Module 12: Musculoskeletal (21)
Musculoskeletal System Assessment
Detailed examination of the joints is usually not included in the routine medical examination. However, joint related complaints are
rather common, and understanding anatomy and physiology of both normal function and pathologic conditions is critically important
when evaluating the symptomatic patient. By gaining an appreciation for the basic structures and functioning of the joint, you'll be
able to "logic" your way thru the exam.
A few general comments about the musculoskeletal exam
Historical clues when evaluating any joint related complaint:
 What is the functional limitation?
 Symptoms within a single region or affecting multiple joints?
 Acute or slowly progressive?
 If injury, what was the mechanism?
 Prior problems with the affected area?
 Systemic symptoms?
Common approach to the examination of all joints:
 Make sure the area is well exposed - no shirts, pants, etc. covering either side - gowns come in handy
 Carefully inspect the joint(s) in question. Are there signs of inflammation or injury (swelling, redness, warmth)? Deformity?
As many joints are symmetric, compare with the opposite side
 Must understand normal functional anatomy - what does this joint normally do?
 Observe the joint while patient attempts to perform normal activity - what can't they do? What specifically limits them? Was
there a discrete event (e.g. trauma) that caused this? If so, what was the mechanism of injury?
 Palpate the joint in question. Is there warmth? Point tenderness? If so, over what anatomic structures?
 Assess the range of motion, both active (patient moves it) and passive (you move it) if active is limited/causes pain.
 Strength, neuro-vascular assessment.
 Specific provocative maneuvers related to pathology occurring in that joint (see descriptions under each joint).
 In the setting of acute injury and pain, it's often very difficult to assess a joint as patient "protects" the affected area, limiting
movement and thus your examination. It helps to examine the unaffected side first (gain patient's confidence, develop sense
of their normal).
Assessing joints requires that you have the knowledge of their structure and function. For that reason, you must be familiar with the
following definitions:
 Articular structures: joint capsule, cartilage, synovium and synovial fluid, ligaments and bone
 Extra articular structures: periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve and overlying skin
 Ligaments: ropelike bundles of collagen fibrils that connect bone to bone.
 Tendons: collagen fibers that connect muscle to bone.
 Bursae: pouches of synovial fluid that cushions the movement of tendons and muscles over bone or other joint structures.
There are several types of joints: synovial joints (knee and shoulder), cartilaginous joints (vertebral bodies) and fibrous joints
(skull structures). Therefore, some of the common problems of the musculoskeletal system include low back pain, neck pain,
inflammatory and infectious joint pain, along with joint pain from systemic illnesses. Again, when assessing the patient about the
pain, you must ask for a full description (OLDCARTS again) and any corresponding problems, such as bladder/bowel
problems with low back or neck pain. Was there a mechanism of injury? Tenderness, warmth, erythema tells you that it is
inflammatory in nature. Look and determine if the person has risk factors for the pain.
Begin by inspecting the joint and surrounding tissues. Assess for symmetry of involvement, any deformities, limitations of
range of motion, muscle strength. Strength is evaluated and documented on a 0-5 scale. Each joint requires special maneuvers in
order to evaluate thoroughly. Please review carefully in Bates and view the videos listed if unsure. The following are frequent
causes of painful joints: fracture, sprain, bursitis, tendinitis, arthritis, tears and cysts. You should be familiar with all of them
and how they will impact the specific joint.
The following are the skills that are essential for you to master this week:
Spine/Back
Extremities
 Assess gait and posture (note
 Inspect symmetry, deformity, weakness,
kyphosis, lordosis, scoliosis)
tremor
 Inspect/palpate spinal
 Active and Passive ROM of fingers, wrists,
processes of cervical,
elbows, shoulders, toes, ankles, knees, hips.
thoracic, lumbar spine (note
Vascular
 Assess capillary refill,
cyanosis, edema, pulses and
lymphatics (this can be done
under cardiovascular also)
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sacral edema, lesions,
birthmarks.
Palpate paravertebral and
spinal muscles
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(Full flexion and extension, abduction,
adduction)
Palpate each joint for swelling, crepitus
Assess muscle strength of all extremities
Assess reflexes, DTRs and Babinski reflex
Note special maneuvers for diagnosing MSK
complaints
o Empty Can Test (RC strength)
o Internal/External Rotations
o Drop Arm test (RC tear )
o Supination, pronation (elbow)
o Phalen and Tinel Signs (CTS)
o Median compression test (CTS)
o Finkelstein’s test (tenosynovitis)
o Allen’s test (vasculation of hand)
o Bulge and Balloon signs (knee
effusion)
o Ant/post drawer sign (ACL/PCL)
o Lachman test (ACL)
o McMurray test (meniscal tear M/L)
o Valgus stress test (MCL)
o Varus stress test (LCL)
o Inversion/eversion
o Straight leg raises (L disc herniation)
o Trendelenburg test (hip)
o Thomas test (hip flexion)
o Gowers sign (L spine weakness)
o Neer’s test (shoulder impingement)
o Hawkin’s test (shoulder
impingement)
o Yeragson’s test (biceps tendonitis)
o Scarf/cross arm test (shoulder)
For purposes of your weekly videos, you will perform a very general musculoskeletal exam. Many of the musculoskeletal
components were already covered in your "neuro" exam video. However, if your client presents with a focused musculoskeletal
complaint, one would perform a detailed assessment on that joint... below are the upper and lower extremity musculoskeletal
checklists for your point of reference.
https://www.youtube.com/channel/UCkXg4f8pFtWjHj_84QAJy-w/videos
https://meded.ucsd.edu/clinicalmed/assets/docs/Musculoskeletal%20Exam%20%20General%20Principles%20and%20Detailed%20Review%20of%20Knee%20and%20Shoulder.pdf
https://meded.ucsd.edu/clinicalmed/joints3.html
https://www.youtube.com/watch?v=n6btorvK3V4&feature=emb_logo&ab_channel=BilderbackHealth
Upper extremity MS sheet
Lower extremity MS sheet
Varus – “var out” – legs turned out (bowlegged)
Valgus – “val in” – legs turned in (knock kneed)
Evaluate specific joints.
1. Evaluate the median nerve in the hand.
2. Assess the rotator cuff in the shoulder.
3. Evaluate the lower spine.
4. For suspected hip problems, use the Thomas test and the Trendelenburg test.
5. For additional knee assessment, use ballottement. Perform the McMurray test. Use the anterior and posterior drawer test,
Lachman test, and varus and valgus stress tests.
6. When you suspect a difference in length or circumference, measure and compare the size of both limbs.
For each of the components below, normal and abnormal findings are presented. The normal findings are presented as a review.
Please focus on the abnormal findings.
Neck
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Abnormal Findings
Spine
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Abnormal Findings
Hands
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Abnormal Findings
Upper Extremity
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Abnormal Findings
Shoulder exam
Knee exam
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Lower Extremity
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Abnormal Findings
Week 13: Abdominal (17)
Abdominal System Assessment
When looking, listening, feeling and percussing imagine what organs live in the area that you are examining. The abdomen is
roughly divided into four quadrants: right upper, right lower, left upper and left lower. By thinking in anatomic terms, you will
remind yourself of what resides in a particular quadrant and therefore what might be identifiable during both normal and pathologic
state. By convention, the abdominal exam is performed with the provider standing on the patient's right side.
Auscultation: Compared to the cardiac and pulmonary exams, auscultation of the abdomen has a relatively minor role. It is
performed before percussion or palpation as vigorously touching the abdomen may disturb the intestines, perhaps artificially
altering their activity and thus bowel sounds. Exam is made by gently placing the pre-warmed (accomplished by rubbing the
stethoscope against the front of your shirt) diaphragm on the abdomen and listening for 15 or 20 seconds. There is no magic time
frame. The stethoscope can be placed over any area of the abdomen as there is no true compartmentalization and sounds produced in
one area can probably be heard throughout. How many places should you listen in? Again, there is no magic answer. At this stage,
practice listening in each of the four quadrants and see if you can detect any "regional variations."
Percussion: The technique for percussion is the same as that used for the lung exam. First, remember to rub your hands together and
warm them up before placing them on the patient. Then, place your left hand firmly against the abdominal wall such that only your
middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your
right middle finger, using the previously described floppy wrist action (see under lung exam). There are two basic sounds which can
be elicited:
1. Tympanic (drum-like) sounds produced by percussing over air filled structures (e.g. stomach).
2. Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined.
*Special note should be made if percussion produces pain, which may occur if there is underlying inflammation, as in peritonitis.
This would certainly be supported by other historical and exam findings.
Liver Span: To determine the size of the liver, proceed as follows:
1. Start just below the right breast in a line with the middle of the clavicle, a point that you are reasonably certain is over the
lungs. Percussion in this area should produce a relatively resonant note.
2. Move your hand down a few centimeters and repeat. After doing this several times, you will be over the liver, which will
produce a duller sounding tone.
3. Continue your march downward until the sound changes once again. This may occur while you are still over the ribs or
perhaps just as you pass over the costal margin. At this point, you will have reached the inferior margin of the liver. The total
span of the normal liver is quite variable, depending on the size of the patient (between 6 and 12 cm). Don't get
discouraged if you have a hard time picking up the different sounds as the changes can be quite subtle, particularly if there is
a lot of subcutaneous fat.
https://www.youtube.com/watch?v=9yqGdu6Un4A
Percussion of the spleen is more difficult as this structure is smaller and lies quite laterally, resting in a hollow created by the left ribs.
When significantly enlarged, percussion in the left upper quadrant will produce a dull tone. Splenomegaly suggested by
percussion should then be verified by palpation. This video demonstrates the technique for both splenic percussion sign and
splenic palpation:
https://www.youtube.com/watch?time_continue=1&v=inDjrPKEk0Y&feature=emb_logo&ab_channel=med4all
Palpation: First warm your hands by rubbing them together before placing them on the patient. The pads and tips (the most
sensitive areas) of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen
as well as the deeper structures. You may use either your right hand alone or both hands, with the left resting on top of the right.
Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort. Examine
each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel.
In order to palpate the liver, place left hand posteriorly around the 11th rib and press up towards the ceiling. Palpate
downward and upward with the right hand, starting from the level of the umbilicus until the lowest rib. Ask the patient to take
a deep breath and try to feel the liver edge as it moves under the fingertips.
https://www.youtube.com/watch?v=HQ0y-oRT8mo&feature=emb_logo&ab_channel=medptusa
You must be familiar with three categories of abdominal pain:
1. Visceral pain occurs when hollow abdominal organs (intestine as an example) contract forcefully, are distended or stretched
2. Parietal pain occurs from inflammation of the peritoneum
3. Referred pain occurs in more distant sites that are innervated at the same spinal levels as the injured organ/area.
All of these pains have different symptomology so you must be very specific when asking patients to describe their
pain. Request that they point to the exact location; visualize and ask about other GI symptoms that they may or may not have (such as
nausea, anorexia and jaundice). Your family and social history must be very specific for alcohol use, hepatitis and colon cancer
risk factors/screening. The assessment sequence changes for the abdomen: inspect, auscultate, percuss, then palpate (first
light, then deep). There are many different organs with the abdomen, and you must be able to locate them. It is best to think of the
abdomen in quadrants (right and left side, upper and lower). Know where each organ is located to help you to differentiate a possible
cause of the discomfort. Is the abdomen distended, soft, firm? Is there a change in bowel sounds? For people with ascites - can you
determine a fluid wave? For urinary tract infection, do they have costovertebral tenderness? What are the different signs for
appendicitis? For cholecystitis? Document accurately.
The following are the skills that are essential for you to master this week:
 Inspect abdomen for distention, scars, abnormal pulsations, striae, dilated veins, ascites
 Auscultate abdomen in 4 quadrants, note bowel sounds, bruits
 Percuss for general tympany, liver span and splenic dullness
 Light Palpation: liver, spleen
 Deep Palpation: liver, spleen
 CVA tenderness
Abdominal assessment findings
 Appendicitis
o Psoas sign – irritation of the iliopsoas muscle group; at extension of the right hip while the patient lies on left side
elicits abdominal pain
o McBurney sign – tenderness on deep palpation of McBurney’s point (midway between the umbilicus and the right
anterior iliac spine in RLQ)
o Obturator sign – internally rotating a flexed right hip elicits abdominal pain
o Rovsing’s sign (reverse palpation) – RLQ pain upon palpation of LLQ
o Heel drop sign – dropping heels on the ground after standing on tiptoes, or forcefully striking the patient’s heels
elicits RLQ pain
o pain that migrates to the right lower quadrant = signs of appendicitis.
 Cholecystitis
o Murphy’s sign – sudden suspension in deep inspiration upon palpation of RUQ, due to tenderness
 Ruptured spleen/injury or ruptured ectopic pregnancy
o Kehr sign – left shoulder tip pain / pain radiating to the left shoulder, specifically when the patient lies supine, due
to irritation of the peritoneum
 Peritoneal irritation/peritonitis
o Cough sign – tenderness when patient is asked to cough
o Rebound tenderness - pain upon removal of pressure rather than application of pressure to the abdomen.
 Retroperitoneal hemorrhage (hemorrhagic pancreatitis, ruptured AAA)
o Cullen’s sign – periumbilical ecchymosis
o Grey Turner sign – flanks ecchymosis
 Aortic aneurysm
o Pulsatile masses – pulsating mass upon palpation of the abdomen
 Ascites
o Fluid wave
o Shifting dullness
 Jaundice – a result of excessive bilirubin that can result from cholecystitis, pancreatitis, or liver problems
 Flank pain and CVA tenderness – pyelonephritis
 Dance sign - the lower quadrant feels empty (in case of intussusception)
https://www.youtube.com/watch?v=FgcqkU5jOQg&ab_channel=BilderbackHealth
https://www.youtube.com/watch?v=rm8TnbVh9pI&ab_channel=LecturioMedical
For each of the components below, normal and abnormal findings are presented. The normal findings are presented as a review.
Please focus on the abnormal findings.
Observation

Abnormal Findings
Auscultation
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Abnormal Findings
Light Palpation
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Abnormal Findings
Deep Palpation
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Abnormal Findings
Module 14: Assessment of the Pregnant Woman
THE MENSTRUAL CYCLE A&P
Physiologic Influences of Endocrine System & Hormonal Controls
Women begin to menstruate in their early teenage years. During the menstrual cycle, the uterine lining is prepared for
implantation of a fertilized egg. If conception does not occur, the lining sloughs off and is discharged as the menstrual flow.
Menstrual discharge consists of blood, mucus, and endometrial membranes that may look like small clots. Individual menstrual flow
varies, usually 6 to 8 ounces in volume per cycle. The cycle is usually 28 days in length but can vary from 21 to 40 days. A
normal menstrual period lasts from 5 to 7 days. The menstrual cycle is regulated by a complex series of interactions between
the hypothalamus and the pituitary gland, the adrenal glands on top of the kidneys, the ovaries and the uterus. More on
Female Reproductive Endocrinology – go to Female Reproductive Endocrinology
PROBLEMS WITH MENSTRUATION
Dysmenorrhea
For the majority of women, menstruation creates no medical problems. However, menstruation causes certain physical and
emotional problems. For example: dysmenorrhea, better known as “cramps” is caused by the normal production of prostaglandins
producing strong contractions of the uterus. This is known as primary dysmenorrhea, or by problems in the uterus, fallopian tubes
or ovaries (secondary dysmenorrhea). Primary dysmenorrhea presents with pain in the lower abdomen or back. Those with
secondary dysmenorrhea feel pain during urination and bowel movements. Treatment for primary dysmenorrhea includes
regular aerobic exercise, stress reduction techniques, adequate sleep and decreased fat, caffeine, and sodium in the diet. Some
women with primary or secondary dysmenorrhea may need anti-inflammatory medications or oral contraceptives to relieve
the pain. Secondary dysmenorrhea is treated based on the underlying condition.
Premenstrual Syndrome (PMS)
PMS encompasses a varied set of symptoms that present in some women before the menstrual flow and may include tension,
increased irritability, water retention, headaches, fatigue, breast tenderness, and may experience symptoms severe enough to
seek treatment. Evidence has shown that estrogen stimulates certain neurotransmitters, specifically dopamine and, serotonin
receptors. A decrease in estrogen prior to the menstrual period causes fluctuation in the levels of neurotransmitters, specifically
dopamine and serotonin receptors. In terms of treatment, estrogen therapy is usually prescribed in the form of combination oral
contraceptives. This treatment generally results in fewer physical PMS symptoms than non-users, although the effects of these
medications remain unclear. Go to U.S. Selected Practice Recommendations for Contraceptive Use 2016
Premenstrual Dysphoric Disorder (PMDD)
When women suffer severe emotional symptoms that interfere with work and social relationships, PMDD results. Women who
are susceptible to depression are more significantly affected by hormonal shifts during the menstrual cycle. Selective serotonin
reuptake inhibitors (SSRIs), a type of anti-depressant, have proved effective in relieving mood changes in women who
experience PMDD.
Amenorrhea
Amenorrhea is the lack of menstrual flow. There are 2 types of amenorrhea: primary and secondary. Primary amenorrhea
occurs in women who have not begun menstruation and may be the result of hormone related problems or extreme low body
fat. Secondary amenorrhea is the lack of menses or blood flow for 3 or more consecutive months, except during pregnancy,
breastfeeding and perimenopause. May be cause by conditions such as anorexia nervosa, ovarian cysts or tumors, substance
abuse, stress, or use of oral contraceptives.
Oligomenorrhea
There is an interesting article entitled: “Oligomenorrhoea: looking at the treatment options by Margaret Perry. Oligomenorrhea is a
menstrual irregularity defined as menses occurring at intervals more than 35 days apart.
Menstruation Disorders in Adolescence
Please go to: Menstrual Disorders in Adolescents This is an excellent overview of menstrual disorders in adolescents.
Also, go to: Delayed Menarche with Normal Pubertal Growth
 Primary amenorrhea is defined as absence of menarche by age 16 years with normal pubertal growth and sexual
development, or a girl who has not started menstruation within 3 years of the first signs of puberty. There are many causes
associated with primary amenorrhea such as anatomic defects, pituitary causes, endocrine gland disorders, and
congenital abnormalities.
 Secondary amenorrhea is defined as a delay of at least 3 periods in a row with previous regular menses for 3 months or
irregular menses for 6 months. Causes of secondary amenorrhea may include stress, eating disorders,
hyperprolactinemia, chemotherapy, or irradiation, among others
PREGNANT PATIENT ASSESSMENT
In primary care offices, most assessments of pregnant women occur for initial visits to determine pregnancy or for acute
illness. Except in extremely rural areas, once the pregnancy is confirmed, the majority of women will then be monitored by a
physician or advanced practice nurse who specializes in OB/GYN.
Confirming Pregnancy
Any woman who is sexually active and does not use protection can become pregnant. Clinical Manifestations include
amenorrhea (delayed period - usually more than 10 days past due date), morning nausea, prickling/fullness sensation in breasts,
increase in urination, fatigue and increased vaginal discharge. The most used first method of confirming pregnancy is the home
pregnancy test. As the fetus grows, HCG is secreted and enters your body. Home pregnancy tests determine through the urine if
HCG is present. During the initial prenatal visit , it is important to confirm the pregnancy, assess the health status of the
mother and any complication risks and counselling the mother/father on ensuring a healthy pregnancy. The health care
provider confirms pregnancy, which can be done through a quantitative serum HCG level. In addition, ultrasound or sonography can
be obtained to determine the "age" of the fetus. Lastly the expected weeks of gestation by dates and the expected date of delivery will
need to be determined. Expected date of delivery is often determined by Naegle's Rule . Once pregnancy is confirmed, the
patient is referred to a physician or advanced practice nurse who specializes in OB/GYN.
Primary healthcare providers need to be aware of the possible complications from infertility medications. These complications
include ovarian hyperstimulation syndrome (OHSS). With this syndrome the woman's ovaries become enlarged causing pain and
bloating, fluid accumulations in the abdomen/chest which leads to swelling and shortness of breath. In addition, this fluid
accumulation can lead to blood volume depletion and low blood pressure. Patients who suffer from Preeclampsia and
pregnancy and diabetes will require specialized assessments and treatment plans to maintain the mother's heath status. Other
special assessments of the pregnant patient are fundal height, pelvic examination and Leopold's maneuvers to determine fetal
lie/presentation and engagement.
Preconception Counseling
Preconception care and counseling provides an important opportunity for health promotion, risk reduction and disease
prevention. It is the promotion of health and well-being of a woman and her partner prior to pregnancy. Preconception
counseling should be a part of preventive healthcare for all women of reproductive age. The goal of the preconception visit is to
identify medical as well as social conditions that may place the woman and fetus at risk. While most pregnancies have good maternal
and fetal outcomes, others may result in adverse health effects for the woman, fetus or neonate. Although some of these outcomes
cannot be prevented, providing a plan to optimize knowledge prior to and conceiving a pregnancy (preconception or pre-pregnancy
care) may reduce the inherent risks.
 ACOG Committee on Gynecologic Practice – Reaffirmed 2017 - ACOG Committee Opinion on Gynecologic Practice Reaffirmed 2017
 The American College of Obstetricians and Gynecologists (ACOG) (2019) Committee Opinion provides a very current guide
to preconceptual counseling.
 This publication provides an overview of preconceptual counseling, an excellent clinical
guide. __Prepregnancy.53.aspx ACOG Opinion 762 Pre-Pregnancy Counseling
 The Family Planning National Training Center (FPNTC) has published a Preconception Counseling Checklist that will be
another clinical resource in a primary care setting. FPNTC Preconception Counseling Checklist
Preconception Patient Interview/History
A discussion related to preconception may be challenging to some patients. It is important that the healthcare provider stress the
importance of health promotion and disease prevention during the reproductive years. The provider should start with the
benefits of intentionally preparing for pregnancy. The healthcare provider needs to understand the important and critical period
of cell differentiation and organogenesis that occurs between days 17 and 56 following fertilization. The customary early
prenatal visit is too late to affect reproductive outcomes associated with abnormal organogenesis secondary to drugs, alcohol, and poor
diet/nutrition. It is important to stress the benefits of optimal medical treatment for disease prior to pregnancy. A more current
publication provides strategies for change in advancing preconception health in the U.S. Advancing Preconception Health in the
United States: Strategies for Change:
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Menstrual History
o Age of menarche
o Last menstrual period – Note dates. Missed or late periods – Use the Gestational Wheel
- https://www.prokerala.com/health/pregnancy/pregnancy-wheel/Pregnancy Wheel - Calculatorl - The pregnancy
wheel is also known as a gestation calculator.
o Menstruation pattern
 Cycle length
 Duration of flow
 Amount of flow
 Moliminal symptoms – breast tenderness (mastalgia), food cravings, fatigue, sleep problems, headaches or
fluid retention that occur during the luteal phase of the menstrual cycle (time between ovulation and when
the menstrual period begins)
 Associated pain
 Intermittent mood disorders
Gravida – Para (TPAL)– Number of pregnancies – Go the Women’s Health Comprehensive Gynecologic Patient History &
Physical Examination/Assessment document (Fagan, K. 2020) for more information on Gravida – Para.
Medications and Teratogenic Agents
Environmental Toxins
Age, Family History, Genetic Disorders
Infections and Immunizations
Social habits and other risk factors
Diet and exercise
Chronic medical problems such as:
o Asthma
o Chronic essential hypertension
o Cardiac disease
o Thromboembolic disease
o Seizure disorders
o Chronic renal disease
o Autoimmune disorders
o Diabetes Mellitus
Preconception health issues in men – paternal smoking and alcohol consumption are associated with low birth weight
neonates. Smoking has been associated with increased incidence of fetal malformations. It is important for the healthcare
provider to discuss such risks, review their family history for genetic disorders and screen for sexually transmitted diseases. It
is important to note that preconception care is considered primary care. Preconception Care is Primary Care: A Call to Action
Basic Elements of Prenatal Care
Over time, prenatal care has steadily increased. Family physicians provide integrated prenatal care that includes evidenced
based screening, counseling, medical care and psychological support. Go to:Update on Prenatal Care As NPs, you will be
expected to not only provide pre-conceptual counseling for patient, but also, to provide care early on in pregnancy and refer to
obstetric specialists for continuance of care through delivery. Patients will likely return to their primary or family practices for
post-partum (beyond the 6 weeks) and beyond. It is imperative that NPs have full knowledge and competency to provide
preconception counseling, early prenatal care and post-partum follow-up, depending on patient’s needs. Women in developed
countries, based on the evidence, have 7 to 12 prenatal visits. Standard components of prenatal care start with the routine
physical assessment, including pelvic examination, usually at the initial visit.
The following standard elements of prenatal care include:
 Maternal weight at all visits – BMI measurement
 Blood pressure at all visits
 Fetal heart rate auscultation after 10 – 12 weeks (Doppler monitor)
 Fetoscope, fundal height after 20 weeks, fetal lie by 36 weeks
 Pelvic exam on initial visit useful in detecting pelvic abnormalities and screen for STIs
 PAP testing/HPV during initial examination (based on risk factors and history)
 Determine PAP/HPV history (normal results/positive results and subsequent procedures)
 Clinical breast examination based on patient or family history
 Oral assessment – periodontal disease is associated with increased risk of pre-term labor
o Assess for HPV lesions
 Abdominal palpation
 Evaluation for edema
 Urinalysis – depending on the accepted recommendations.
 Testing for ABO blood group and RhD antibodies should be performed early in pregnancy
o
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Rho(D) immune globulin, 300 mcg, is recommended for non-sensitized women at 28 weeks and within 72 hours of
delivery
Screening for anemia
Genetic testing and neural tube defects
Thyroid testing
Infectious diseases
o BV or Gardnerella vaginal infection – evidence supports placing the mother at risk for pre-term labor
o Rubella screening
o Varicella – assess varicella history at first visit
o Asymptomatic bacteria – urinary tract infections
o Influenza – vaccination recommended
o Tetanus and Pertussis
o Group B Streptococcus
o Sexually transmitted diseases
o Other infections
o Genetics
Psychosocial Issues
o Domestic violence
o Depression screening
Complications of Pregnancy
 Gestational diabetes
 Hypertension in pregnancy
 Pre-Term birth
 Post-term pregnancy
 Other
Medicine Guidelines During Pregnancy - From a Consumer Viewpoint - Excellent resource for providing patient education.
Medicine Guideline During Pregnancy - Cleveland Clinic
Contraceptive Management
One of the most important roles of the NP is to provide an understanding of the variables that influence a women’s
contraceptive decisions including the patient’s past medical history and risk factors in order to provide the appropriate and
available contraceptive options and solutions that are culturally acceptable as well as affordable. Go to: U.S. Selected Practice
Recommendations for Contraceptive Use - CDC. There are a few excellent informational handouts for clinical application. This
resource reviews the eligibility criteria that is important to know when prescribing contraception. Prescribing contraception is one
of the most difficult tasks when patients have different medical conditions as well as pregnancy and breastfeeding. Go to the
Boxes and the Appendices for important information. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016
Module 15: Comprehensive Health Assessment of the Infant and Child, and Care of the Older Adult (24)
Older Adult Assessment
Aging is the normal physical and behavioral changes that occur under normal environmental conditions as people mature and
advance in age. It begins at birth. Older adults are expected to grow in numbers to approximately 86 million by 2050 (a 230%
increase). Life span is growing and with increasing "health span" seniors can maintain full and functioning lives rich in social and
physical activities. Life expectancy as of 2004 is 80.4 years for women; 75.2 for men. Older adults look back on their lives, both
positive and negative experiences. They determine if they are satisfied with their experiences in which case they develop ego integrity
and hopefully become less fearful of death. Aging, in and of itself, has few effects on the brain. Age related changes to the brain do
include slow decrease in short term memory, but long-term memory is less likely to be impacted.
When interviewing the older adult, always address by last name unless instructed otherwise. Use open ended
sentences. Assessment of older adults requires that you understand this and add a functional assessment (6th vital sign) when
promoting senior health and safety. Since the older adult takes longer to process information, you will need to pace the visit, direct
the conversation, understand that cultural values affect medical and life decisions. There is some additional information that you may
need to elicit from your patient. Some of the common concerns impacting the older adult are activities of daily living,
medications, nutrition, acute/chronic pain and advance directives. It is essential that if a patient has a "living will" that you as
the primary care practitioner have a copy and understand/agree with the directives. There are many health promotion
screenings that impact the older adult, such as cognitive impairment, elder mistreatment/abuse, immunizations and cancer
screenings up to age 75. You should use a family-oriented approach as family members are often involved in the care of the older
adult.
The physical assessment is no different than that of any adult patient. However, in addition to a full system assessment it is
important to assess for the 6th vital sign - Functional Status. There are several instruments available - Katz functional
assessment tool being one of them. In addition to functional assessment, it is also important to assess for potential fall risk.
Polypharmacy means "many drugs". The average number of medications taken by the older adult age group is between 35/day, not including over the counter medications. Rational polypharmacy means the use of several medications to manage
multiple disease conditions. Irrational polypharmacy means the inappropriate use of multiple drugs where by the prescriber
doesn't want to discontinue a mediation the patient has been taking for a long time; ordering a medication to alleviate adverse
reactions to other medications and when the patient wants medications due to what s/he has read or heard. With age, there are
alterations in the pharmacokinetics of drugs. The medical conditions that create polypharmacy are Diabetes Mellitus,
Cardiovascular Disease, Arthritis, GI disorders and Bladder dysfunction. Polypharmacy is a leading cause of orthostatic
hypotension, which is a leading cause of fall and injury in the elderly. Therefore, it is essential that you complete a full medication
review at every visit, including any OTC or herbals the patient may be taking.
Pediatric Assessment
Children have tremendous variations in physical, cognitive and social development when compared to adults. There is no way to
complete an assessment of a child without knowing child development and developmental milestones. Anticipatory health
promotion guidance is based on the child's development. Children mature at different rates and there are many factors that
influence child development and health. However, the child's developmental level also affect how you conduct your medical
history and physical examination.
When conducting the history interview add the following features:
1. first and last names of parents
2. who is expressing the concern about the child (parent, teacher, etc.)
3. birth history (premature, ETOH abuse)
4. feeding history (taking vitamins, breast/bottle)
5. Growth/Developmental history
6. Current health status, which includes Immunization Schedules .
Talk about upcoming health behaviors, such as oral health, safety/prevention, peer relationships, etc. Each age group will
require specific information to be assessed.
Immediate Assessment of Newborn
 APGAR Score (activity, pulse, grimace, appearance, respirations)
 Gestational Age and Birth Weight
 umbilical cord abnormalities
 color
Infants
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how do they breast or bottle feed?
What is the parent's affect toward child?
Height/Weight, head circumference, pulse, respiratory rate.
Examine the fontanelles carefully
Is there a startle response to sudden noise, observe your patient carefully, the use your stethoscope, note that infants have
primitive reflexes.
Children (1-10 years)
 Establish a rapport by calling the child by name and meeting them on their level.
 Blood pressure is usually obtained after age 2 and then every 2 years thereafter.
 Remember that when viewing the ear canal, the ear canal is straightened by pulling down and back (until age 5).
Adolescents
 The key to examining teens successfully is to make the environment comfortable and confidential, otherwise they will not
open up to you during the interview stage.
 The physical examination is similar to that of an adult, except by adding Maturation and sexual development - Tanner
Staging
Development
 Growth is continuous, and change occurs throughout the entire life cycle.
 Developmental stages are qualitative changes in thinking, feeling, and behaving that characterize particular time
periods of development.
 There is physical development, psychosocial development (think Erik Erikson), cognitive development (think Jean
Piaget), and behavioral development (motor and language skills).

Denver 2 Developmental Assessment This is a screening instrument designed to detect delays in development for
infants and preschoolers. It tests four functions: gross motor, language, fine motor adaptative and personal-social
skills. It is not an intelligence test; it does not predict current or future intellectual ability. All the Denver II does is screen
and help to identify children who may be slow in development. Denver 2 Developmental Example
Child abuse is ever rising in the United States. Sexual abuse in children is alarming. Though the numbers are staggering the actual
number far exceeds it. Many cases of sexual abuse go unreported, often because the child knows his/her abuser, who is usually
a close family contact.
Please note that several different videos are presented to demonstrate the different acceptable exam techniques. These are optional
videos to assist you in learning the various techniques. Please be patient when clicking on the links, it can take several minutes for the
information to become available, depending on the speed of your internet connection. Each student should focus on areas in which
they need review.
Comprehensive health assessment of the pregnant client
 Examination of the pregnant woman
 Examination of the pregnant patient - abdomen
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Fetal Non-Stress test
Multi-Dimensional assessment of the older adult
 Geriatric Assessment Powerpoint - Be Certain to Click on the Full Screen Shoot (right and corner of presentation). This
powerpoint slide show offers multiple testing to determine dementia Geriatric Assessment Power Point Presentation
 Nutrition in aging https://www.youtube.com/watch?v=9oT7pF_Gck8&feature=emb_logo&ab_channel=MNAelderly
 Link to geriatric depression scale - quick easy yes/no questions to help to determine depression in an older person. There are
many other tools, such as the Beck's Depression Inventory II that also only take 5 minutes or less to give you objective
scoring on depression.
https://www.youtube.com/watch?v=QLuR2PZy4Og&feature=emb_logo&ab_channel=HartfordInstituteforGeriatricNursing
Comprehensive Health Assessment of the Infant/ Child
Assessment Videos for the Infant to Adolescents. There are several videos that you can view at this site.
Pediatric History and Physical Exam
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Pediatric Examination
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Crying baby examination
Growth and Development
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CDC Growth Charts
Focused Exams * Know Abnormals*
 Abnormalities in the Pediatric Eye Exam
 Pediatric Eye Exam
A. Criteria for abnormal
1.
Age 3-5 years
1. Either eye Vision <10/20 or 20/40 (<4 of 6 correct)
2. Two-line difference between eyes (20/25 and 20/40)
2. Age 6 and up
1. Either eye Vision <10/15 or 20/30 (<4 of 6 correct)
2. Two-line difference between eyes (20/20 and 20/30)
B. Additional testing: Pinhole Test
1. Distinguishes Refractive Error from Amblyopia
2. Indicated for failed Vision Screening