Transcript Physical Assessment of Women

Physical Assessment
the Pregnant Woman
Happy Barnes, CNM
ATM Conference
May 2006
Review of Systems – 1st Trimester
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Nausea
Vomiting
Headaches
Dizziness
Cramping
Urinary frequency
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Pain with urination
Changes in discharge
(amount, color, odor)
Pruritis
Bleeding
Review of System – 2nd Trimester
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Gums bleeding
Nose bleeding
Constipation
Fetal movement
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Cramping
Bleeding
Dysuria
Abnormal discharge
pruritis
Review of Systems – 3rd Trimester
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Indigestion
Swelling
Leg cramps
Fetal movement
Difficulty sleeping
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Contractions
Bleeding
Calf pain
Headaches
Epigastric pain
Visual changes
History - Menstrual
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Menarche
Interval
Length
Recent birth control or
lactation
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LMP
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Sure of date?
Normal in length & flow
Other helpful tidbits
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Date of conception
ER sonogram
Obstetric History
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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
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Last Pap
Abnormal pap
Gyn surgery or problems (e.g. infertility)
Family planning methods
Sexually transmitted infections
Medical/Surgical History
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Serious illnesses
Hospitalizations
Surgery
Drug allergies or unusual reactions
Meds since LMP
Family History
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Maternal
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Diabetes
CAD
Pre-eclampsia
Preterm delivery
Cancers (breast,
ovarian, colon)
Depression, bipolarity
Twins
Anesthesia reactions
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Maternal or Paternal
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Birth defects
Mental retardation
Bleeding disorders
Chromosomal
abnormalities (e.g. Dpwn
Syndrome)
Vital Signs
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Temperature
Blood pressure
Respirations
Radial pulse
Additional Measurements
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Height
Weight
BMI
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Wt in lbs X 730 / Ht in inches²
Wt in Kgs / Ht meters²
http://www.whathealth.com/bmi/calculator.html
The hands and nails
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Clubbing – caused
by chronic hypoxia
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Severe asthma
Severe anemia, e.g.
sickle cell disease
COPD
Cardiac conditions
Disappearance of
“diamond” seen when
nails opposed
Beau’s lines
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Lines coincide with
periods of acute
illness or stress
Caused by
disruption of nail
plate growth
Koilonychia
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Spoon-shaped nails
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Chronic iron deficiency anemia
Cyanosis of nail beds
Simian crease
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Certain syndromes
(Down, FAS, Turner,
Klinefelter, trisomy 13)
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In 3% of normal
population
HEENT – Lymph Nodes
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Occipital
Posterior cervical
Supraclavicular
Anterior cervical
Parotid
Submandibular
Submental
Lymph Nodes
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Anterior cervical chain
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Located along the
sternocleidomastoid
muscle
Check Jaw for Dysfunctional TMJ
Pregnancy and the mouth
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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
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Angular cheilitis
– B vitamin
deficiency
– Fungal infections
– Over-biting
The mouth
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Actinic cheiliosis
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Sun exposure
Precancerous (SC)
“Gingivitis of pregnancy”
The mouth
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Mild aphthous ulcer
(AKA canker sore)
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Viral, bacterial
Stress
Underlying immune
disease if frequent
Oral candidiasis (thrush)
The tongue
The normal tongue
The tongue
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Geographic tongue
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“designs” shift
May resolve
spontaneously
Often asymptomatic
The tongue
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Black hairy tongue
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ideopathic
candidiasis
antibiotics
The tongue
Blacker and hairier
tongue
Ankyloglossia (tongue tie)
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Heart-shaped
Tongue doesn’t
extend over lower
gum ridge
Clicking noise while
nursing
Severe tongue tie
Throat
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Deviated uvula
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Can be a normal finding
In conjunction with other
symptoms, indicates a
central nervous system
lesion.
Enlarged Tonsils
Chronic tonsilitis
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Large tonsils
Chronic
inflammation
Crypts
Tonsilar “stones”
Superficial Nasal Sinuses
Eyes
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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
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Some amount of thyromegaly is normal in
pregnancy
Important to explore history
Important to explore other signs & symptoms
Signs & symptoms
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Hypothyroid
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Cold intolerance
Slow pulse
Thin, dry hair & dry,
puffy skin
Fatigue
Thick tongue
Delayed relaxation
of Achilles reflex
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Hyperthyroid
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Heat intolerance
Rapid pulse
Flushed, sweating
Anxious
Fine tremors
Exaggerated
reflexes
Palpation of the thyroid
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Best palpated with
examiner behind
Have patient
swallow
Palpate both lobes
Normal position of the thyroid
The thyriod
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Massive goiter
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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
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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
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Scoliosis
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Rib prominence
Curving spine
Uneven waist
Lumbar prominence
Scoliosis
The Back – Costovertebral angle
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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
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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)
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Normal breath sounds
Crackles
Rhonchi
Wheezes
Normal breath sounds
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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)
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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
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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
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Most commonly
assessed:
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Patellar
Achilles
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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
Reinforcement
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When unable to obtain a patellar reflex, have
the patient hook together their flexed fingers
and pull apart.
Patellar reflex
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Leg should dangle
freely
Support the thigh
above the knee
Tap sharply on the
space just beneath
the knee cap
Achilles reflex
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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
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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
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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
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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
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Evaluate the supraclavicular notches
Evaluate the tail of Spence and axilla
Check for nipple discharge
The cardiac cycle
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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.
Flow murmur
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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
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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
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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)
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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
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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
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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
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Inspect abdomen
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Listen for bowel sounds
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present, increased, decreased, absent, high-pitched
Light palpation for tenderness
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contour
asymmetry
scars, rashes, or other lesions.
most sensitive indicator is facial expression
voluntary or involuntary guarding may also be present.
Deep palpation for masses
Rebound tenderness
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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
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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
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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
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Edema
Signs of deep vein thrombosis
Homan’s sign
Abnormalities of toe nails
Edema
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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
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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.
DVT left saphenous vein.
Homan’s sign
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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
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Our largest and heaviest organ
Linea negra
Melasma
Atypical moles
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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.
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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
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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
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