1. Physical Assessmentthe Pregnant Woman Happy Barnes, CNM ATM Conference May 2006

2. Nausea Vomiting Headaches Dizziness Cramping Urinary frequency Pain with urination Changes in discharge (amount, color, odor) Pruritis Bleeding Review of Systems – 1st Trimester

3. Gums bleeding Nose bleeding Constipation Fetal movement Cramping Bleeding Dysuria Abnormal discharge pruritis Review of System – 2nd Trimester

4. Indigestion Swelling Leg cramps Fetal movement Difficulty sleeping Contractions Bleeding Calf pain Headaches Epigastric pain Visual changes Review of Systems – 3rd Trimester

5. Menarche Interval Length Recent birth control or lactation LMP Sure of date? Normal in length & flow Other helpful tidbits Date of conception ER sonogram History - Menstrual

6. 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

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

8. Medical/Surgical History • Serious illnesses • Hospitalizations • Surgery • Drug allergies or unusual reactions • Meds since LMP

9. 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) Family History

10. Vital Signs • Temperature • Blood pressure • Respirations • Radial pulse

11. 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

12. 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

13. Beau’s lines • Lines coincide with periods of acute illness or stress • Caused by disruption of nail plate growth

14. Koilonychia • Spoon-shaped nails • Chronic iron deficiency anemia

15. Cyanosis of nail beds

16. Simian crease • Certain syndromes (Down, FAS, Turner, Klinefelter, trisomy 13) • In 3% of normal population

17. HEENT – Lymph Nodes • Occipital • Posterior cervical • Supraclavicular • Anterior cervical • Parotid • Submandibular • Submental

18. Lymph Nodes • Anterior cervical chain • Located along the sternocleidomastoid muscle

19. Check Jaw for Dysfunctional TMJ

20. 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)

21. The mouth • Angular cheilitis • B vitamin deficiency • Fungal infections • Over-biting

22. The mouth • Actinic cheiliosis • Sun exposure • Precancerous (SC)

23. “Gingivitis of pregnancy”

24. The mouth • Mild aphthous ulcer (AKA canker sore) • Viral, bacterial • Stress • Underlying immune disease if frequent

25. Oral candidiasis (thrush)

26. The tongue The normal tongue

27. The tongue • Geographic tongue • “designs” shift • May resolve spontaneously • Often asymptomatic

28. The tongue • Black hairy tongue • ideopathic • candidiasis • antibiotics

29. The tongue Blacker and hairier tongue

30. Ankyloglossia (tongue tie) • Heart-shaped • Tongue doesn’t extend over lower gum ridge • Clicking noise while nursing

31. Severe tongue tie

32. Throat • Deviated uvula • Can be a normal finding • In conjunction with other symptoms, indicates a central nervous system lesion.

33. Enlarged Tonsils

34. Chronic tonsilitis • Large tonsils • Chronic inflammation • Crypts • Tonsilar “stones”

35. Superficial Nasal Sinuses

36. Pupillary light reflexes Eyes

37. Swinging Light Test

38. Chalazion (plugged sebaceous gland)

39. Conjutivitis – bacterial (strep)

40. Conjuctivitis - allergic

41. Conjunctivitis - viral

42. Conjunctivitis - gonococcal

43. The eyes - pterygium

44. The eyes - icterus

45. The thyroid • Some amount of thyromegaly is normal in pregnancy • Important to explore history • Important to explore other signs & symptoms

46. 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 Signs & symptoms

47. Palpation of the thyroid • Best palpated with examiner behind • Have patient swallow • Palpate both lobes

48. Normal position of the thyroid

50. 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