Well Woman

Physical OBJECTIVES:
Dan Bright RN, MSN
• Improve our observational and listening skills
Ed.
• Increase our medical knowledge

• Effectively perform a full history and complete physical

methodically and thoroughly
The Interview

• Introduce yourself and your status (nurse, PA, midwife)

• Observation (overview- “doorway assessment”)

• Importance of the exam (provides baseline, potentially identify current issues)

• Assure confidentially

• Short explanation of how the exam will progress

 Menarche?
Pain/meds?
Menstrual Last Pap?
History LMP?
Flow?
Regular?
 • Past and current methods?

• Problems?
Contraceptiv
e History • Satisfaction?

• Need Education?
OB/GYN History

• Gravida, para?

• Term/premature?

• Delivery?

• Number of living children?

• Problems during pregnancies?

Medical Surgical
History
• Childhood diseases?
• Current immunizations?
• Transfusions?
• Surgeries?
• Chronic disease/meds?
• Alcohol use?
• Tobacco?
 Mother: G,P, endometriosis, osteoporosis,
female or other cancers, congenital disease?

Family History Father: CA, DM, CV, congenital diseases?

Siblings- any significant histories?

 • Occupation?
• Support system?
•8
Occupational / • Quality of primary relationship?
Social History
• Abuse, verbal/physical/sexual?
• Nutritional status?
• Access knowledge of a healthy diet?
• Exercise/activity levels?
Review of Systems

Does the If they answer Pain related? Ask about:

patient Yes, you need Pain scale 1 Location,
currently to know: -10 Duration,
have any Onset, Severity, and
problems that Duration, Treatment
need Current status
investigation?
Review of Systems
Dr. Jessica
Nishikawa DNP,
NP
 • Excessive daytime
sleepiness?
• Fatigue?
• Fevers?
Constitution • Low energy?
• Trouble getting to sleep?
• Trouble staying asleep?
• Weight gain?
• Weight loss?
 Hearing problems?
Earaches?
Nasal congestion?
Postnasal drip?
Sore throat?
HEENT Headache?
Scalp problems?
Corrective lenses?
Eye diseases?
 • Chest pain?
• Dyspnea (SOB)?
• Edema?
• Exercise tolerance?
Heart and
• Wheeze?
Lungs • Cough?
• Exposure to TB?
• On any cardiac
medications?
 Breast feeding?

SBE?

Mammogram? Guidelines are changing

Breast Pain?

Lumps?

Nipple discharge?
Abdomen
Appetite?

Nausea?

Vomiting?

Constipation?

Diarrhea?

Hemorrhoids?

Gastritis (heartburn, reflux)?

 • Vaginal bleeding? (not on
period- dysfunctional
bleeding)
• Last Pap?
• Vaginal discharge?
Pelvis • Libido?
• STD?
• Dyspareunia?
• Dysuria, urgency, frequency?
 Neurology

WEAKNESS? LOST USE OF SYNCOPE? BALANCE

OR SENSATION (FAINTING) PROBLEMS?
IN AN
EXTREMITY?
Orthopedics

• Ask about pain, swelling, or other problems in

muscles, bones and joints

• Specifically, back pain

• Medications?

• Mobility impinged ?
Integumentary
•
Color/ pigmentation
• Rash
• Abnormal hair(hirsutism)
• Nails
• Chills/ sweats
• Sunscreen
• Abnormal lesions
 • DM

• DM of pregnancy
Endocrin • Heat/cold intolerance
e
• Weight changes

• Thyroid disease
The Physical
Exam
 • It is usually best to get the client naked,
although she will need a gown, open in the
front and sheet for modesty

• Skin cannot be fully examined with clothes

Clothes or No
Clothes?? • May have a person that refuses to undress

• Must consider cultural/experiential

preferences.

• Be sure to document
 • Blood pressure

• Heart rate and rhythm

• Respirations
Vital Signs
• Pulse oximetry

• Height

• Weight, can do BMI now

25
HEENT/
Cranial Nerves
• There are 12 pairs of
cranial nerves that
originate in the brain
(not the spinal
column) and leave
through their own
individual apertures.
 HEENT/ Cranial Nerves
• I. olfactory (smell)
• II. Optic (sight)
• III. Oculomotor (moves the
eyelid, eyeball, adjusts the pupil
and lens)
• IV. Trochlear (moves eyeballs)
• V. Trigeminal (facial muscles and
sensations, chewing)
 HEENT/ Cranial Nerves
• VII. Facial (taste, tears, saliva, facial
expressions)

• VIII. Vestibulocochlear (auditory)

• IX. Glossopharyngeal (swallowing, saliva,

taste)

• X. Vagus(control of the PNS e.g. smooth

muscles of the digestive tract

• XI. Accessory (moving the head and shoulders)

• XII. Hypoglossal (tongue muscles, speech,

swallowing)
Cranial Nerve Exam
 • As you go through the exam, you will be able
to include the 12 cranial nerves

You will inspect (visual) and palpate (feel):

• Head: Scalp, Shape, Hair condition,
Symmetry, ROM (CN 5 and 9)
• Eyes: PERRLA, EOMS, conjunctiva, lids,
lashes, vision,(includes CN 2,3,4,6)
HEENT • Nose: symmetry, air flow, olfactory (CN 1),
inflammation, nares
• Ears: pinna, tragus, canal, gross hearing, (CN
8), TM
• Mouth and Throat: gag reflex (CN 9,10),
movement of tongue,(CN 12)TMJ, gum and
teeth (CN7), smile
• Neck: glands (anterior and posterior
cervical, clavicular, thyroid
Ear
Exam
 • Inspection, palpation,
auscultation

• Inspect: nail beds for

Heart and cyanosis, capillary return,
clubbing, ridges, edema of
Lungs extremities, distended neck
veins

• Palpate: for edema

• Auscultate: heart for rate,

rhythm, murmurs, carotid
arteries for bruits, lungs in all
fields for respirations, rales,
rhonchi, wheezes
• Compare pulse strength at
different locations
(bilaterally).
•The apical pulse is
located at the 4th
intercostal space
within the left
midclavicular line.
Apical Pulse

• Taken with a stethoscope at the apex of

the heart
• Counted for 1 full minute
• Pulse deficit occurs when there is a
difference between apical and radial
pulses
• Most accurate way to check a pulse
• Each lubb-dubb counted as 1 beat
 • Heart is beating but blood
is not reaching peripheral
areas
• Increased Anxiety
• After exercise or physical
activity
• Heavy blood loss
• Extreme pain
• Low BP (hypotension)
• Heart disease/failure
• Overactive thyroid
Assessing Pulse Deficit
 • Simultaneous auscultation
Assessing Pulse Deficit of apical site and
palpation of distal site.
• Start at proximal locations
(radial) and move distally
(femoral, popliteal, radial,
etc)
• May require two people
for distal locations
• Compare auscultation
versus palpation, should
be close
Respiratory
Abnormalities

• Crackles (rales)
• Coarse Crackles (rale
s)
• Rhonchi
• Stridor
• Expiratory Wheezing
Breast
• Observation, inspection and palpation, Tanner staging

• Observe size, symmetry, skin tone and color, shape, nipple discharge, any
irregularities
• Inspect in sitting and lying positions
• Palpate: can use whatever method feels right for you and the patient. Do not be
shy. You must palpate deeply to really feel anything
• Palpate for any lesions: lumps, sores, fibrocystic lesions
• If you feel anything suspicious, palpate the other breast in the same place.
Frequently, fibrocystic lesions are bilateral.
• Palpate the axilla for enlarged glands
• Palpate and squeeze the nipple for discharge (good time to take a sample if
indicated)
 • Women ages 40 to 44 should
start to have annual breast
cancer screening with
mammogram, if they wish to
do so.

American Cancer Society

guidelines for mammograms
• Women aged 45 TO 54 should
get mammograms every year

• Women 55 or older should

switch to mammograms every
2 years, or can continue annual
screening
 • Inspection: scars, lesions, contour

Abdomen • Auscultation: bowel sounds in all

quads, vascular sounds of
abdominal aorta, femoral arteries (1
min each or until positive)

• Palpation: all quads for pain, masses

of liver, gall bladder, spleen, CVAT

• Anus and rectum: inspect for

hemorrhoids, lesions digital exam
for blood
 • Inspection and palpation

• Labia majora, labia minora,

urethral meatus, perineum

Pelvic • This is a good time to talk about

and practice Kegels

• Rashes, excoriation, hair

distribution, discharge, odor
 • Be sure to choose the correct speculum for
the size of your patient.
• Have it at room temperature or warmed
• Inspect the vagina and cervix for position,
color, note discharge, warty lesions, friability,
Speculum and mobility, Pap, cultures, sides for
microscopic evaluation if needed (see new
Exam Pap guidelines)
• Bi-manual exam: palpate the uterus, note
pain, difficulty, CMT, size of uterus, mobility,
any tenderness,
• Adnexa: tenderness on palpation, size,
mobility, lumps
• You an do the rectal exam now, ck. of occult
blood if indicated. A good time to educate
about the HPV vaccine
Orthopedic Exam

Check muscles, bones

Deep tendon reflexes:
and joints: ROM, Spine: straight,
elbows, knees, heel,
lesions, edema, lordosis, kyphosis
wrist
strength, sensation

Assess risk for

Check toenails and
Palpate para spinous osteoporosis, Calcium
fingernails for
muscles intake, DEXA scan, if
discoloration, ridges
over age 50
45
Skin
• Note color, turgor, lesions(moles, warts, crusty spots), varicosities,
burns, bruises, tattoos, piercing

• Note use of sunscreen, Vit.D3?

• Look for petechiae, hematomas

 Neuro Exam
You examined 11 cranial nerves when you did the HEENT
exam
Note affect, sensory(touch),strength

Deep tendon reflexes(knees and wrists)

Plantar response

Clonus?

Balance (cerebellar function)

47
 After the exam is completed, leave the
patient to dress

Go over your notes, make decisions about

problems or concerns encountered
Assessment
and
Treatment Prepare your patient education

Meet with the patient to discuss your

findings.
 • Immunizations, vaccines, HPV, HIV,
shingles
• Sunscreen
• Diet and exercise

Patient • Smoking cessation

• Take cultural factors into
Educatio consideration
• Discussion of positive findings

n • Referrals if indicated
• Lab: CBC, CMP, Lipids
• Nutrition counseling, contraceptive
counseling, marriage counseling,
parenting classes, BMI