Download - Physical Assessment Slide Show
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Physical Assessmentthe 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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Medical/Surgical History
Serious illnesses
Hospitalizations Surgery
Drug allergies or unusual reactions
Meds since LMP
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Family History
Maternal
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 inches
Wt in Kgs / Ht meters
http://www.whathealth.com/bmi/calculator.html
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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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Beaus lines
Lines coincide with
periods of acuteillness 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 thesternocleidomastoid
muscle
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Check Jaw for Dysfunctional TMJ
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The mouth
Angular cheilitis
B vitamindeficiency
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 resolvespontaneously
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 doesntextend 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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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 inpregnancy
Important to explore history
Important to explore other signs & symptoms
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Signs & symptoms
Hypothyroid
Cold intolerance Slow pulse
Thin, dry hair & dry,puffy skin
Fatigue
Thick tongue
Delayed relaxationof Achilles reflex
Hyperthyroid
Heat intolerance Rapid pulse
Flushed, sweating
Anxious
Fine tremors
Exaggeratedreflexes
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Palpation of the thyroid
Best palpated withexaminer 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 withiodine 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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Scoliosis
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The Back Costovertebral angle
Use your fist to
strike the anglemade by the ribs
and the spine
Do this gently, as
there is extremetenderness with
pyelonephritis
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Lung fields
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Auscultation points
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Lungs sounds (the CliffNotes)
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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Deep tendon reflexes
Most commonlyassessed: Patellar
Achilles
: absent reflex
1+: trace, or seen only
with reinforcement
2+: normal
3+:brisk
4+: nonsustained
clonus (i.e., repetitivevibratory movements)
5+: sustained clonus
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Reinforcement
When unable to obtain a patellar reflex, have
the patient hook together their flexed fingersand pull apart.
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Patellar reflex
Leg should dangle
freely Support the thigh
above the knee
Tap sharply on the
space just beneaththe knee cap
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Achilles reflex
Loosely support the ballof the foot.
Sharply tap the Achillestendon
Note whether plantarflexion and dorsiflexionare equal
Delayed dorsiflexion isa possible sign ofhypothyroidism
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Clonus
Hold the relaxed lower
leg in your hand
Sharply dorsiflex the
foot and hold it
dorsiflexed.
Feel for oscillationsbetween flexion and
extension of the foot.
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Babinski reflex
The great toe flexes towardthe top of the foot and theother toes fan out after the
sole of the foot has beenfirmly stroked.
Abnormal after the age of 2.
Indicates damage to thenerve paths connecting thespinal cord and the brain
May be seen for a short timeafter 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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Flow murmur
You are listening to an innocent flow murmur.
Caused by abnormally high flow throughnormal 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 bedescribed 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 intothe left atrium.
This is common in young adult women.
It can present as attacks of palpitations, anxiety, orlight-headedness.
Although rarely serious, patients with mitral valveprolapse with regurgitation by echo are givenantibiotic prophylaxis during invasive procedures toprevent 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 differencebetween the ventricles is generated almost instantly
at the onset of systole, with a left to right shuntcontinuing throughout ventricular contraction.
There is usually no diastolic component to themurmur.
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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 atrialoutput is delivered to the ventricles.
If the ventricle is stiff and non-compliant, as inventricular hypertrophy due to long-standinghypertension, the atrial contraction produces an
S4.
A good mnemonic to remember the cadence andpathology 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 withstethoscope partly off chest
6/6 - may be heard with stethoscopecompletely off chest; +/- thrills
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Positions of cardiac auscultation
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Abdominal assessment
Inspect abdomen 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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Diastasis recti
A separation between theleft and right side of therectus abdominis muscle,
which covers the frontsurface of the abdomen
Diastasis recti is a commonand normal condition innewborns. It is seen mostfrequently in premature andAfrican-American infants.
It is also common in womenpostpartum
A diastasis recti appears asa ridge running down themidline of the abdomen fromthe 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 Homans sign
Abnormalities of toe nails
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Edema
1+ slight pitting, disappears rapidly (2 mm)
2+ deeper pit, disappears in 10-15 secs.(4 mm)
3+ pit is noticeably deep and may last more than a minute. Theextremity looks fuller & swollen (6 mm)
4+ the pit is very deep, lasts 2-5 mins, and the extremity isgrossly 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
(+ Homans 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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Homans sign
Elicitation:With the
knee in the flexed
position, forcibly
dorsiflex the ankle.
Response:Pain in the
calf with this maneuveris consistent with deep
venous thrombosis.
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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 fromeach 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 incomparison 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, noburning, usually no symptoms
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Malignant melanoma
Atypical mole of the
trunk.
The center is elevatedand 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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Thanks!!!!!!