The following presentation on history, physical and pelvic examination, laboratory tests, and adjunctive studies is not meant to be a definitive work on the subject of physical assessment. Several excellent textbooks detailing the content of and procedures and skills used in physical diagnosis are listed in the bibliography. What is presented here, rather, is an outline of what is included in a history, physical and pelvic examination, laboratory tests, and adjunctive studies that will initially screen a woman for ab- normality and determine normalcy. Assessment of the neonate is discussed in Chapters 37, 39, and 80.
Before 1970, routine physical assessment by nurse-midwives consisted primarily of thorough examination of the breasts and the pelvis; limited examination of the mouth, throat, thyroid gland, abdomen, and extremities; and hemoglobin, hematocrit, urinalysis, and Pap smear. In the early 1970s, however, nurse-midwives added intercon- ceptional care to their services by virtue of their involvement in family planning and in accord with their philosophy of providing continuity of care. It became clear from nurse-midwives’ work in family planning that the only physical exami- nation many women received from year to year was the one the nurse-midwives were doing when the woman returned for her annual or semiannual family planning visit. Obviously, the physical ex- amination being done was inadequate for pur- poses of detecting medical problems not related to contraceptive methods. The solution was for nurse-midwives to learn the content, procedures, and skills of a total history and physical exami- nation. Physical assessment was added to the cur- riculum in nurse-midwifery education programs, and in-service education was held for staff nurse- midwives. By 1974, physical assessment was an accepted part of nurse-midwifery practice. The comprehensiveness of this examination has increased through the years, in keeping with the expansion of nurse-midwifery practice into gyne- cology and the primary care of women from pu- berty through senescence.
A screening examination is aimed at detecting relatively gross evidence of abnormalities and dis- ease. Any such findings start the process of formu- lating a differential diagnosis for discussion with the consulting physician or referral to a medical specialist. The midwife has the responsibility of ob- taining a relevant history in relation to any abnor- mality detected. This history becomes part of the
midwife’s report to the consulting physician or spe- cialist and addresses the following questions:
Is the woman aware of the abnormality?
What brought the abnormality to her attention (e.g., she has pain; she was told during a previ- ous physical)?
Are any related symptoms present?
How long has the abnormality been present, and what has been its course since discovery?
Has the woman ever been seen and treated for the abnormality?
By whom?
When?
What was the diagnosis as the woman understands it?
What was the treatment?
How effective was the treatment?
Is she continuing to receive care for this abnormality?
In taking a history and doing a physical and pelvic examination, midwives go into greater detail in those areas germane to childbearing, pregnancy, gynecology, and family planning than is usual for a woman admitted to a medical unit for a diagnostic workup. This is not surprising, because most often a woman sees a midwife for preventive health care or conditions related to the reproductive tract. For this reason the following outline of a history, physical and pelvic examination, and laboratory tests lacks detail for some body systems but offers considerable detail for aspects specifically related to women’s health care. It includes concerns about domestic vi- olence, occupational hazards, sexually transmitted diseases, HIV/AIDS, and substance abuse. It also in- cludes skills, detailed in Part 8, that are not strictly related to the reproductive system but are frequently used. Examples include checking for costovertebral angle (CVA) tenderness, because urinary tract infec- tions are a common complaint of women, and checking deep tendon reflexes, essential in evaluat- ing the possible severity of preeclampsia.
History
Principles of History Taking (Figure 2-1):
1.Introduce yourself and state what you are going to do and your purpose for doing it.
2.Observe all rules of interviewing:
a. Use open-ended, not closed-ended, ques- tions.
b. Ask only one question at a time.
c. Avoid leading questions or questions that
“put answers in the woman’s mouth.”
d. Clarify what the woman’s behavior means to her.
e. Use a level of terminology the woman will understand.
3.Be tactful and respectful of the woman’s right to privacy about her person and personal life at all times.
4.Listen to the woman with interest and concern, and be responsive to what she is saying. For ex- ample, if she is talking about a past difficult time in her life, a response denoting sympa- thetic understanding is appropriate.
5.Be responsive to requests for clarification or in- formation.
6.Be precise, thorough, and accurate in obtaining all essential information.
7.Keep the history taking focused without wast- ing time on a wandering line of questioning.
8.Screen out and do not record any irrelevant ma- terial.
9.Allow the woman time to answer. Don’t inter- rupt unless she starts to ramble or you need clarification.
10.Listen to the woman carefully. She may in one answer give an answer to a later question as well. If so, don’t repeat the later question. Also, don’t make her repeat what she just said be- cause you weren’t paying attention.
11.Follow up on unclear responses, pertinent in- formation, or pertinent information not di- rectly related to the current question.
12.Be sure you understand what the woman is say- ing. Accents and expressions vary from one part of the country to the next. Don’t hesitate to ask the woman to spell or explain words she is using.
13.Do not express negative judgments through facial expression, body language, or tonal inflection.
14.Provide as much privacy from being overheard as possible.
15.Speak in well-modulated, soothing, calming tones.
16.Maintain eye contact—don’t always be reading from the history form, writing responses, and charting.
17.Don’t ask a question unless you can explain to the woman your reason for asking it. A woman may consider social, sexual, economic, educa- tional, occupational, and housing information extremely personal. Not all of the information that can be obtained in these areas is necessary information. You should obtain such informa- tion only with a purpose, because otherwise the woman may interpret your questioning as pry- ing into her personal life and react accordingly.
For example:
a. Housing is important to ascertain. Some women are homeless, and life in shelters lim- its their ability to maintain personal hygiene and exposes them to a higher incidence of certain diseases, such as tuberculosis. Other women may be in group homes for drug re- habilitation, mental retardation, protection from domestic violence, etc.
b. Sexual and substance use histories have be- come imperative as part of screening for sex- ually transmitted diseases and for HIV/AIDS.
c. Before talking about diet and meal prepara- tion with a woman, you should know if she does the grocery shopping and meal prepa- ration. When possible, include the person who does these chores in your discussion if it is not the woman herself.
d. Before talking about taking showers or soak- ing in a tub of warm or hot water, you should know what bathing facilities a woman has, if any.
e. Knowing a woman’s occupation and house- hold responsibilities is important in identify- ing risks for such job-related injuries as carpal tunnel syndrome and environmental hazards, and, if pregnant, in ascertaining ap- propriate job restrictions and planning rest periods with her feet elevated.
Identifying Information 1.Name
2.Age
3.Race/ethnicity 4.Gravida and para 5.Address/telephone 6.Religion
FIGURE 2-1 A midwife taking a woman’s history.
7.Marital status 8.Occupation 9.Date of interview Chief Complaint (CC)
The reason the woman is seeing you in the clinic, office, emergency room, birth center, hospital, or her home, as stated in her own words (may relate to any body system).
History of Present Illness (HPI) (relates to the chief complaint or problem)
1.Date and time of onset 2.Mode of onset
3.Precipitating or predisposing factors related to onset
4.Course since onset, including duration and re- currence
5.Specific location
6.Type of pain or discomfort and severity or in- tensity
7.Other associated symptoms
8.Relationship to bodily functions and activities 9.Description of quality (color, consistency) and quantity (amount, volume, or number), if ap- plicable (e.g., rash, discharge, bleeding) 10.Factors influencing the problem, either aggra-
vating or relieving
11.Previous medical help (and from whom) for this problem; diagnosis and treatment
12.Effectiveness of any treatments or medications used (self- or medically initiated)
Past Medical and Primary Care History (includes social history)
1.Childhood diseases/immunizations, such as measles (type), mumps, or chickenpox
2.Recent laboratory screening tests for infectious diseases (e.g., hepatitis, measles, tuberculosis, HIV); date, result
3.Major illnesses (e.g., pneumonia, hepatitis, rheumatic fever, diphtheria, polio)
4.Hospitalizations; date, reason 5.Surgery; date, reason
6.Accidents; fractures, injuries, unconsciousness 7.Blood transfusions; date, reason, reaction 8.Allergies (e.g., food, hay fever, environmental,
dust, animals; asthma) 9.Drug allergies
10.Alcohol abuse/alcoholism; treatment
11.Drug abuse/addiction; substance(s), treatment 12.Habits
a. smoking (amount; duration) b. alcohol (amount; duration)
c. caffeine (coffee, tea, sodas, chocolate) d. “recreational” drugs (substance, amount;
duration)
e. safety (seat belts, helmets) 13.Sleep patterns
14.Diet/malnutrition 15.Exercise/leisure activity
16.Occupational hazards: position (standing, sit- ting), strain (eye, muscle), ventilation, exposure to toxic chemicals
17.Environmental hazards: air, water, sewage, lack of window screens, open fireplace, lead paint 18.Childhood physical/sexual abuse
19.Domestic violence/battering/rape/isolation: his- torical, current; safety
20.Genetic screening tests, when applicable (e.g., sickle cell, Tay-Sachs, G6PD, fragile X, cystic fi- brosis); results
21.Specific diseases a. diabetes
b. heart disease (diagnosis, e.g., mitral valve prolapse), including rheumatic fever c. tuberculosis
d. asthma e. liver/hepatitis
f. kidney/urinary tract infections (UTI) g. varicosities/thrombophlebitis
h. glandular/endocrine (diagnosis, e.g., hypo/
hyperthyroidism)
i. gastrointestinal (diagnosis e.g., gastric ulcer) j. cancer
k. hypertension l. HIV/AIDS
m.mental illness (diagnosis: e.g., depression, bipolar)
n. epilepsy
o. blood dyscrasias, such as anemia (type) p. eating disorders (diagnosis, e.g., bulimia,
anorexia) 22.Medications
a. prescription b. nonprescription
Family History (pertains to mother, father, siblings, grandparents, aunts, and uncles)
1.Mother, father, siblings a. age
b. status, i.e., living and well? If deceased, what was the cause of death?
2.Mental retardation 3.Cancer
4.Heart disease 5.Hypertension 6.Diabetes 7.Kidney disease 8.Mental illness 9.Congenital anomalies 10.Multiple pregnancies 11.Tuberculosis
12.Epilepsy
13.Blood dyscrasias, such as anemia (type) 14.Allergies
15.Genetic disorders
16.Autoimmune disorder (e.g., lupus) Menstrual History
1.Age at menarche
2.Frequency; range if irregular 3.Duration
4.Amount of flow
5.Characteristics of flow (e.g., clots)
6.Last menstrual period (LMP); duration and amount normal?
7.Dysmenorrhea
8.Dysfunctional uterine bleeding, i.e., intermen- strual spotting or bleeding, menorrhagia, metrorrhagia
9.Sanitary product use (tampons, pads) 10.Toxic shock syndrome
11.Premenstrual symptoms/premenstrual syn- drome (PMS)
12.Perimenopausal symptoms Sexual History
1.Type of sexual relationship (heterosexual, ho- mosexual, bisexual)
2.Monogamous relationship or number of partners 3.Partner monogamous or number and type of
partners
4.Sexual frequency, satisfaction 5.Satisfaction with sexual relationship 6.Problems
a. insufficient foreplay b. insufficient lubrication c. lack of personal consideration d. pain, vaginismus
e. fear of becoming pregnant f. fear of hurting fetus, if pregnant
g. problems of partner (e.g., impotence, prema- ture ejaculation)
h. postcoital bleeding i. sexual violence Obstetric History
1.Gravida/para (four- or five-digit system) 2.Rh and ABO blood type
3.Each pregnancy a. date of termination b. weeks gestation
c. where delivered, i.e., hospital (name), child- birth center (name), home
d. length of labor
e. type of delivery (spontaneous, C-section, forceps, vacuum extraction)
f. RhoGAM received
g. any obstetric, medical, or social problems (1)during pregnancy (e.g., preeclampsia,
UTI, domestic violence)
(2)during labor and delivery (e.g., malpre- sentation, malposition, preeclampsia, eclampsia, pitocin induction, pitocin stimulation, major perineal laceration, cervical laceration)
(3)during postpartum period (e.g., UTI, hemorrhage, uterine infection, depres- sion, domestic violence)
h. weight of baby at birth i. sex of baby
j. any congenital anomalies or neonatal com- plications (e.g., jaundice, respiratory prob- lems)
k. status of infant at birth (alive or dead) l. present status of infant (e.g., living and well,
problems, cause of death) Gynecological History
1.Infertility
2.Diethylstilbestrol (DES) exposure
3.Vaginal infections (i.e., monilia, bacterial vagi- nosis)
4.Sexually transmitted diseases (STD) (i.e., chlamydia, syphilis, gonorrhea, herpes, trichomonas, condylomata acuminata)
5.Chronic cervicitis 6.Endometritis
7.Pelvic inflammatory disease (PID) 8.Cysts (Bartholin’s, ovarian) 9.Endometriosis
10.Myomas
11.Pelvic relaxations (cystocele, rectocele) 12.Polyps
13.Breast masses
14.Abnormal Pap smears
15.Biopsies (cervical, endometrial, breast) 16.Gynecological cancer
17.Gynecological surgery 18.Rape
Contraceptive History
1.Whether contraception is wanted 2.Knowledge of contraceptive options 3.Present contraceptive method
a. type b. satisfaction c. side effects d. consistency of use
e. length of time using this method 4.Previous contraceptive methods
a. types
b. duration of use for each c. side effects of each
d. reasons for discontinuing each Hormone History
1.Reason for use of contraceptive hormones (e.g., to regulate menses)
2.Hormone replacement therapy a. present, past, how long used b. type
c. side effects Douching History
1.Frequency 2.Method 3.Solutions used 4.Reasons for douching
5.Length of time woman has been douching 6.Last time douched
Review of Systems
The review of systems (ROS) is a structured inquiry about past or current symptoms or complaints re- lated to each body system. Because some examiners prefer to do the review of systems during the phys- ical examination, usually in the interest of saving time, and because it makes sense to ask questions about specific systems, organs, or body parts while they are being examined, the ROS is included in the following outline of the physical examination and designated as such. Combining the ROS with the examination has caused information about some systems (the lymphatic and hematopoietic systems, the central nervous system, and the endocrine sys-
tem) to be split up so as to tie them to specific body structures. The advantage of proceeding this way is that it eliminates repetition.
Physical Examination
Principles of Doing a Physical Examination (Figure 2-2):
1.Wash your hands immediately before doing the examination.
2.Be sure that your fingernails are clean and cut to a length that will not hurt the woman.
3.Warm your hands prior to touching the woman by washing them in warm water, rubbing them together, or holding them under a lamp.
4.Tell the woman what you will be doing in gen- eral. During the examination itself, tell the woman more specifically what you will be doing just before doing it—that is, let her know where you will be touching her, what you want her to do, and whether this portion of the ex- amination will be uncomfortable.
5.Use a touch that is gentle yet firm enough not to tickle the woman and as firm as needed to elicit accurate information.
6.Let your approach and touch bespeak respect for her body as well as respect for her right to modesty and privacy.
FIGURE 2-2 A midwife doing a physical examination of a woman.
7.Drape the woman in such a way that only the area being examined at that particular point during the exmaination is exposed.
8.Organize your examination as follows:
a. Progress from head to toe.
b. Minimize movement of the woman; e.g., while having her sit up so you can inspect her breasts, also listen to her lungs from the back, observe and palpate for spinal defor- mities, and check for CVA tenderness rather than having her return to a sitting position several times during the examination.
c. Wait until the end of the examination to touch parts of the body that will require you to rewash your hands (e.g., the bottom of her feet).
d. Make sure the examination progresses in the same way for every woman; this will help you to remember everything.
9.Be alert for any inconsistency between the woman’s history and your physical findings.
10.Share your findings with the woman. If she is anxious about something that you find to be normal, immediately tell her your findings. If you find something that concerns you because it may be a possible deviation from normal, tell her that you are not sure of what you have found and want a physician to check it.
Remember, it is the woman’s body and she has a right to know everything about it. Be honest and truthful with her.
Physical Measurements 1.Temperature 2.Pulse 3.Respirations 4.Blood pressure 5.Height
6.Weight General ROS:
1.Woman’s evaluation of own health status 2.Woman’s evaluation of own dietary patterns 3.Unusual weight changes
4.Weakness 5.Fatigue 6.Malaise
7.Fever, chills, sweating
8.Woman’s evaluation of own emotional status 9.Ability to carry out activities of daily living Observations:
1.Appropriateness of appearance for age
2.General nutritional status 3.Apparent state of health 4.General personal appearance
5.General mental and emotional state: speech;
appropriateness of mood or affect; general mood (e.g., anxiety, depression); orientation to time, place, person; memory; logic and coher- ence of thought processes; general behavior (e.g., hostile, friendly, cooperative, confused) 6.Striking or obvious findings (e.g., pallor,
cyanosis, respiratory distress, persistent cough, voice or speech abnormality, facial asymmetry, orthopedic abnormalities)
7.General posture, gait, body movements
Skin and Hair ROS:
1.Skin a. pruritus b. rashes
c. moles: any change noted d. lesions
e. tendency to bruise
f. general character (i.e., dry, oily) g. hirsutism
2.Hair and scalp
a. general character (i.e., dry, oily) b. loss of hair
c. wearing wig or not; if so, why d. scalp infections, dandruff, lice Observations and examination:
1.Skin
a. temperature
b. color: pigmentation, pallor, cyanosis, jaun- dice
c. moisture d. turgor e. moles f. scars
g. rashes, lesions, bruises
h. patterns of injury, showing repetition of in- jury: fresh or in various stages of healing (e.g., cigarette burns)
i. tumors 2.Hair and scalp
a. hair pattern
b. scalp infections, dandruff, lice, lesions c. bald spots (alopecia)
d. general character (i.e., dry, oily) e. lumps
Head ROS:
1.Headaches: location, duration, time of day when they occur, frequency, type of pain, sever- ity, relief measures and their effectiveness, any known causative factors, associated symptoms (e.g., nausea and vomiting, dizziness)
2.Dizziness
3.Syncope (fainting) 4.Sinusitis
Observations and examination:
1.Size, shape, contour, symmetry 2.Facial symmetry
3.Location of facial structures 4.Involuntary movements
5.Tenderness over frontal and maxillary sinuses Eyes
ROS:
1.Blurring of vision
2.Scotomata (blind spots in vision) 3.Diplopia (double vision)
4.Spots before eyes 5.Flashing lights
6.Pressure or pain symptoms 7.Photophobia (sensitivity to light) 8.Lacrimation (excessive tearing) 9.Discharge, redness, burning
10.Woman’s evaluation of her own visual acuity and any recent changes
11.Glasses or contact lenses: for what, last time eyes examined, last time prescription changed 12.Injuries
13.Diseases or conditions Observations and examination:
1.Eyelids: closure, edema, signs of infection, blinking, squinting, masses, lesions, ptosis (drooping eyelid)
2.Eyelashes: matting from discharge, absence 3.Lacrimal ducts: signs of infection, tenderness 4.Involuntary eye movements
5.Color of lower conjunctival sac 6.Color of sclera
7.Abrasions or opacities of lens and cornea 8.Strabismus (cross-eyes)
9.Size, shape, and equality of pupils
10.Parallel movement of eyes and gross visual fields 11.Pupillary reaction to light and accommodation 12.Protrusion of eyeball and intraocular pressure
as determined by finger tension
13.Ophthalmoscopic examination a. presence of red reflex
b. color and outline of optic disc
c. color, size, and shape of retinal vessels d. hemorrhagic areas
e. color and shape of macula and fovea f. papilledema
Ears ROS:
1.Woman’s evaluation of her own hearing acuity and any recent changes
2.Earaches 3.Discharge
4.Tinnitus (ringing in the ears) 5.Vertigo (lack of balance) 6.Infections, injuries 7.Pain
Observations and examination:
1.Enlargement or tenderness of mastoid 2.General hearing acuity
3.Placement of ears on head
4.Shape, growths, lesions, and discharge noted in auricles and outlets of external ear canal 5.Color, obstruction, lesions, edema, discharge,
foreign objects in external auditory canal 6.Otoscopic examination of tympanic membrane
a. color
b. bulging or retraction c. bony landmarks
d. cone of light: presence or absence e. scars, perforations
Nose ROS:
1.Nasal obstruction (difficulty with nasal breath- ing)
2.Epistaxis (nosebleeds)
3.Discharge: nasal and postnasal
4.Woman’s evaluation of her own sense of smell 5.Injuries
6.Frequency of colds
Observations and examination:
1.Flaring of nares
2.Deformity or septal deviation
3.Symmetry, size, placement, including symmetry of nasolabial fold
4.Patency of nostrils
5.Perforation of nasal septum 6.Nasal speculum examination