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Physical Assessment the Pregnant Woman
Happy Barnes, CNM ATM Conference May 2006
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Review of Systems – 1st Trimester
Nausea Vomiting Headaches Dizziness Cramping Urinary frequency Pain with urination Changes in discharge (amount, color, odor) Pruritis Bleeding
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Review of System – 2nd Trimester
Gums bleeding Nose bleeding Constipation Fetal movement Cramping Bleeding Dysuria Abnormal discharge pruritis
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Review of Systems – 3rd Trimester
Indigestion Swelling Leg cramps Fetal movement Difficulty sleeping Contractions Bleeding Calf pain Headaches Epigastric pain Visual changes
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History - Menstrual Menarche Interval Length
Recent birth control or lactation LMP Sure of date? Normal in length & flow Other helpful tidbits Date of conception ER sonogram
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Obstetric History Dates of all pregnancies (include previous miscarriage or termination) GA Gender, weight Length of labor Coping techniques Route of delivery Special events AP, IP, PP, Neo
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Gynecologic History Last Pap Abnormal pap
Gyn surgery or problems (e.g. infertility) Family planning methods Sexually transmitted infections
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Medical/Surgical History
Serious illnesses Hospitalizations Surgery Drug allergies or unusual reactions Meds since LMP
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Family History Maternal Maternal or Paternal Diabetes CAD
Pre-eclampsia Preterm delivery Cancers (breast, ovarian, colon) Depression, bipolarity Twins Anesthesia reactions Maternal or Paternal Birth defects Mental retardation Bleeding disorders Chromosomal abnormalities (e.g. Dpwn Syndrome)
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Vital Signs Temperature Blood pressure Respirations Radial pulse
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Additional Measurements
Height Weight BMI Wt in lbs X 730 / Ht in inches² Wt in Kgs / Ht meters²
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The hands and nails Clubbing – caused by chronic hypoxia Severe asthma
Severe anemia, e.g. sickle cell disease COPD Cardiac conditions Disappearance of “diamond” seen when nails opposed
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Beau’s lines Lines coincide with periods of acute illness or stress
Caused by disruption of nail plate growth
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Koilonychia Spoon-shaped nails Chronic iron deficiency anemia
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Cyanosis of nail beds
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Simian crease Certain syndromes (Down, FAS, Turner, Klinefelter, trisomy 13) In 3% of normal population
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HEENT – Lymph Nodes Occipital Posterior cervical Supraclavicular
Anterior cervical Parotid Submandibular Submental
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Lymph Nodes Anterior cervical chain
Located along the sternocleidomastoid muscle
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Check Jaw for Dysfunctional TMJ
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Pregnancy and the mouth
Hypertrophy of the gums Increased vascularity Changes in salivary composition Increased plaque deposition Exposure to stomach acids (1st trimester) Loosening of teeth (3rd trimester)
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The mouth Angular cheilitis B vitamin deficiency Fungal infections
Over-biting
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The mouth Actinic cheiliosis Sun exposure Precancerous (SC)
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“Gingivitis of pregnancy”
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The mouth Mild aphthous ulcer (AKA canker sore) Viral, bacterial
Stress Underlying immune disease if frequent
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Oral candidiasis (thrush)
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The tongue The normal tongue
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The tongue Geographic tongue “designs” shift May resolve spontaneously
Often asymptomatic
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The tongue Black hairy tongue ideopathic candidiasis antibiotics
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The tongue Blacker and hairier tongue
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Ankyloglossia (tongue tie)
Heart-shaped Tongue doesn’t extend over lower gum ridge Clicking noise while nursing
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Severe tongue tie
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Throat Deviated uvula Can be a normal finding
In conjunction with other symptoms, indicates a central nervous system lesion.
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Enlarged Tonsils
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Chronic tonsilitis Large tonsils Chronic inflammation Crypts
Tonsilar “stones”
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Superficial Nasal Sinuses
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Eyes Pupillary light reflexes
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Swinging Light Test
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Chalazion (plugged sebaceous gland)
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Conjutivitis – bacterial (strep)
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Conjuctivitis - allergic
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Conjunctivitis - viral
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Conjunctivitis - gonococcal
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The eyes - pterygium
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The eyes - icterus
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The thyroid Some amount of thyromegaly is normal in pregnancy
Important to explore history Important to explore other signs & symptoms
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Signs & symptoms Hypothyroid Hyperthyroid Cold intolerance Slow pulse
Thin, dry hair & dry, puffy skin Fatigue Thick tongue Delayed relaxation of Achilles reflex Hyperthyroid Heat intolerance Rapid pulse Flushed, sweating Anxious Fine tremors Exaggerated reflexes
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Palpation of the thyroid
Best palpated with examiner behind Have patient swallow Palpate both lobes
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Normal position of the thyroid
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The thyriod Massive goiter
Seen in areas with iodine deficient soil (at the base of rocky mountain ranges) This woman is from the mountains of Viet Nam
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The Neck - Acanthosis nigrans
Appears slowly without symptoms Dark, velvety skin with markings and creases Neck, armpits, and groin Associated with obesity, Type II DM, PCOS, some cancers Can be normal, isolated finding
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The Back Scoliosis Rib prominence Curving spine Uneven waist
Lumbar prominence
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Scoliosis
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The Back – Costovertebral angle
Use your fist to strike the angle made by the ribs and the spine Do this gently, as there is extreme tenderness with pyelonephritis
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Auscultation of the lungs
Warm your stethoscope. Use the diaphragm. Move from one point to the same point on the other side, to compare sounds There are 3 lobes on the right & 2 on the left Always assess the posterior back If there are concerns, check the anterior fields, also
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Lung fields
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Auscultation points
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Lungs sounds (the Cliff Notes)
Normal breath sounds Crackles Rhonchi Wheezes
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Normal breath sounds Normal vesicular breath sounds.
Heard over most of the peripheral lung fields. Soft, low pitched, and with a gentle rustling quality. In this sample you can also hear the heart beat in the background
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Crackles (rales) Scattered wet crackles. Also known as coarse rales
Usually caused by excessive fluid in the airways. Crackles are typically inspiratory. Dry crackles sound more like rubbing hair together next to your ear or like the sound of opening Velcro.
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Wheezes Wheezes are ususally expiratory
Caused by air forced through collapsed airways with residual trapping of air. Commonly associated with asthma May also be caused by airway swelling, tumor, or obstructing foreign bodies.
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Deep tendon reflexes Most commonly assessed: 0: absent reflex
Patellar Achilles 0: absent reflex 1+: trace, or seen only with reinforcement 2+: normal 3+: brisk 4+: nonsustained clonus (i.e., repetitive vibratory movements) 5+: sustained clonus
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Reinforcement When unable to obtain a patellar reflex, have the patient hook together their flexed fingers and pull apart.
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Patellar reflex Leg should dangle freely
Support the thigh above the knee Tap sharply on the space just beneath the knee cap
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Achilles reflex Loosely support the ball of the foot.
Sharply tap the Achilles tendon Note whether plantar flexion and dorsiflexion are equal Delayed dorsiflexion is a possible sign of hypothyroidism
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Clonus Hold the relaxed lower leg in your hand
Sharply dorsiflex the foot and hold it dorsiflexed. Feel for oscillations between flexion and extension of the foot.
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Babinski reflex The great toe flexes toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked. Abnormal after the age of 2. Indicates damage to the nerve paths connecting the spinal cord and the brain May be seen for a short time after a seizure. Also seen in ALS, tumors, head injury, meningitis, MS, stroke, some forms of polio, spinal cord injury.
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Visual Inspection Retractions Increased vascularity Skin changes
Dimpling Marked differences in configuration Spontaneous discharge As she moves, note any differences in mobility or visible masses
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Positions for visual inspection
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Lateral and medial patterns
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Method of palpation
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Levels of palpation
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Additional aspects of exam
Evaluate the supraclavicular notches Evaluate the tail of Spence and axilla Check for nipple discharge
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The cardiac cycle S1 and S2 (Lub-Dub) are the most obvious normal sounds This is a normal sinus rhythm, with a sharp S1 and S2 S1 marks the beginning of systole, and is created when the heart muscle’s contraction causes closing of the tricuspid and mitral (or AV) valves. At the end of systole, the ventricles begin to relax, and the pressures within the heart become less than that in the aorta and pulmonary artery A brief back flow of blood causes the semilunar valves to snap shut, producing S2.
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Flow murmur You are listening to an innocent flow murmur.
Caused by abnormally high flow through normal valves. These are very common in pregnancy. The murmur is in early systole, has a definite start and end point, is crescendo-decrescendo in shape, and could be described as “twangy”.
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Mitral valve prolapse This is a murmur of mitral valve prolapse.
The papillary muscles fail to firmly hold the mitral valve during late systole, and the valve bulges into the left atrium. This is common in young adult women. It can present as attacks of palpitations, anxiety, or light-headedness. Although rarely serious, patients with mitral valve prolapse with regurgitation by echo are given antibiotic prophylaxis during invasive procedures to prevent bacterial endocarditis.
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Aortic regurgitation This murmur is caused by aortic valve regurgitation. 3:1 ratio male:female. 2/3 are secondary to rheumatic heart disease Other causes are congenital, syphilis infection, Marfan syndrome, or valvular damage due to infective endocarditis. The most notable aspect of the murmur is the diastolic sound characterized as a blowing decrescendo.
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VSD (ventricular septal defect)
This murmur is heard best over the lower left sternal border, radiating to the right lower sternal border. It is caused by blood flowing through a hole in the wall between the right and left ventricles. It is a holosystolic because the pressure difference between the ventricles is generated almost instantly at the onset of systole, with a left to right shunt continuing throughout ventricular contraction. There is usually no diastolic component to the murmur.
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S4 or gallop A fourth heart sound, or S4, is due to a stiff ventricle.
The late stage of diastole is marked by atrial contraction, or kick, where the final 20% of the atrial output is delivered to the ventricles. If the ventricle is stiff and non-compliant, as in ventricular hypertrophy due to long-standing hypertension, the atrial contraction produces an S4. A good mnemonic to remember the cadence and pathology of an S4 is: “a-STIFF-wall a-STIFF-wall”
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Grading murmurs 1/6 - very faint; not always heard in all positions
2/6 - quiet but not difficult to hear 3/6 - moderately loud 4/6 - loud +/- thrills 5/6 - very loud +/- thrills; may be heard with stethoscope partly off chest 6/6 - may be heard with stethoscope completely off chest; +/- thrills
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Positions of cardiac auscultation
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Abdominal assessment Inspect abdomen Listen for bowel sounds
contour asymmetry scars, rashes, or other lesions. Listen for bowel sounds present, increased, decreased, absent, high-pitched Light palpation for tenderness most sensitive indicator is facial expression voluntary or involuntary guarding may also be present. Deep palpation for masses
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Rebound tenderness This is a test for peritoneal irritation. Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness.
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Diastasis recti A separation between the left and right side of the rectus abdominis muscle, which covers the front surface of the abdomen Diastasis recti is a common and normal condition in newborns. It is seen most frequently in premature and African-American infants. It is also common in women postpartum A diastasis recti appears as a ridge running down the midline of the abdomen from the bottom of the breastbone to the navel.
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Measurement of the diastasis
It is measured with the woman supine and relaxed, then again as she lifts her head. It is recorded as fingerbreadths: relaxed/contracted.
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The lower extremities Edema Signs of deep vein thrombosis Homan’s sign
Abnormalities of toe nails
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Edema 1+ slight pitting, disappears rapidly (2 mm)
2+ deeper pit, disappears in secs.(4 mm) 3+ pit is noticeably deep and may last more than a minute. The extremity looks fuller & swollen (6 mm) 4+ the pit is very deep, lasts 2-5 mins, and the extremity is grossly distorted (8 mm)
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Pedal edema
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Edema
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Deep vein thrombosis Swelling of the affected extremity.
Area over vein may be red, discolored. Area may be tender, warm to the touch Pain with stretching of the overlying muscle (+ Homan’s sign). May have systemic symptoms, i.e., fever, chills, flu-like symptoms, shortness of breath.
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DVT left saphenous vein.
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Homan’s sign Elicitation: With the knee in the flexed position, forcibly dorsiflex the ankle. Response: Pain in the calf with this maneuver is consistent with deep venous thrombosis.
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Dermatophyte infection of toe nails
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The skin Our largest and heaviest organ
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Linea negra
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Melasma
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Atypical moles Number of moles: Often over 50
Uniformity: Neighboring moles differ from each other Size: Many over 5mm, usually some over 8mm Color: Multiple shades of tan, brown, black, red and pink, often variegated
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Atypical moles, cont. Elevation: Center is only slightly raised in comparison with the relatively large diameter Perimeter (edge): Often irregular, usually fuzzy, edges blend imperceptibly with surrounding skin "Shoulder": Outer periphery is usually flat and tan, often with a pink base Surface: Often mammillated with tiny outward dome-like dimples Symptoms: No pain, no itching, no tenderness, no burning, usually no symptoms
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Malignant melanoma Atypical mole of the trunk.
The center is elevated and the size of a pencil eraser. Note an appearance close to a "fried egg."
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The ABCDs of abnormal moles
A. Asymmetry: One-half of the mole does not match the other half B. Border of the mole is jagged or irregular C. Color – more than one is present D. Diameter is greater than 5 mm (the size of a pencil eraser)
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Asymmetry
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Border
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Color
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Diameter
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