physical assessment slide show

8/6/2019 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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