Kidney Foundation, 582 National Poison Control Center (1-800-222-1222), 981 Natural drugs, 807 See also Pharmacology Naval Medical Research Center, 962 NCCLS. See National Committee for Clinical Laboratory Standards Nearsightedness, 756757 Nebulizers, 513514 Needle holders, 382, 384385 Needles, 872874 accidental needlestick: what to do, 874 needle-adapter, 872 puncture-proof needle-disposal containers, 873 safety needles, 873874 used during venipuncture, 874 winged infusion sets (buttery needle), 874875

Needlestick safety, 296297 Needlestick Safety and Prevention Act, 297 Negative feedback system, 522 Neglect, 64, 67, 674 Negligence, 56 gross, 58 Neonatal care circumcision, 671 umbilical cord, 671 Neonates, 603 assessment of, 629 Neoplasms, 427 Nephrons, 568, 569, 687 Nerves, 437441 Nervous system. See Neurology Neuroleptic malignant syndrome, 815 Neurology, 436459 aging population and, 686 assisting with examination, 456, 457 central nervous system disorders, 444451 brain tumor (ICD-9-CM code: 239.6), 451 encephalitis (ICD-9-CM code: 323.9), 447 epilepsy (ICD-9-CM code: 345.90), 446447 meningitis (ICD-9-CM code: 322.9), 447448 migraine headache (ICD-9-CM code 346.9), 445446 multiple sclerosis (ICD-9-CM code: 340), 450451 Parkinson disease (ICD-9-CM code: 32.0), 449450 stroke (ICD-9-CM code: 436), 444445 transient ischemic attack (ICD-9-CM code: 435), 445 traumatic brain injury (concussion, ICD-9-CM code: 850.9) (contusion, ICD-9-CM code: 851), 448449 computed tomography (CT) scanning, 457 electroencephalography (EEG), 455456 lumbar puncture, 456457, 458 magnetic resonance imaging (MRI), 457 medical terminology related to, 438, 446441, 443 peripheral nervous system disorders, 451454 amyotrophic lateral sclerosis (ICD-9-CM code: 335.20), 451452 Bell palsy (ICD-9-CM code: 351.0), 452 carpal tunnel syndrome (ICD-9-CM code: 354.0), 453 peripheral neuropathy (ICD-9-CM code: 356.9), 452453 spinal stenosis (ICD-9-CM code: 956.0), 454 spinal cord injury (ICD-9-CM code: 344.1 paraplegia, 344.0quadriplegia), 449, 450 structures and functions of the nervous system, 436440 central nervous system (brain and spinal cord), 437, 438, 439440 neurons, 436, 438 peripheral nervous system, 437439, 441

Neurons, 436437, 439 Neurotransmitters, 450 Neutrophils, 892, 893 New patients, 135136 registration form, 73, 232 Newsletters, 201 Nightingale, Florence, 31, 32 Nitrite, urine and, 927 Nocturia, 920 Nomogram (for plotting body surface area), 828 Noncompliance, 6061 of HIPAA, 82, 84 Nonconsecutive ling system, 178179, 180 Nonfeasance, 56 Non-Hodgkin lymphoma (ICD-9-CM code: 202.8), 480 Non-insulin-dependent diabetes mellitus (adult-onset diabetes), 528529 Nonmalecence, 87 Nonmedical physician health care providers, 37 Nonprot hospitals, 33 Non sufcient funds (NSF) checks, 263, 267, 272 Nonverbal communication, 46 Normal ora, 289 Normal range, 857 Nose and throat, 748749, 750, 752 See also Ophthalmology and otolaryngology Nose and throat disorders and diseases. See Ophthalmology and otolaryngology Nosebleed, 980981 No-show patients, 135, 140, 144 Notice of Privacy Practices (NPP), 7982 NPP. See Notice of Privacy Practices NSF. See Non sufcient funds (NSF) checks Nuclear medicine, 10031005 positron emission tomography (PET), 1004 radiation safety, 10041005 radiation therapy, 10031004 radioactive iodine uptake, 1004 Numeric ling system, 177180 accession log ling, 179180 consecutive ling, 178, 179, 180 nonconsecutive ling, 178179, 180 Nurses, 3738 nursing credentials, 38 Nursing centers (skilled nursing facilities; nursing homes), 703 Nursing homes, 703 Nutrients, metabolism, 778 Nutrition, 778799 anorexia nervosa (ICD-9-CM code: 307.1), 554, 655 bulimia nervosa (ICD-9-CM code: 307.51), 554, 665 carbohydrates, 778781, 782 complex, 779781, 782 digestion of, 781 glycemic index, 784785 regulation of blood glucose, 781, 783, 784785 simple, 779 celiac disease (ICD-9-CM code: 579.0), 554

1076

INDEX

economics of proper nutrition, 779 fats, 786788, 789 cholesterol (a sterol), 788, 789 digestion of, 788 fatty acids, 786787 phospholipids, 787788 triglycerides, 787 gastric bypass surgery, 799 macronutrient disorders, 796800 kwashiorkor (ICD-9-CM code: 260), 797 marasmus (ICD-9-CM code: 261), 797798 morbid obesity (ICD-9-CM code: 278.01), 798 syndrome X (metabolic syndrome), 798799 micronutrient disorders, 800802 beriberi (ICD-9-CM code: 265.0), 801802 pellagra (ICD-9-CM code: 265.2), 801 rickets (ICD-9-CM code: 268), 800, 801 scurvy (ICD-9-CM code: 267), 800801 minerals, 789790, 791792 MyPyramid.gov, 793 pediatric by age, 679680 planning for good nutrition, 792794 portion control and eating out, 793 proteins, 781783, 785786 body protein manufacturing, 785786 bone health and, 786 digestion of, 783, 785 essential and nonessential, 782783 food sources, 785786 special populations, 794796 adolescence, 795 ages, 212, 795 bland diet, 796 cancer, 796 diabetes, 796 HIV/AIDS, 795-796 infancy to age, 2, 794 older adults, 795 pregnancy, 794, 795 sodium-restricted diet, 796 soft diet, 796 weight-loss diets, 796 vitamins, 789790 water, 790, 792

Obesity (ICD-9-CM code: 278.00), 660, 789800 O blood type, 914 Obstetrics and gynecology, 601639 amniocentesis, 637 amplied DNA probe test, 637638 assisting with examinations, 629, 632633, 634635 breast examination, 632633 breastfeeding, 603, 604, 629 cancers, 621624 breast cancer (ICD-9-CM code: 174.9), 621623 cervical cancer (ICD-9-CM code: 180.9), 623

ovarian cancer (ICD-9-CM code: 183.0), 623624 uterine cancer (ICD-9-CM code: 179), 623 chorionic villus sampling (CVS), 637 colposcopy with biopsy, 638 contraception, 630631 cryosurgery, 634635 dilatation and curettage (D&C), 635 endometrial biopsy, 638639 fetal ultrasound, 637 brocystic breast disease (ICD-9-CM code: 610.1), 625 food and drug safety during, 628 hysterectomy, 636, 637 infertility (ICD-9-CM code: 628.9), 624625 laparoscopy, 635 LEEP (loop electrosurgical excision procedure), 638 mammography, 639 medical terminology, 607, 608610 menstrual disorders, 614615 amenorrhea (ICD-9-CM code: 626.0), 614 dysmenorrhea (ICD-9-CM code: 625.3), 614 ovarian cysts (ICD-9-CM code: 620.2), 614 premenstrual syndrome (ICD-9-CM code: 625.4), 615 toxic shock syndrome (ICD-9-CM code: 040.89), 615 neonate assessment, 629 OB-GYN interview questions, 625 Pap test, KOH preparation, and wet preparation, 633, 634 pelvic examination, 632633 postpartum visit, 629 pregnancy complications, 618621 abortion (ICD-9-CM code: 632), 618 abruptio placentae (ICD-9-CM code: 641.20), 620621 eclampsia (ICD-9-CM code: 642.60), 621 ectopic pregnancy (ICD-9-CM code: 633.9), 618 gestational diabetes (ICD-9-CM code: 648.8), 618619 placenta previa (ICD-9-CM code: 641.00), 619620 prenatal care, 625629 reproductive cycle, 604607 birth process, 606607 breastfeeding, 603 menopause, 607 menstruation, 604, 605 pregnancy, 604605 structures and functions of the female reproductive system, 601604 breasts, 602, 603604 external structures, 601602, 603 internal structures, 601, 602603 supplements during pregnancy, 627 urine testing for pregnancy, 928, 933 uterine ablation, 636

uterine disorders, 615618 endometriosis (ICD-9-CM code: 617.9), 615616 pelvic inammatory disease (ICD-9-CM code: 553.3), 616 uterine broids (ICD-9-CM code: 218.9), 616617 uterine prolapse (ICD-9-CM code: 618.1), 617618 vaginal infections, 610614 acquired immune deciency syndrome (AIDS) (ICD-9-CM code: 042), 613 Bartholin gland cyst (ICD-9-CM code: 616.3), 613614 candidiasis (yeast infection) (ICD-9-CM code: 553.3), 610611 chlamydia (ICD-9-CM code: 553.3), 611 genital herpes (ICD-9-CM code: 553.3), 611 genital warts (ICD-9-CM code: 553.3), 612 gonorrhea (ICD-9-CM code: 553.3), 612 syphilis (ICD-9-CM code: 553.3), 612613 trichomoniasis (ICD-9-CM code: 553.3), 613 weight gain during pregnancy, 627 Occlusion, 473 Occupational Safety and Health Administration (OSHA), 295296 Bloodborne Pathogens Standard, 297 gloves, 875 needle-adapter disposal, 872 Occupational therapists (OTs), 39 OCR. See Ofce of Civil Rights Odor, urine and, 926 Ofce communication. See Business letters; Faxed documents; Internal marketing; Mail; Transcription Ofce design. See Ofce environment Ofce emergencies, 968986 ABCs of rst-aid (airway, breathing, circulation), 969 animal bite (ICD-9-CM code: 879.8), 982 burns rst-degree (ICD-9-CM codes: 940.1-949.1), 983 second-degree (ICD-9-CM codes: 940.2-949.2), 983985 third-degree (ICD-9-CM codes: 940.3-949.3), 985 CMS (circulation, motion, sensation), 986 crash cart, 970, 971 emergency guidelines, 970 epistaxis (nosebleed) (ICD-9-CM code: 784.7), 980981 equipment for, 970, 971 eye injury (ICD-9-CM code: 930.9), 986 fractures (ICD-9-CM codes: 800829), 985986 frostbite (ICD-9-CM code: 991.3), 982 heat exhaustion (ICD-9-CM code: 992.5), 982

INDEX

1077

heat stroke (ICD-9-CM code: 992.0), 982 hypothermia (ICD-9-CM code: 991.6), 982 insect sting (ICD-9-CM code: 919.4), 983 laceration (ICD-9-CM code: 879.8), 978, 980 muscle strain (ICD-9-CM codes: 840848), 986 planning, 968970 poisoning (ICD-9-CM codes: E850E858, E950E952.9, E962E962.9, E980E982.9), 981 RICE (rest, ice, compression, elevation), 986 signs and symptoms, 972978 acute abdominal pain, 978, 979980 altered consciousness (ICD-9-CM code: 780.09), 974, 977 chest pains, 974, 975976 diabetic emergencies (ICD-9-CM code: 250.90), 978 dyspnea (difculty breathing), 972974 generalized seizure (ICD-9-CM code: 345.90), 977 head injury (ICD-9-CM codes: 852, 852.4, 852.2), 978 syncope (fainting) (ICD-9-CM code: 780.2), 977 snake bite (ICD-9-CM code: 989.5), 982983 sprains (ICD-9-CM codes: 840848), 985986 triage, 971972 Ofce environment, 111120 Americans with Disabilities Act (ADA), 112 cleanliness, 117118 colors, 116 diagram of, 116 educational resources, 118 ergonomics, 113114 lighting, 115, 116 managing ofce space, 114115 music, 117 ofce design, 112114 privacy, 112113 reading materials, 116117 reception area, 114118 safety in, 118 sick child area, 115 welcoming new patients, 112 workow, 113 Ofce management, 187202 conducting an interview, 190192 conducting employee evaluations, 192194 conducting staff meetings, 192, 194 disciplinary actions and terminations, 194195 inventory and supplies, 195198 marketing, 198202 new employee orientation, 192, 193 physician travel arrangements, 198, 199 policies and procedures manual, 192, 193 praising while problem solving, 188189 qualities of leadership, 188189 roles and responsibilities, 189190 Ofce manager (OM), 189 See also Ofce management

Ofce of Civil Rights (OCR), 82, 84 Ofce of the Inspector General (OIG), 84 OIG. See Ofce of the Inspector General Ointments, 407 Olfaction, 752 Oliguria, 581, 920 OM. See Ofce manager Omission, 56 On-call system, 34 One Step glucometer, 863 One Touch Ultra glucose monitoring system, 908 Open-ended HMOs, 223 Open-ended questions, 309 Open hours, 135 Open-shelf lateral les, 174175 Operating microscope, 397 Ophthalmology and otolaryngology, 745776 assisting with examinations, 761774 audiometric testing, 770, 771772 diseases and disorders, macular degeneration (ICD-9-CM code: 362.50), 758 ear diseases and disorders, 758760 labyrinthitis (ICD-9-CM code: 386.30), 759 Mnire disease (ICD-9-CM code: 386.0), 758 otitis externa (swimmers ear) (ICD-9-CM code: 380.10), 758, 759 otitis media (ICD-9-CM codes: 381.0, 382.0), 759 tinnitus (ICD-9-CM code: 388.3), 759760 vertigo (ICD-9-CM code: 386.2), 760 eardrops, 772, 774 ear irrigation, 772773 eye diseases and disorders, 755758 astigmatism (ICD-9-CM code: 367.20), 755, 757 blepharitis (ICD-9-CM code: 373.0), 755 cataracts (ICD-9-CM code: 366), 758 conjunctivitis (ICD-9-CM codes: 372.0, 372.1), 755 diabetic retinopathy (ICD-9-CM code: 362.01), 755, 756 exophthalmos (ICD-9-CM code: 376.30), 756 glaucoma (ICD-9-CM code: 365), 758 hyperopia (farsightedness) (ICD-9-CM code: 367.0), 757 hypertensive retinopathy (ICD-9-CM code: 362.11), 755, 756 myopia (nearsightedness) (ICD-9-CM code: 367.1), 756757 photophobia (ICD-9-CM code: 368.13), 757758 presbyopia (ICD-9-CM code: 367.4), 757 instilling eyedrops, 762, 768769 irrigating the eye, 762, 766768 Ishihara color vision test, 762, 765766 measuring near visual acuity, 762, 764765 medical terminology, 752754 mouth diseases and disorders, 760761 cleft lip (ICD-9-CM code: 749.10), 760761

cleft palate (ICD-9-CM code: 749.00), 761 oral herpes (cold sore) (ICD-9-CM code: 054.9), 760 oral thrush (ICD-9-CM codes: 112.0, 771.7), 760 nose and throat diseases and disorders rhinitis (ICD-9-CM code: 477), 761 tonsillitis (ICD-9-CM code: 463), 761 Snellen chart (for distance and visual acuity), 762764 structures and functions ears, 747748, 751 eyes, 746747, 749751 mouth, 748, 751752 nose and throat, 748749, 752 tuning fork tests, 770, 771 Opportunistic pathogens, 296 Oral (enteral) route of medication administration, 831832, 833 Oral cancer (ICD-9-CM code: 145.9), 556557 Oral cavity (mouth), 748 Oral contraceptives, 631 Oral-dependent learners, 56 Oral herpes (cold sore) (ICD-9-CM code: 054.9), 760 Oral temperature measurement (with digital thermometer), 324325 Oral thrush (ICD-9-CM code: 112.0 (neonate 771.7)), 652, 760 Ordering supplies, 195198 Organ of Corti, 748 Orientation, employee, 192, 193 Oropharynx, 466, 749, 750 Ortho-Evra, 631 Orthopedics, 707744 assisting with examinations, 722725 independent function strategies, 725 transferring a patient from an examination table to a wheelchair, 724725 transferring a patient from a wheelchair to an examination table, 723724 bone fractures, 714716 bone injuries, 717719 dislocation (ICD-9-CM codes: 830839), 717 gout (ICD-9-CM code: 274.0), 718, 719 juvenile rheumatoid arthritis (ICD-9-CM code: 714.30), 719 kyphosis (ICD-9-CM codes: 737.0, 737.1), 717 lordosis (ICD-9-CM codes: 737.20, 754.2), 718 osteoarthritis (ICD-9-CM code: 715.9), 718 osteoporosis (ICD-9-CM code: 733.00), 718 rheumatoid arthritis (ICD-9-CM code: 714.0), 718719 scoliosis (ICD-9-CM code: 737.43), 717 canes, 728, 733, 734 casting, 730, 733, 735, 738, 739740 crutches, 730, 736738

1078

INDEX

cryotherapy, 740 gait belt, 727, 731732 goniometry, 725726 independent function strategies, 725 medical terminology, 712716 muscle disorders, 719721 epicondylitis, medial and lateral (ICD-9-CM codes: 726.32, 726.31), 721 bromyalgia (ICD-9-CM code: 729.1), 719, 720 herniated disk (ICD-9-CM code: 722), 721 myasthenia gravis (ICD-9-CM code: 358.0), 720 rotator cuff tear (ICD-9-CM codes: 840.4, 726.10), 720721 strain (ICD-9-CM codes: 840848), 719720 muscle strength scale, 725 ofce emergencies and, 967990 range of motion (ROM), 718, 725727 structures and functions of the musculoskeletal system, 709712 bones, 709, 710 cardiac muscle, 709, 711712 skeletal muscles, 709, 710, 711 smooth muscles, 709, 711 tendons and ligaments, 709, 712 tendon and ligament injuries, 721722 anterior cruciate ligament tear (ICD-9-CM code: 717.83), 721 sprain (ICD-9-CM codes: 840848), 722 tendonitis (ICD-9-CM code: 726), 722 thermotherapy, 735 transcutaneous electrical nerve stimulation (TENS), 741742 ultrasound, 741 walkers, 727728, 733734 Orthopnea, 470, 475 Orthostatic hypotension, 339 OSHA. See Occupational Safety and Health Administration Ossicle bones, 751 Osteoarthritis (ICD-9-CM code: 715.90), 693694 Osteoporosis (ICD-9-CM code: 733.0), 693 risk factors and preventive measures, 693 OTC. See Over-the-counter drugs Otitis externa (swimmers ear) (ICD-9-CM code: 380.10), 758759 Otitis media (ICD-9-CM codes: 381.0, 382.0), 649650 Otoscope, 385, 770, 774 OTs. See Occupational therapists Out guides, 181 Outpatient referrals, 145148 Outside release form, 8283 Ova and parasite determination, 945 Oval window, 748749, 751 Ovarian cancer (ICD-9-CM code: 183.0), 623624 Ovarian cysts (ICD-9-CM code: 620.2), 614615 Ovaries, 522, 523, 601602, 604

Overdue accounts, 252, 253 See also Credit and collections Overnutrition, 796 Overt event, 960 Over-the-counter drugs (OTC), 807 See also Pharmacology Owners equity, 261 Oxygen saturation, 339341 factors that affect pulse oximeter reading, 340 measuring using a pulse oximeter, 341 Oxygen therapy, 514516 Oxytocin, 522523, 604

Pacemaker, 486 Packing slip, 267268 Pain management, geriatric patients and, 700 Palliative care, 704 drugs and, 809 Palpation, 347 Pancreas, 520522, 539, 541 Pancreatic cancer (ICD-9-CM code: 157.9), 558 Pancreatitis (ICD-9-CM code: 577.0), 553 Pandemic, dened, 960 Pandemic inuenza, 964965 epidemic vs. pandemic, 964 preparing for, 960 response plan, 964965 World Health Organization pandemic phases, 964 Panels, 850 Panic attack (ICD-9-CM code: 300.01), 976 Papanicolaou (Pap) test (Pap smear), 422, 633634 Paramedics, 40 Parasites, 289 worms, 938, 942, 944 See also Rickettsia Parasitic infestations, 424 Parasitic worms, 942, 944945 Parasympathetic nervous system, 439 Parenteral route of medication administration. See Medication administration Paresthesia, 444 Parkinson disease (ICD-9-CM code: 32.0), 449450 Paroxysmal nocturnal dyspnea, 475 Part Ahospital insurance (Medicare), 226 Part Bphysician services (Medicare), 226 Part CMedicare Advantage, 226 Part Dprescription drug services (Medicare), 226 Partial mastectomy, 622 Partnerships, 34, 58 PAs. See Physician assistants Passive-aggressive pattern of communication, 47 Passive articial immunity, 295 Passive natural immunity, 295 Passive pattern of communication, 47 Past-due message, 252, 254 See also Credit and collections Pasteurization, 30 Pasteur, Louis (Father of Bacteriology), 30

Past medical history (PMH), 313 Patch test, 429430 Paternalism, 88 Pathogenic microorganisms, surgical asepsis and, 388 Pathogens, 289290, 941 bacteria, 289, 939941, 943 fungus, 289, 942 parasitic worms, 942, 944945 prions, 941 protozoa, 289, 942, 944 rickettsia, 289 viruses, 289, 941 See also Microbiology; Microorganisms Pathologic terms, 374, 379 cardiovascular and lymphatic systems, 468469, 472481 endocrinology, 532 gastroenterology, 538, 558 geriatrics, 689 integumentary system, 415417 neurology, 443 obstetrics and gynecology, 609 ophthalmology and otolaryngology, 753754 pediatrics, 644 pulmonology, 500501 urology and the male reproductive system, 573575 Patient education, 95108 100-gram meal, 906 about medical assistants role, 15 affective domain, 97 age-related teaching considerations, 102, 104 alternatives to hysterectomy, 637 Alzheimer disease, 690692 analogy and role play, 105 antacid overuse, 547 antibiotic overuse, 775 articial sweeteners and weight loss, 800 assessing learning needs, 9798 barriers to, 101103 Botox (trademark), 433 breaking the chain of infectious diseases, 291 burn wound infection, 985 caloric value, 798 capillary puncture, 894 cast care, 738 chemical peel aftercare, 433 choosing insurance, 224 cognitive domain, 97 conjunctivitis, 775 constipation, 657 counting radial pulse, 331 cultural variations in communication, 50 diabetic self-care, 529 drugs, 826 evaluation of learning, 106 explaining specialists, 37 eye care, 647 eyedrops, 768769 ber and colorectal health, 780 foods that cause diverticular disease, 550 glucose monitoring tips, 909

INDEX

1079

glucose tolerance test (GTT), 906907 home care for croup, 646647 home care for otitis media, 649650 home safety for patient with dementia, 692 home treatment for diarrhea, 647648 home treatment for sprains, 722 independent function strategies, 725 inuenza vaccination, 504 inner ear disturbance, 760 interviewing patients, 312 lead poisoning prevention, 660661 learning in practice, 5 learning objectives, 98 learning styles, 9697 legal implications, 106 locus of control, 99 lumbar puncture, 459 magnetic resonance imaging (MRI) scanning, 459 mammography, 639 medical alert, 977 medical assistants role in, 96 mercury thermometer disposal, 323 motivation to learn, 98100 myocardial infarction warning signs, 475 nebulizers, 516 Notice of Privacy Practices (NPP), 8182 on-call system, 34 organizing the teaching session, 98 outside release form, 8283 pandemic preparation, 965 patient teaching literature, 96, 105106 pediatric temperatures by route, 666 portion control, 792794 post-prostate surgery, 584 preoperative and postoperative education, 402 preschool prevention practices, 646 preventing constipation, 550 preventing musculoskeletal injuries, 722 preventing poisoning, 981 protein and bone health, 786 psychomotor domain, 97 radiation and chemotherapy, 624 reducing heart disease, 474 self-administration of medication, 846 self-assessment of needs, 310 self-efcacy, 99100 services not covered by Medicare, 227 skill demonstration tips, 98 spacers, 513 specimen collection, 859, 861862 sterile eld and, 388394 swimmers ear, 758759 taking medication, 293 teachable moment, 355 teaching by example, 23 teaching strategies, 49, 104105 teaching wellness and prevention, 669 team members, 34 testicular cancer, 584585 tourniquets, 980 translating medical terminology, 369, 376

treating and preventing urinary tract infections, 577 treating dehydration, 556 urine specimen collection, 921922 workers compensation claims, 230 Patient noncompliance, 6061 Patients established, 135, 136 new, 135136 See also Patient education Patients right to access, 7779 Payment denials and appeals process, 241 Payment processing, 239241 See also Health insurance Payroll, 268271 PCP. See Primary care provider PEACH survey (Parent Eating and Nutrition Assessment for Children with Special Health Needs), 658659 Peak-ow measurement, 512513 Pediatric advanced life support, 40 Pediatrics, 641682 Apgar score, 670671 assisting with examinations, 662 blood pressure, 667668 categories of children, 642 communicable diseases and disorders, 645653 chickenpox (ICD-9-CM code: 052.9), 652653 common cold (ICD-9-CM code: 460), 645646 conjunctivitis (pink eye) (ICD-9-CM code: 372.30), 646647 croup (ICD-9-CM code: 646.4), 696697 diarrhea (ICD-9-CM code: 787.91), 647648 impetigo (ICD-9-CM code: 684), 648649 inuenza virus (ICD-9-CM code: 487.1), 649 oral thrush (ICD-9-CM code: 112.0 (neonate 771.7)), 652 otitis media (ICD-9-CM code: 382), 649650 respiratory syncytial virus (ICD-9-CM code: 079.6), 651 Strep throat (ICD-9-CM code: 034.0), 651 warts (ICD-9-CM code: 078.10), 653 Denver Developmental Screening Tool (DDST), 672 drugs and, 823 growth and development, 642643 head circumference, 667668 hearing screening, 668 height and weight measurement, 662663 hemoglobin and hematocrit, 679 immunizations, 674676 medical terminology, 642645 MyPyramid, 680 noncommunicable diseases and disorders, 653662 allergies (ICD-9-CM code: 995.3), 653654

asthma (ICD-9-CM code: 493.0), 655656 autism (ICD-9-CM code: 299.0), 656657 behavioral disorders (ADD, ICD-9-CM code: 314.00), (ADHD, ICD-9-CM code: 314.01), 656 cerebral palsy (CP) (ICD-9-CM code: 343.9), 658 constipation (ICD-9-CM code: 564.0), 657658 Down syndrome (trisomy 21) (ICD-9-CM code: 758.0), 657 eating disorders (anorexia nervosa) (ICD-9CM code: 307.1) (bulimia nervosa) (ICD-9-CM code: 307.51), 655 eczema (ICD-9-CM code: 692.6), 658659 failure to thrive (FTT) (ICD-9-CM code: 783.41), 657658 lead poisoning (ICD-9-CM code: 984.9), 660661 obesity (ICD-9-CM code: 278.00), 660 phenylketonuria (ICD-9-CM code: 270.1), 661662 scoliosis (ICD-9-CM code: 737.30), 660 nutritional counseling by age, 679680 PEACH survey (Parent Eating and Nutrition Assessment for Children with Special Health Needs), 658659 plotting growth, 664665 pulse, 666667 rapid Strep test, 679 reporting child abuse, 673674 respirations, 666 sick-child examination, 672673 sports physical examination, 672 temperature measurement, 664, 666 urinalysis, 677678, 924 vision screening, 668 vital signs, 662668 vitamin and mineral supplements, 680681 well-child examination, 668672 Pediculosis (lice) (ICD-9-CM code: 132), 425 Performance evaluation, 1014 Pellagra (ICD-9-CM code: 265.2), 801 Pelvic inammatory disease (ICD-9-CM code: 553.3), 616 Penis, 570571 Peptic ulcer disease (ICD-9-CM codes: 531.90, 530.2), 545546, 980 Percussion, 347 Performance maintenance, 196197 Perfusion, 478 Pericardial sac, 466 Pericarditis (ICD-9-CM code: 420.91), 980 Pericardium, 462 Perilymph, 748 Peripheral blood, 439 Peripheral nervous system (PNS), 437439, 444 Peripheral neuropathy (ICD-9-CM code: 356.9), 452453 Peristalsis, 540 Peritoneal dialysis, 581 Peritoneum, 538

1080

INDEX

Per member per month (PMPM) rate, 239 Personal and condential, 168 Personal and social skills, 672 Personal problems, 24 Personal protective equipment (PPE), 296 Personal space, 46 Personnel ofce, 1010 PET. See Positron emission tomography Petty cash, 271, 282 P foods, diarrhea and, 648 pH, urine and, 926 Phagocytosis, 294, 295, 467 Pharmacodynamics, 808, 810 Pharmacokinetics, 808, 810 Pharmacology, 807823 assisting with, 807 contraindications, 817 dened, 807 drug action and uses factors that affect drug action, 808 pharmacodynamics, 808, 810 pharmacokinetics, 808, 810 pharmacotherapeutics, 809810 drug classications, examples, and therapeutic effects, 811 drug disposal, 820 drug forms, 807 drug names chemical, 810811 generic, 810 trade name, 810811 drug references, 820, 822 drug safety, 819820 drug sources, 807808 effects, 811, 814817 adverse effects and reactions, 814817 therapeutic effect, 814815 geriatrics, 823 interactions antagonism, 815816 with foods, 816 potentiation, 816817 synergism, 815 natural, 807 over-the-counter (OTC), 807, 817, 819 patient education about drugs, 820822 pediatrics, 823 prescription, 807 regulation buying drugs outside the country, 819 controlled substances, 817819 drug abuse, 817 Drug Enforcement Agency (DEA), 817 Food and Drug Administration (FDA), 819 over-the-counter (OTC) drugs, 807, 819 record keeping, 818 See also Dosage calculation; Medication; Medication administration Pharmacotherapeutics, 809810 Pharyngeal tonsils, 749 Pharyngitis (ICD-9-CM code: 462), 503 Pharynx (throat), 748, 749

Phenylketonuria (ICD-9-CM code: 270.1), 661662 PHI. See Protected health information Philosophical divide, 89 Phlebotomy, 868887 capillary (dermal) puncture, 877, 882, 884 blood composition, 882, 884 collection containers, 884 patient preparation for, 885 procedure, 885886 puncture devices, 884 site selection for, 884885 failing to obtain blood, 887 fainting, 886 problem specimens, 887 venipuncture, 868, 869877 accidental needlestick: what to do, 874 blood composition, 868869 gloves, 875 needles, 872875 order of the draw, 877 patient preparation for, 877 phlebotomy tray, 876 plastic adapters, 872 procedure, 868, 877882 site selection for, 876877 syringes, 874 tourniquet, 875 tubes, 870872 winged infusion sets, 874875 See also Coagulation; Hematology; Physicians ofce laboratory (POL) Phlebotomy technicians (RPT), 16, 40 Phlebotomy tray, 876 Phlegm, 30 Phonophobial, 446 Phospholipids, 787788 Photometric reectance, 905 Photophobia, 446 Photophobia (ICD-9-CM code: 368.13), 757758 pH scale, 498 Physical abuse, 65, 67, 674 Physical and personal barriers to learning, 101102 Physical examinations, 346363 assisting, 352353, 354355 dorsal recumbent position, 357 Fowler and semi-Fowler position, 360 jack-knife position, 359 knee-chest position, 359, 360, 361 lithotomy position, 356, 358, 359 Sims position (side-lying or lateral position), 355, 356, 358 sitting position, 354355, 356, 357, 359, 360, 362 supine position, 355, 357, 362 Trendelenburg position, 357, 361 auscultation, 347348 components and ndings, 348, 349352 examination room preparation, 348, 352 height measurement, 362363 inspection, 346

manipulation, 348 menstruation, 348 palpation, 347 patient preparation, 352 patients with special needs, 352 percussion, 347 purpose of, 346 scheduling of, 347 supplies and equipment for, 352 weight measurement, 343 Physical therapists (PTs), 39 Physician assistants (PAs), 38 Physicians, 3435 letters to, 156 nonmedical physician health care providers, 37 specialists, 3536 Physicians Desk Reference, 820 Physicians ofce laboratory (POL), 856857 chemistry, 904917 blood chemistry tests and normal ranges, 905 blood glucose testing, 906908 cardiac panel, 912 chemistry analyzers, 904905 diseases associated with chemistry tests, 912913 electrolyte panel, 911 hepatic panel, 912 lipid testing (cholesterol and triglycerides), 910912 metabolic panel, 912 renal panel, 911 specimen types, 905 thyroid panel, 912 laboratory report, 857859 laboratory requisition slip, 857, 946 rapid streptococcal test, 953, 954955 serology, 913917 antibodyantigen reactions, 913914 blood groups and typing, 914 HIV testing, 915916 mononucleosis testing, 916917 rheumatoid factor (RA), 915 syphilis testing, 916 throat culture test, 951, 953, 955957 urinalysis, 924 See also Hematology; Laboratory tests; Phlebotomy Pill container, 823 Pineal gland, 521 Pink eye, 646 Pinna, 747 Pituitary gland, 521522, 523, 525, 526 anterior lobe, 522 posterior lobe, 522 Placenta, 604 Placenta previa (ICD-9-CM code: 641.00), 619620 Plasma, 869 substances found in, 869 Plasma proteins, 899 Platelet plug, 899

INDEX

1081

Platelets (thrombocytes), 868, 891, 892893, 894 Platform crutches, 730, 736 Plotting growth, 664665 Plumbism (lead poisoning), 660661 Plural forms, 377, 378 PMH. See Past medical history PMI. See Point of maximal impulse PMPM rate. See Per member per month Pneumonectomy, 509 Pneumonia (ICD-9-CM code: 486), 503 PNS. See Peripheral nervous system Point of maximal impulse (PMI), 331 Point-of-service HMOs, 223 Poisoning (ICD-9-CM codes: E850E858, E950E952.9, E962E962.9, E980E982.9), 981 POL. See Physicians ofce laboratory Policies and procedures manual, 192, 193 Policyholder, 204 Polycystic kidney disease (ICD-9-CM codes: 753.13, 753.14), 580 Polycythemia, 898 Polydipsia, 528 Polyphagia, 528 Polypharmacy, 823 Polyunsaturated fats, 786, 787 Polyuria, 528 POMR. See Problem-oriented medical record Popliteal pulse, 334 Portion control, 793794 Positive attitude, 22 Positron emission tomography (PET), 1003 Postal abbreviations, 163164 Posterior tibialis, 334 Postmenopausal women, 687 Postoperative care, 399, 402 Postpartum visit, 629 Postphlebitic syndrome, 478 Potassium hydroxide (KOH) preparation, 633, 945 Potentiation, 816817 Povidone-iodine, 407 PPE. See Personal protective equipment PPM. See Provider-performed microscopy PPOs. See Preferred provider organizations Practice-based scheduling, 134 Practicum. See Externship Praise, 188189 Preceptors, 1008 Preferred provider organizations (PPOs), 223 Prexes, 369371 Pregnancy, 604605 nutrition and, 794, 795 teratogenic (contraindicated) drugs and, 817 urine testing for, 928, 933934 See also Obstetrics and gynecology Pregnancy complications. See Obstetrics and gynecology Prehospital care specialists, 3940 Prehypertension, 470 Premenstrual syndrome (ICD-9-CM code: 625.4), 615 Premiums, 204

Prenatal care, 625629 Prenatal period, 605 Preoperative care, 399, 402 Prepuce. See Foreskin Presbycusis (ICD-9-CM code: 388.01), 696697 Presbyopia (ICD-9-CM code: 367.4), 694, 757 Prescription drugs, 807 See also Pharmacology Prescription information inserts, 820, 822 Prick test. See Scratch test Primary (essential) hypertension, 471 Primary care provider (PCP), 222, 223 Prions, 941 Prior surgical history (PSH), 313 Privacy, ofce design and, 112113 Privacy standards, 79 Private hospitals, 33 Private law, 60 Proactive, vs. reactive, 24 Probes, 385386 Probing and dilating instruments, 384386 Problem-oriented medical record (POMR), 315 SOAP or SOAPE method (subjective, objective, assessment, plan of care, evaluation), 316 Problems, personal, 24 Procaine, 407 Procedural coding, 204208, 221222 See also Coding Procedure recipe cards, 399 Prodromal stage of disease, 291, 292 Professionalism, 1926 barriers to, 24 characteristics of, 2023 professional appearance, 2223 resources for, 26 role models and, 2324 team players and, 24 Professional organizations, 1516 Prociency testing, 854 Prole. See Panel Prots, 261 Progesterone, 603, 604 Program coordinator, 1008 Projection, 4849 Prolactin, 522, 604 Pronation, 726 Pronunciation, 122, 377, 378 Proofreading, 152, 160, 1011 Prostaglandins, 294 Prostate cancer (ICD-9-CM code: 185), 583584 Prostate gland, 570, 571, 586 Prostate surgery, post, 584 Prostatitis (ICD-9-CM codes: 601.0, 601.1), 586 Protected health information (PHI) accounting of disclosures, 79 amendment of, 78 dened, 72 in the medical record, 72 outside release form, 8283 outside the ofce, 77

public health and safety and, 78 release of for non-treatment, payment, or operations (TPO), 7677 safeguards for, 7980 See also Health Information Portability and Accountability Act (HIPAA) Protein, urine and, 927 Protein energy malnutrition, 796 Proteins, 781783, 785786 amino acids (essential and nonessential), 782783 body protein manufacturing, 785786 digestion of, 783, 785 food sources of, 785786 Prothrombin time, 900 Protocol, 968 Protozoa, 289, 939, 942, 944, 945 Provider-performed microscopy (PPM) procedures, 855 Proxemics, 46 PSH. See Prior surgical history Psoriasis (ICD-9-CM code: 696), 426 Psychomotor domain, 97 PTs. See Physical therapists Pulmonary edema, 476 Pulmonary embolism (ICD-9-CM code: 415.1), 478, 976 Pulmonary function tests (spirometry), 509511 Pulmonary tuberculosis (ICD-9-CM code: 011.90), 507508 Pulmonologist, 509 Pulmonology, 495518 aging population and, 690 assisting with examinations, 509 bronchoscopy, 511, 512 incentive spirometry, 513514 lower respiratory system diseases and disorders, 503509 asthma (ICD-9-CM codes: 493.90, 493.20), 505506 bronchitis (ICD-9-CM codes: 466, 491), 505 chronic obstructive pulmonary disease (ICD-9-CM code: 490), 504505 emphysema (ICD-9-CM code: 492.8), 506507 Epstein-Barr virus (ICD-9-CM code: 075), 508 inuenza (ICD-9-CM code: 487), 503504 lung cancer (ICD-9-CM code: 162.9), 508509 pneumonia (ICD-9-CM code: 486), 503 pulmonary tuberculosis (ICD-9-CM code: 011.90), 507 Mantoux test (puried protein derivative test), 511512 medical terminology, 498501 metered-dose inhaler, 507, 513, 515 nebulizer treatments, 513, 516 oxygen therapy, 514515, 516 peak-ow measurement, 512, 513 performing respiratory testing, 510511 pulmonary function tests (spirometry), 509510

1082

INDEX

spacers, 519, 520 structures and functions of the pulmonary system, 503504 lower airway, 503, 504 lungs, 503, 504 upper airway, 503504 upper respiratory diseases and disorders, 504, 507509 allergic rhinitis (ICD-9-CM codes: 477.0, 477.1, 477.2, 477.8), 504, 507 pharyngitis (ICD-9-CM code: 462), 508509 sinusitis (ICD-9-CM codes: 461.9, 473.9), 508 upper respiratory infection (ICD-9-CM code: 460), 507508 Pulse, 331336 apical, 333, 335336 brachial, 333 carotid, 332333 dorsal pedis, 336 factors that affect, 331332 femoral, 336 pediatrics, 670671 popliteal, 336 posterior tibialis, 336 radial, 333, 334 temporal, 332 using pulse points to control bleeding, 332 Pulse decit, 333 Pulse oximeter, 340, 342, 343344 Pulse points, 469 Pulse pressure, 338 Punctur-Guard needle, 877 Purging medical records, 184 Purulent, 296 Puscallosotomy, 450 Pyelonephritis (ICD-9-CM code: 590.80), 582 Pyloric stenosis (ICD-9-CM codes: 537.0, 750.5), 553554

QC. See Quality control Quad cane, 732 Qualitative results, 856 Quality control (QC), 859860, 929 log, 197 Quantitative results, 856 Questions, types of, 311 See also Interviewing patients QuickVue In-Line Strep test, 918 QuickVue urine pregnancy test, 937

RA. See Rheumatoid factor Radial pulse, 333, 334 Radiation, 31 Radiation therapy, 626, 10071008 Radioactive iodine uptake, 541542 Radioallergosorbent test, 434, 658 Radiograph, 997 Radiologic technologist, 40, 1001 Radiologists, 1001

Radiology and diagnostic imaging, 9951010 computer imaging, 1002, 10041007 computed tomography, 1007 magnetic resonance imaging (MRI), 10041007 ultrasound, 1002, 1004 uoroscopy, 10011002 mammography, 10001001 medical assisting and, 997, 1001 nuclear medicine, 10071009 positron emission tomography (PET), 1008 radiation safety, 10081009 radiation therapy, 1008 scheduling, 1009, 1010 x-rays, 9971000, 1005 lm, 997998 patient preparation, 1000, 1005 Radiolucent, 997 Radiopaque, 997 Random urine testing, 925 Range of motion (ROM), 722, 730, 732735 exercises, lower body, 734735 exercises, upper body, 732734 Rapid Streptococcal test, 683, 955, 957, 958959 Rapport, 314 Ratio and proportion dosage calculation, 831 Rationalizations, 48 RBCs. See Red blood cells RBRVS. See Resource-based relative value scale RDs. See Registered dietitians Reactive, vs. proactive, 24 Reading materials, 118 Reagents, 859 Reagent strip, 928 Receivers, 45 Reception area, 114116 Recertication, 1024 Reconciling bank statements, 277282 Recorder, 974 Records management. See Medical records management Records release, 185 Rectal medication administration, 847, 850 Rectal temperature measurement (with digital thermometer), 328329 Red blood cells (RBCs), 483, 547, 872, 873, 898 cell antigens, 919 Redirecting, 311 Reduction of a fracture, 739740 Reed-Sternberg cells, 483 Reference (independent) laboratories, 854, 967 References for drugs, 824, 825826 employees and, 191 See also Websites Referents, 45 Referrals generating, 164, 167168 obtaining, 234 procedures for, 145149 requesting, 200 Reecting, 311 Registered dietitians (RDs), 39

Registered medical assistant (RMA), 1417 continuing certication, 1024 credentialing, 1417, 1020, 10221026 recertication, 1024 Registration form, 73 Regression, 48 Regulatory organizations, 1516 Relaxation, test-taking and, 7 Release of medical records, 185 Reminder notes, 164, 165 Renal angiography, 600 Renal calculi (kidney stones) (ICD-9-CM code: 592), 585586 Renal cancer (ICD-9-CM code: 189.0), 584 Renal computed tomography (CT) scan, 595 Renal failure acute, 586587 chronic, 587588 Renal panel, 915 Renal pelvis, 574 Renal threshold, 930931 Repetitive motion injuries, 114 Repression, 48 Reproductive system, aging population and, 691 See also Obstetrics and gynecology; Urology and the male reproductive system Rescheduling, 144 See also Appointment scheduling Reservoir host, 292293 Residents, 33 Res ipsa loquitor, 56 Resistance to antibiotics, 951953, 954 Resolution stage of grief and loss, 101102 Resource-based relative value scale (RBRVS), 239 Respect, 9192 Respectfulness, 20 Respiration, 334, 336338 depth of, 337338 expiration, 336 external, 336 factors that affect, 337 inspiration, 336 normal rate by age, 337 pediatrics, 670 rate, 337 rhythm, 337 Respiratory syncytial virus (ICD-9-CM code: 079.6), 655 Respiratory system. See Pulmonology Respiratory therapists (RTs), 39 Respondeat superior, 55 Restating, 311 Rest, ice, compression, elevation (RICE), 990 Restitution, 55 Resumes chronological, 1015 functional, 10151016 targeted, 1016, 1017 Reticulocyte count, 902 Retina, 750751, 754755 Retinopathy, 758759, 760 Retractors, 387388

INDEX

1083

Retrovirus, 480 Review of systems (ROS), 314 Rheumatoid arthritis (ICD-9-CM code: 714.0), 718719 Rheumatoid factor (RA), 915, 917 Rh factor, 914, 915 Rhinitis (ICD-9-CM code: 477), 502, 761 Rhonchi, 506 RICE (rest, ice, compression, elevation), 986 Rickets (ICD-9-CM code: 268), 800 Rickettsia, 289 Rinnie test, 770, 771 Risk management, 6162 RMA. See Registered medical assistant RNA, viruses and, 289, 613, 941 R/O. See Rule out Rods, 747748 Roentgenography, 31 Roentgen, Wilhelm Konrad, 31, 32, 993 Roe v. Wade, 86 Role models, 2324 Role play, 105 ROM. See Range of motion ROS. See Review of systems Rotation, 726, 729, 731 Rotator cuff tear (ICD-9-CM codes: 840.4, 726.10), 720721 Routine tests, 856 RPT. See Phlebotomy technicians RTs. See Respiratory therapists Rugae, 538, 540 Rule of Nines, 983 Rule out (R/O), 316 Rumors, 24

Safeguards, for private health information (PHI), 7980 Safe instrument exchange, 399 Safety, 295298 biohazard spill, 297298 bloodborne pathogen exposure, 297 disposal of biohazardous waste, 296297 drug, 819820 geriatric patients and, 697698 in the laboratory, 196197 in the ofce, 118 personal protective equipment, 296 protected health information and public health and safety, 78 radiation, 10041005 sharps and needlestick safety, 296297 vaccinations, 297 Saliva, 539 Salmonella infection (ICD-9-CM code: 003.0), 556 Sandwich approach, 194 Scabies (mites) (ICD-9-CM code: 133.0), 425 Scalpels, 384 Schedule (Medicare fee system), 226 Scheduling. see Appointment scheduling Sciatic nerve injury (ICD-9-CM code: 956.0), 454

Scissors, 383 Sclera, 746749, 750 Scoliosis (ICD-9-CM code: 737.30), 660 Scoliosis (ICD-9-CM code: 737.43), 717 Scope of practice, 56 Scopes, 385 Scratch test, 429, 654 Scrotum, 570, 571 Scurvy (ICD-9-CM code: 267), 800801 Sebaceous (oil) glands, 412413 Sebum, 412 Secondary hypertension, 471, 472 Secondary syphilis (ICD-9-CM code: 091.1), 586587 Second-degree burns (ICD-9-CM codes: 940.2949.2), 983985 Second trimester, 605 Security standard (HIPAA), 72 Seizures, 446447, 974977 See also Epilepsy Self-administration of medication, 846 Self-assessment questionnaires, 310 Self-care, 89 Self-efcacy, 99100 Self-esteem, 99 Self-pay patients, 231 Senders, 45 Sensitive topics, 311312 Sensory system, aging and, 688 See also Ophthalmology and otolaryngology Sepsis, 475 Serological tests. See Physicians ofce laboratory (POL); Hematology; Phlebotomy; Blood glucose testing Serum, 869 Seven rights of medication administration, 831832 Sexual abuse, 65, 67, 674 Sexual activity, aging and, 687 Sexually transmitted diseases (STDs) acquired immune deciency syndrome (AIDS) (ICD-9-CM code: 042), 480481, 613 chlamydia (ICD-9-CM codes: 079.98, 553.3), 586587, 611 genital herpes (ICD-9-CM codes: 054.10, 553.3), 586587, 611 genital warts (ICD-9-CM code: 553.3), 612 gonorrhea (ICD-9-CM codes: 098.0, 553.3), 586587, 612 human papillomavirus (HPV) (ICD-9-CM code: 078.1), 422, 586587 syphilis (ICD-9-CM codes: 091.0, 091.1, 097.1, 553.3), 586587, 612613 SH. See Social history Shock (ICD-9-CM codes: 785.50, 785.51, 785.59), 478 Short-timers syndrome, 1015 Sick-child examination, 672, 673 See also Pediatrics Side-lying or lateral position (Sims position), 355356, 358, 364 Sigmoidoscope, 560, 561562

Silence, 309 Simple carbohydrates, 779 Simplied business letters, 154, 157 Sims position (side-lying or lateral position), 355356, 358, 364 Single bacilli, 939 Sinoatrial node, 464465 Sinuses, 748, 750, 752 Sinusitis (ICD-9-CM codes: 461.9, 473.9), 502503, 752 Sitting position, 356 Skeletal muscles, 709, 710711 actions and names of, 711 See also Orthopedics Skeletal system, 709 See also Orthopedics Skill demonstration tips, 98 Skilled nursing facilities, 703 Skill sets, 1011 Skin common lesions of, 418420 layers and structures of, 412, 413 for protection, 412413 for temperature regulation, 414 See also Dermatology Skin sensors, 7 Skin tags (small noncancerous growths), 398 Slander, 59 Slang, 122124 Sleep apnea, 335 Slings, 735, 740 Small intestine, 538 Smallpox, 30 Smooth muscles, 709, 710, 711 Snake bite (ICD-9-CM code: 989.5), 982983 Snellen eye charts, 668, 762764 SOAP or SOAPE method (subjective, objective, assessment, plan of care, evaluation), 316 Social history (SH), 313 Social learners, 46 Sodium-restricted diet, 796 Soft diet, 796 Software, purchasing, 198 Sole proprietorships, 3334, 58 Solitary learners, 4, 6 Soluble ber, 780 Solutions, 407 SOMR. See Source-oriented medical record Sore throat, 501, 773 Source-oriented medical record (SOMR), 315 Spacers, 513, 514 Spanish inuenza pandemic, 964 Specialists administrative, 4041 medical, 3536 Special needs patients, 352 Specic gravity, urine and, 926 Specimen collection and submission, bioterrorism and, 963964 Specimen collection, handling, and transport, 856857, 859862 See also Laboratory tests; Physicians ofce laboratory (POL)

1084

INDEX

Specimen collection manual, 862 Specimen rejection, 951 Specimen storage, 937 Specula, 384385 Speech therapists (STs), 39 Spermatogenesis, aging and, 687 Sphenoid sinuses, 748 Sphygmomanometer (blood pressure cuff ), 338 Spinal cord, 437 Spinal cord injury (ICD-9-CM code: 344.1paraplegia, 344.0quadriplegia), 449 Spinal fusion, 449, 454 Spinal nerves, 437, 439 Spinal stenosis (ICD-9-CM code: 956.0 sciatic nerve injury, 724.00 spinal stenosis), 454 Spinal tracts, 454 Spiral bacteria, 940, 941, 943 Spirilla bacteria, 289 Spirochetes, 941 Spirometry, 505, 509, 512513 Spleen, 467 Spontaneous pneumothorax (ICD-9-CM code: 512.8), 976 Spores, 288 Sports physical examination, 672 Sprains (ICD-9-CM codes: 840848), 722 Sputum specimen collection for testing, 949, 952953 Squamous cell carcinoma (ICD-9-CM code: M807013), 428 SSI. See Supplemental Security Income Staff meetings, conducting, 189, 192 Staff model HMOs, 223 Staff of Asclepius, 29 Standard of care, 5657 Standard precautions (CDC), 295 Standard cane, 728, 733 Stapes (stirrups) bones, 747 Staphylococci, 939, 941 Staples, 403 Starch, 780 Statin drugs, liver and, 564 STAT reports, 857, 859 Statute of limitations, 61 Statutes, 55 Stat vital signs, 320 STDs. See Sexually transmitted diseases Stem cells, 32 Sterile eld, 388, 392394 Sterile gloving, 394, 395397 Sterile technique (aseptic technique), 387389, 392 Sterile toss, 392 Sterilization, 300301 with an autoclave, 304 Sterols, 788 Stethoscope, 331 Stills disease, 719 Stool card (fecal occult blood test), 559, 560 Stool specimen collection, 559 Stream scheduling, 134135

Strep test QuickVue In-Line, 914 rapid, 683, 951, 953, 954955 Strep throat (ICD-9-CM code: 034.0), 651 Streptobacilli, 939, 942 Streptococci, 939, 941 Stress test, 486 Stroke (ICD-9-CM code: 436) Stromal tumors, 623 STs. See Speech therapists Study strategies, 6 See also Learning styles Subacute care, 33 Subcutaneous injections, 833, 836, 838, 839 Subjective, objective, assessment, plan of care, evaluation. See SOAP or SOAPE Subpoenas, 57 Substance abuse, 817 Sucrose, 779 Sudoriferous (sweat) glands, 412 Sufxes, 370374 Summary of care letter, 160, 161 Summary of patient interview, 308 Suntan, 413 Superbills, 216 Superinfection, antibiotics and, 651652 Supination, 726 Supine position, 355, 357 Supplemental Security Income (SSI), 226 Supplements for children, 681 during pregnancy, 679 See also Minerals; Vitamins Supplies and equipment, for physical examinations, 352353 Suprapubic aspirate urine testing, 921 Surgery. See Minor surgical procedures Surgical asepsis, 305, 307, 386394, 395397, 634 dened, 386387 sterile eld, 388, 392394 sterile gloving, 394, 395397 sterile technique, 387389, 392 surgical scrub, 388, 389391 See also Asepsis Surgical instruments, 382386, 387 biopsy equipment, 386, 387 dilators, 385, 386 grasping-clamping instruments, 384, 385 laryngeal mirror, 386, 387 probes, 385386 retractors, 385386 scalpels, 384 scissors, 383 scopes, 385 specialty instruments, 386 specula, 383385 Surgical packs, wrapping instruments and loading the autoclave, 301304 Surgical procedures. See Minor surgical procedures Surgical scissors, 383 Surgical scrub, 388, 389391

Surgical skin preparation, 400401 Surgical sterilization. See Surgical asepsis Sutures, 403, 404405 Suture scissors (stitch scissors), 383 Sweet mnemonic, 542 Swimmers ear, 758759 Sympathetic nervous system, 939 Symptomatic infected hosts, 291 Synarthrosis, 710 Syncope (fainting) (ICD-9-CM code: 780.2), 886, 977 Syndrome X (metabolic syndrome), 798799 Synergistic drug effect, 815 Syphilis (ICD-9-CM codes: 091.0, 091.1, 097.1, 553.3), 586, 612613 Syphilis testing, 916 Syringes, 874 Systemic circulation, 465 Systemic lupus erythematosus (ICD-9-CM code: 710.0), 426427 Systole, 465 Systolic blood pressure, 336337

Tachypnea, 335 Tactfulness, 2122 Targeted resume, 1011, 1014 Tattoos, 22 Teaching hospitals, 33 Teaching session, organizing, 98 Teaching strategies conversational, 105 group, 105 verbal lecture, 104105 Team captain, 969 Team players, 24 See also Health care team Technical language, 311 Technicians, 40 Teleological philosophies, 89 Telephone collections, 254257 Telephone techniques, 121132 answering service or machine, 130131 automated routing units, 130 caller ID, 124, 128 condentiality and, 122 demonstrating, 125 difcult callers, 130 documentation, 130131 ending calls, 124 etiquette, 122124 incoming calls, 123124, 127128 making outgoing calls, 124 multilingual callers, 123124 nonemergency calls, 129130 taking messages, 128 time zones and, 124, 126 triaging calls, 128129 Temperature, 320329 Celsius vs. Fahrenheit, 329 chemical thermometers, 323 digital thermometers, 321, 323

INDEX

1085

disinfecting thermometers, 328329 factors that affect, 321 fever, 321 glass thermometers, 321, 323 pediatrics, 664, 666 temporal thermometers, 323, 328329 tympanic thermometers, 323, 327, 329 Temporal pulse, 330 Temporal thermometers, 323, 328329 Tendonitis (ICD-9-CM code: 726), 722 Tendons, 709, 712 See also Orthopedics Tennis elbow, 721 TENS. See Transcutaneous electrical nerve stimulation Teratogenic drugs, 817 Terminal-digit ling, 179 Termination of services, 147, 156, 159 Terminations, employee, 194195 Terminology, 374379 abbreviations, 374 cardiovascular and lymphatic systems, 468480 combining forms, 369 directional terms, 377 endocrinology, 532 gastroenterology, 544, 558 geriatrics, 688690 integumentary system, 414417 memorizing, 377379 neurology, 441 obstetrics and gynecology, 607610 ophthalmology and otolaryngology, 752754 origins of medical language, 368 orthopedics, 712, 713718 pathological terms, 374, 376, 377 pediatrics, 642645 plural forms, 377, 378 prexes, 369371 pronunciation, 377, 378 pulmonology, 498501 radiography, 999 sufxes, 370374 translating medical language for patients, 369 translating terms, 376 urology and the male reproductive system, 571, 572576 See also Abbreviations; Pathologic terms; Word elements Testes, 521, 523, 571 Testicular cancer (ICD-9-CM code: 186.9), 584, 585 Testicular self-examination, 584, 585 Test-taking strategies, 5, 78 before, 7 biofeedback, 7 during, 78 meditation and relaxation, 7 Tetrads, 939, 941 Theory (lecture) classes, 4 Therapeutic communication. See Communication; Interviewing patients Therapists, 39

Thermometers. See Temperature Thermotherapy, 736, 738 dry heat, 740741 moist heat, 738, 740 Third-degree burns (ICD-9-CM codes: 940.3949.3), 983984 Third trimester, 605 Thomas Jones vs. State of Illinois, 59 Three-sticker ling system, 178 Throat. See Nose and throat; Ophthalmology and otolaryngology Throat culture life cycle of, 948 specimen collection, 949, 951 testing, 951, 953, 955, 957 Thyroid tests, 535 Thrombin time, 900 Thrombocytes. See Platelets Thrombocytopenia, 899 Thrombophilic disorder, 900 Thrombotic stroke, 444 Thymus, 467 Thymus gland, 521, 522 Thyroid disorders, 530532 hyperthyroidism, 531532 hypothyroidism, 530532 See also Endocrinology Thyroid gland, 521, 522 Thyroid panel, 912 Thyroid scan, 535 Thyroid stimulating hormone, 522, 523 Thyroid tests, 535 Time zones, 124, 126 Tinea (ringworm) (ICD-9-CM code: 110.9, 110.0, 110.1, 110.4, 110.3), 424 Tinnitus (ICD-9-CM code: 388.3), 759760 Tissue adhesive, 981 Title I: Insurance Reform (HIPAA), 74 Title II: Administrative Simplication (HIPAA), 7475 patients right to access, 7779 privacy protection, 75, 77 reduced cost, 7475 Title IV of the Social Security Act, 226 Title XIX of the Social Security Act, 226 T-lymphocytes, 522 Tobacco, pregnancy and, 628 Tolerance (to drugs), 815 Tongue, 539540, 752 Tonsillitis (ICD-9-CM code: 463), 761 Topical medication administration, 841, 845846 Torts, 55, 5859 Total cholesterol, 910911 Total mastectomy, 622 Touch, 46 Tourniquet, 875 Towel clamps, 384, 385 Toxic effect of drugs, 815 Toxic shock syndrome (ICD-9-CM code: 040.89), 615 TPO. See Treatment, payment, or operations Tracking medical records, 181 Trade names (drugs), 810811

Traditional insurance, 224 Transaction code sets (HIPAA), 7475 Transactions, 74 Transcription, 169171 medical transciptionist, 41 Transcutaneous electrical nerve stimulation (TENS), 741, 742743 Transdermal patch, 845846 Transducer, 998 Transection of spinal cord, 449 Transferring a patient from an examination table to a wheelchair, 723, 724725 Transferring a patient from a wheelchair to an examination table, 723724 Transient ischemic attack (ICD-9-CM code: 435), 445 Translating terms, 369, 376 Traumatic brain injury (concussion, ICD-9-CM code: 850.9) (contusion, ICD-9-CM code: 851), 448449 Travel arrangements, 198, 199 Treatment, payment, or operations (TPO), 169, 184 protected health information (PHI) and, 7881 release of protected health information for non TPO purposes, 7677 Trendelenburg position, 357, 361 Triage, 971972 appointments and, 138139, 140, 142, 144145 triaging calls, 128129, 142, 144145 Trials, 58 Triangular arm sling, 736, 740 Tricare (CHAMPUS), 228 Trichomoniasis (ICD-9-CM code: 553.3), 613 Triglycerides, 787, 908, 910 Trimesters, 605606 Troponin level, 474 Trust, 91 Truthfulness, 88 Tubal ligation, 630 Tuberculosis (ICD-9-CM code: 011.90), 507508 Tubes for blood, 869872 color meaning, 870872 size selection, 870, 872 Tuning fork tests, 770, 771 Turbid, 926 24-hour urine testing, 921 2-hour postprandial glucose test, 906 Tympanic membrane, 650 in otitis media, 759 Tympanic thermometers, 321, 323, 327 Tympanostomy, 650 Type I diabetes, 527, 528 Type II diabetes, 527, 528529

UCR. See Usual, customary, and reasonable Ulcerative colitis (ICD-9-CM code: 556.9), 551, 980 Ulcers, 546547 Ultrasonography, 32

1086

INDEX

Ultrasound, 564, 637, 741, 10001002 coding, 637 Umbilical cord care, 671 Undernutrition, 796 Uninsured Americans, 231 United States Pharmacopeia-National Formulary, 820 United States recommended daily allowances (USRDA), 681 Upper airway, 497498 See also Pulmonology Upper respiratory diseases and disorders. See Pulmonology Upper respiratory infection (ICD-9-CM code: 460), 502 Ureters, 568, 569570, 921 Urethal meatus, 601, 602 Urethra, 568, 569570, 921 Uric acid metabolism, 718 Urinalysis, 576, 577, 919934 characteristics of urine, 920921 chemical components, 926927 bilirubin, 927 blood, 927 glucose, 926927 ketones, 927 leukocytes, 927 nitrite, 927 pH, 926 protein, 927 urobilinogen, 927 collection procedure, 921923 microscopic components, 927, 928932 pediatrics, 677678 performing, 932933 physical components, 925926 clarity, 925926 color, 925, 926 glucose, 926927 odor, 926 specic gravity, 926 in the physicians ofce laboratory (POL), 920 pregnancy testing, 928, 933, 934 quality control, 925 reagent strips, 924 specimen types, 921 urinary system overview, 920, 921 urine analyzer, 924925 See also Urology and the male reproductive system Urinary bladder, 568, 569570, 921 Urinary system, aging population and, 687 See also Urology and the male reproductive system Urinary system diseases and disorders. See Urology and the male reproductive system Urinary tract infections (UTIs) (bacterial cystitis and urethritis (ICD-9-CM codes: 595.9, 597.80)), 576577, 687 Urine albumin, 582 Urine glucose test, 535 Urobilinogen, 927

Urology and the male reproductive system, 567598 assisting with examinations, 588 blood urea nitrogen, 595 catheterization, 588589, 590593 creatinine, 595 cystoscopy, 594 intravenous pyelography, 593594 kidneys, 568, 569, 570, 687 male reproductive system, 570571 male reproductive system diseases and disorders, 582587 balanoposthitis (ICD-9-CM code: 607.1), 586 benign prostatic hypertrophy (ICD-9-CM code: 600.2), 582583 epididymitis (ICD-9-CM code: 604.90), 586 erectile dysfunction (ICD-9-CM codes: 607.84, 302.72), 587 prostate cancer (ICD-9-CM code: 185), 583584 prostatitis (ICD-9-CM codes: 601.0, 601.1), 586 sexually transmitted diseases (ICD-9-CM codes), 586587 testicular cancer (ICD-9-CM code: 186.9), 584, 585 medical terminology, 571, 572576 nephrons, 568, 569, 570 renal angiography, 595 renal computed tomography (CT) scan, 589, 593 structures and functions of, 568571 ureters, urinary bladder, and urethra, 568, 569570 urinary system diseases and disorders, 576582 acute renal failure (ICD-9-CM code: 584), 580582 bacterial cystitis and urethritis (ICD-9-CM codes: 595.9, 597.80), 576577 bladder cancer (ICD-9-CM code: 239.4), 578 chronic renal failure (ICD-9-CM code: 585), 582 glomerulonephritis (ICD-9-CM codes: 580, 582), 577578 hydronephrosis (ICD-9-CM code: 591), 579580 polycystic kidney disease (ICD-9-CM codes: 753.13, 753.14), 580 pyelonephritis (ICD-9-CM code: 590.80), 577 renal calculi (kidney stones) (ICD-9-CM code: 592), 580 renal cancer (ICD-9-CM code: 189.0), 578579 Wilms tumor (ICD-9-CM code: 189.0), 579 vasectomy, 595 voiding cystourethrography, 594 See also Urinalysis U.S. Army Medical Research Institute for Infectious Diseases, 962

U.S. Department of Health and Human Services (HHS), 82, 204 Usefulness, 89 U.S. Public Health Service, 297 USRDA. See United States recommended daily allowances Usual, customary, and reasonable (UCR), 234, 239 Uterine ablation, 636 Uterine cancer (ICD-9-CM code: 179), 623 Uterine dilator, 386 Uterine disorders. See Obstetrics and gynecology Uterine broids (ICD-9-CM code: 218.9), 616617 Uterine prolapse (ICD-9-CM code: 618.1), 617618 Uterus, 601 Utilitarianism, 89 Utility, 89 Utilization review, 222 UTIs. See Urinary tract infections

Vaccinations, 295, 297 immunization schedule, 675 for inuenza, 504 objections to, 676 vaccine information sheet, 676 vaccine registry, 674, 676 Vacutainer Eclipse needle, 873 Vagina, 601602 Vaginal infections. See Obstetrics and gynecology Vaginal medication administration, 841, 843 Vaginal specula, 384, 385 Validation, 49 Variable costs, 260 Varicose veins (ICD-9-CM code: 454), 477478 Vas deferens, 570, 571 Vasectomy, 595, 630 Vasoconstriction, 710 Vasodilation, 710 V codes (ICD-9-CM), 213 Vector, 289 Venipuncture. See Phlebotomy Venous blood, 534 Venules, 466 Veracity, 88 Verbal communication, 46 Verbal lectures, 104105 Versatility, 1213 See also Front ofce-back ofce connection Vertebral column, 439 Vertical les, 174 Vertigo (ICD-9-CM code: 386.2), 760 Very-low-density lipoprotein (VLDL), 910 Vesalius, Andreas (Father of Modern Anatomy), 30 Vial preparation for injections, 832, 834835 Vibrio, 941, 943 Vicarious liability, 55 Vinci, Leonardo da, 30 Viral culture, 945 Viral hepatitis (ICD-9-CM codes: 070.1, 070.30, 070.51, 070.54, 070.52, 070.53), 551552 Viral skin infections, 422423

INDEX

1087

Viruses, 291, 941, 943, 944 life cycle of, 943 shapes of, 944 Vision screening, pediatrics, 668 Visual acuity, 758 Ishihara color vision test, 762, 765766 measuring near, 762, 765766 Snellen eye charts, 668, 762764 See also Ophthalmology and otolaryngology Visual learners, 56 Visual reinforcement audiometry, 668 Vital signs (VT), 320341 blood pressure, 336339 oxygen saturation, 339341 pediatrics, 664666 prociency taking, 320 pulse, 329334 respiration, 332, 334336 stat vital signs, 320 temperature, 320329 See also Headings under each vital sign Vitamins, 789790 for children, 680681 Vitreous humor, 747, 751 VLDL. See Very-low-density lipoprotein Voice box, 497 Voiding cystourethrography, 594 Volkmann retractor, 386 Vomiting (emesis), 547 VT. See Vital signs Vulva, 601602

W-2. See Wage and Tax Statement Wage and Tax Statement (W-2), 271274 Waived tests, 854 See also Clinical Laboratory Improvement Amendment Walk cane, 733 Walkers, 727728, 733734 Warfarin (Coumadin), 899 Warts (ICD-9-CM code: 078.10 (common warts)), 422, 653 Warts (ICD-9-CM code: 553.3 (genital)), 612 Washing hands, 298300 Waste products, 541 Water, 790, 792 Wave scheduling, 135 WBC. See White blood cells Weber test, 770 Websites accreditation programs, 17 American Association of Medical Assistants (AAMA), 26 American Medical Technologists (AMT), 26 Applied Psychophysiology and Biofeedback, 10 appointment scheduling, 149 billing and collections, 257 bioemergencies, 966 bioethics, 93 business communications, 171 cardiology and lymphatics, 494 certied medical assistant (CMA) credentialing programs/examination, 17, 1022

coding and insurance, 246 communication, 52 continuing education, 26 credentialing, 17, 1022 cultural competency articles, 52 dermatology, 434 disease prevention, 306 dosage calculation and medication administration, 848 endocrinology, 536 gastroenterology, 566 geriatrics, 706 health care team, 42 Help Guide, 10 hematology and coagulation, 902 HIPAA and patients rights, 84 infection control, 306, 410 interviewing patients, 318 job searches, 1022 laboratory tests, 866, 918 learning styles, 10 legal considerations, 70 medical assisting and examination review and preparation, 1022 medical records management, 186 medical terminology, 380 microbiology, 958 Mind Tools, 52 minor surgery, 410 neurology, 460 nutrition, 804 obstetrics and gynecology, 619, 640 ofce emergencies, 990 ofce environment, 120 ofce management, 202 ophthalmology and otolaryngology, 776 orthopedics, 744 patient education, 108 pediatrics, 682 pharmacology, 824 phlebotomy, 888 physical examinations, 366 physicians ofce laboratory (POL), 918 professionalism, 26 pulmonology, 518 radiology and diagnostic imaging, 1006 registered medical assistant (RMA) credentialing, 17, 1022 telephone techniques, 132 urinalysis, 934 urology and the male reproductive system, 598 vital signs, 344 Wedge resection, 509 Weight gain, during pregnancy, 627 Weight-loss diets, 796 Weight measurement, 359, 362 pediatrics, 663 Well-child examination, 668670 Western blot test, 480, 916 Wet preparation, 611, 633 White blood cells (WBC), 467, 479, 868, 869 agranulocytes, 892 granulocytes, 892 urine and, 927

White matter, 436, 437 White space, 1010 Whole blood, 868, 869, 890 Wilms tumor (ICD-9-CM code: 189.0), 579 Windpipe, 497 Winged infusion sets (buttery needle), 874, 883 Withdrawal and deposit report, 275 Withdrawal of care letter, 61 Word elements, 368376 cardiovascular and lymphatic systems, 468469 endocrinology, 524525 gastroenterology, 542543 geriatrics, 688689 integumentary system, 414415 neurology, 442 obstetrics and gynecology, 608609 ophthalmology and otolaryngology, 752753 orthopedics, 712713 pediatrics, 643644 pulmonology, 498499 radiography, 994 urology and the male reproductive system, 571573 Word root, 369 Workers compensation, 228230 Workow, 113 World Health Organization (WHO) disinfecting thermometers, 328 pandemic phases, 964 Wound care anesthetics, 407408 bandages, 405, 407 creams, ointments, and solutions, 407 dressings, 403, 405, 406 staples, 403, 405 sutures, 403405 Wound specimen collection for testing, 952 Write-offs, 239 Writing checks, 267 payroll, 268269 Writing-dependent learners, 56

X-ray lm, 995 X-rays, 31, 995998 gonad shields, 998 patient preparation and assisting, 995999 upper and lower GI, 561 See also Radiology and diagnostic imaging X-ray views, 995996

Yeasts, 942, 944 Yellow bile, 30 Yellow Pages advertisement, 202 You language, 4950

Z-track injection, 838, 843 Zygote, 604605