Physical Assessment the Pregnant Woman

Happy Barnes, CNM ATM Conference May 2006

Review of Systems 1st Trimester

     

Nausea Vomiting Headaches Dizziness Cramping Urinary frequency

 

 

Pain with urination Changes in discharge (amount, color, odor) Pruritis Bleeding

Review of System 2nd Trimester

   

Gums bleeding Nose bleeding Constipation Fetal movement

    

Cramping Bleeding Dysuria Abnormal discharge pruritis

Review of Systems 3rd Trimester

    

Indigestion Swelling Leg cramps Fetal movement Difficulty sleeping

     

Contractions Bleeding Calf pain Headaches Epigastric pain Visual changes

History - Menstrual
   

Menarche Interval Length Recent birth control or lactation

LMP

Sure of date? Normal in length & flow Date of conception ER sonogram

Other helpful tidbits

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

Gynecologic History
    

Last Pap Abnormal pap Gyn surgery or problems (e.g. infertility) Family planning methods Sexually transmitted infections

Medical/Surgical History
    

Serious illnesses Hospitalizations Surgery Drug allergies or unusual reactions Meds since LMP

Family History


Maternal

Maternal or Paternal

Diabetes CAD Pre-eclampsia Preterm delivery Cancers (breast, ovarian, colon) Depression, bipolarity Twins Anesthesia reactions

Birth defects Mental retardation Bleeding disorders Chromosomal abnormalities (e.g. Dpwn Syndrome)

Vital Signs
   

Temperature Blood pressure Respirations Radial pulse

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

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

Beaus lines


Lines coincide with periods of acute illness or stress Caused by disruption of nail plate growth

Koilonychia


Spoon-shaped nails

Chronic iron deficiency anemia

Cyanosis of nail beds

Simian crease

Certain syndromes (Down, FAS, Turner,

Klinefelter, trisomy 13)

In 3% of normal population

HEENT Lymph Nodes

      

Occipital Posterior cervical Supraclavicular Anterior cervical Parotid Submandibular Submental

Lymph Nodes


Anterior cervical chain

Located along the sternocleidomastoid muscle

Check Jaw for Dysfunctional TMJ

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)

The mouth


Angular cheilitis B vitamin deficiency Fungal infections Over-biting

The mouth

Actinic cheiliosis

Sun exposure Precancerous (SC)

Gingivitis of pregnancy

The mouth


Mild aphthous ulcer (AKA canker sore)

Viral, bacterial Stress Underlying immune disease if frequent

Oral candidiasis (thrush)

The tongue

The normal tongue

The tongue

Geographic tongue

designs shift May resolve spontaneously Often asymptomatic

The tongue

Black hairy tongue

ideopathic candidiasis antibiotics

The tongue

Blacker and hairier tongue

Ankyloglossia (tongue tie)

 

Heart-shaped Tongue doesnt extend over lower gum ridge Clicking noise while nursing

Severe tongue tie

Throat


Deviated uvula

Can be a normal finding In conjunction with other symptoms, indicates a central nervous system lesion.

Enlarged Tonsils

Chronic tonsilitis
 

 

Large tonsils Chronic inflammation Crypts Tonsilar stones

Superficial Nasal Sinuses

Eyes


Pupillary light reflexes

Swinging Light Test

Chalazion (plugged sebaceous gland)

Conjutivitis bacterial (strep)

Conjuctivitis - allergic

Conjunctivitis - viral

Conjunctivitis - gonococcal

The eyes - pterygium

The eyes - icterus

The thyroid

 

Some amount of thyromegaly is normal in pregnancy Important to explore history Important to explore other signs & symptoms

Signs & symptoms



Hypothyroid

Hyperthyroid

Cold intolerance Slow pulse Thin, dry hair & dry, puffy skin Fatigue Thick tongue Delayed relaxation of Achilles reflex

Heat intolerance Rapid pulse Flushed, sweating Anxious Fine tremors Exaggerated reflexes

Palpation of the thyroid

Best palpated with examiner behind Have patient swallow Palpate both lobes

Normal position of the thyroid

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

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

The Back


Scoliosis

Rib prominence Curving spine Uneven waist Lumbar prominence

Scoliosis

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

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

Lung fields

Auscultation points

Lungs sounds (the Cliff Notes)

   

Normal breath sounds Crackles Rhonchi Wheezes

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

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.

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.

Deep tendon reflexes



Most commonly assessed:

    

Patellar Achilles

: absent reflex 1+: trace, or seen only with reinforcement 2+: normal 3+: brisk 4+: nonsustained clonus (i.e., repetitive vibratory movements) 5+: sustained clonus

Reinforcement


When unable to obtain a patellar reflex, have the patient hook together their flexed fingers and pull apart.

Patellar reflex


Leg should dangle freely Support the thigh above the knee Tap sharply on the space just beneath the knee cap

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

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.

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.

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

Positions for visual inspection

Lateral and medial patterns

Method of palpation

Levels of palpation

Additional aspects of exam

  

Evaluate the supraclavicular notches Evaluate the tail of Spence and axilla Check for nipple discharge

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 muscles 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.

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 crescendodecrescendo in shape, and could be described as twangy.

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.

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.

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.

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

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

Positions of cardiac auscultation

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

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.

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.

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.

The lower extremities

   

Edema Signs of deep vein thrombosis Homans sign Abnormalities of toe nails

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. 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)

Pedal edema

Edema

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.

DVT left saphenous vein.

Homans 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.

Dermatophyte infection of toe nails

The skin


Our largest and heaviest organ

Linea negra

Melasma

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

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 domelike dimples Symptoms: No pain, no itching, no tenderness, no burning, usually no symptoms

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."

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)

Asymmetry

Border

Color

Diameter

Thanks!!!!!!