Physical Assessmentthe 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

Other helpful tidbits– Date of conception– ER sonogram

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– 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)

Vital Signs

Temperature Blood pressure Respirations Radial pulse

Additional Measurements

Height Weight BMI

– Wt in lbs X 730 / Ht in inches²– Wt in Kgs / Ht meters²– 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

Beau’s 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 doesn’t

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– 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

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

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

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 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

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”.

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 Homan’s 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

(+ Homan’s sign). May have systemic symptoms, i.e., fever,

chills, flu-like symptoms, shortness of breath.

DVT left saphenous vein.

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.

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 dome-like 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

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