Nursing Final Examination AL 2023 with Correctly Answered Questions, Exams of Nursing

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[Date] NURSING FINAL EXAMINATION AL 2023 WITH CORRECTLY ANSWERED QUESTION Chapter 12 [Date] The Peripheral Vascular System Anatomy and Physiology - Arteries Arteries must respond to the variations that cardiac systole and diastole generate in cardiac output Anatomy and size vary according to their distance from the heart Arterial pulses are palpable when artery lies close to body surface Arms [Date] Subcutaneous with poor tissue support Include great saphenous and small saphenous veins Anastomotic veins connect two saphenous veins Perforating veins connect superficial (saphenous) system with deep system Deep, superficial, and perforating veins have one-way valves [Date] Propel blood toward heart, preventing pooling, venous stasis, and backward flow Anatomy and Physiology – Lymphatic System Extensive vascular network that drains lymph from body tissues and returns it to venous circulation [Date] Lymph nodes Round, oval, or bean-shaped structures Vary in size according to location Important role in body’s immune system Cells in lymph nodes engulf cellular debris/bacteria and produce antibodies Only superficial lymph nodes accessible to physical examination [Date] Swelling of feet and legs Ask about ulcers on lower legs, often near ankles Health Promotion and Counseling Most patients with peripheral arterial disease (PAD) have no symptoms or non-specific symptoms Triad of exercise-induced calf pain that causes patient to stop exercise and experience relief of pain in 10 minutes is present in only 10% of affected patients [Date] Screen for subclinical PAD Aggressive risk factor intervention Ankle-Brachial Index (ABI) Detects stenosis of 50% or more in major vessels of legs Measure systolic blood pressure (with Doppler ultrasonography) in each arm and in pedal pulses Calculate reading for right and left Divide arm pressure by ankle pressure [Date] ABI 0.90-1.30: normal ABI 0.41-.90: mild to moderate disease ABI 0.00-0.40: severe disease with critical stenosis Techniques of Examination Important areas of examination Arms Size, symmetry, skin color Radial pulse, brachial pulse [Date] Use finger pads on flexor surface of wrist Partially flex patient’s wrist Compare pulse in both arms Palpate brachial pulse Flex elbow slightly Palpate artery medial to biceps tendon in antecubital crease Epitrochlear nodes [Date] Flex elbow 90° Support forearm Feel in groove between biceps and triceps muscle, 3 cm above medial epicondyle Techniques of Examination - Legs Patient should lay down, draped so external genitalia is covered and legs are fully exposed MUST remove patient’s stockings or socks Inspect both legs from groin and [Date] buttocks to feet Note the following: Size, symmetry, and any swelling Venous pattern/venous enlargement Pigmentation, rashes, scars, or ulcers Color and texture of skin, color of nail beds, distribution of hair on lower legs, feet, and toes Palpate superficial inguinal nodes [Date]  •  3 Bounding  •  2 Brisk, expected (normal)  •  1 Diminish ed, weaker than expected  •  0 Absent, unable to palpate Techniques of Examination - Edema [Date] Compare one foot and leg with the other Note relative size and prominence of veins, tendons, and bones Check for pitting edema Press firmly with thumb for 5 seconds over dorsum of each foot, behind medial malleolus and shins Severity of edema graded on four- point scale (slight to very marked) If edema is present, look for causes [Date] Recent deep venous thrombosis Chronic venous insufficiency Lymphedema Note color of skin Local area of redness Brownish areas near ankles Ulcers and where Thickness of skin Special Techniques [Date] the lower calf area Ulceration is present on the medial side of the ankle Affected leg feels warm to the touch All the above Answer e. All the above Question A patient you are seeing complains of severe pain in her right foot. Based on examination findings, you suspect arterial insufficiency. Which of the clinical findings below would [Date] suggest arterial insufficiency as the cause of her problem? Brisk posterior tibial and dorsalis pedis pulses Pallor of the foot upon elevation Pitting edema of the lower leg Warmth of the right foot Answer b. Pallor of the foot upon elevation [Date] Decreased posterior tribal and dorsalis pedis pulses No edema of the lower leg Cool right foot [Date] posterior surfaces of body, palms and soles, and webspaces ▶ Inspect entire skin surface in good light Preferably in natural light (or artificial light that resembles natural) o Artificial light often distorts colors ▶Hair Inspect and palpate Note quantity, distribution, and texture ▶Nails Inspect and palpate fingernails/toenails Note color and shape Note lesions [Date] Longitudinal bands of pigment may be a normal finding in people with darker skin ▶ Inspect and palpate skin ▶ Note characteristics of: Color Moisture Temperature Texture Mobility and turgor Lesions ▶Color Patients often notice change in color before physician [Date] Look for increased pigmentation, loss of pigmentation Look for redness, pallor, cyanosis, and yellowing Red color of oxyhemoglobin best assessed at fingertips, lips, and mucous membranes In dark-skinned people, palms and soles For central cyanosis, look in lips, oral mucosa, and tongue Jaundice - sclera ▶Moisture Dryness, sweating, and oiliness ▶Temperature [Date] ▶Plaque ▶Patch ▶Wheel ▶ Vesicle – clear or cloudy fluid? ▶Bulla ▶Pustule ▶Cyst ▶Crust ▶Erosion ▶Ulcer ▶Fissure ▶Excoriation ▶Scar ▶Scale ▶Telangiectasias ▶Burrow [Date] ▶Comedo ▶ Petechial – assess for blanching ▶Purpura ▶Hypopigmented ▶Hyperpigmented ▶ Erythematous – mild, moderate, marked ▶Annular ▶Linear ▶Dermatomal ▶Grouped ▶Lichenified ▶Coalesced [Date] Incisions – sutures intact? erythema? drainage? all edges approximated? *Tattoos ▶ Skin lesions in context Whenever you see a skin lesion, look it up in a well-illustrated textbook of dermatology To arrive at a dermatologic diagnosis, consider the type of lesions, location, and distribution, along with the patient’s history and physical [Date] ▶ Skin tags (acrochordons) Acrochordons : fleshy papules arise in axillae, neck, groin, and eyelids Skin colored to brown Often pedunculated ▶ Acanthosis Nigricans ▶ An eruption of velvety, hyperpigmented plaques and warty- papules in the axillae, groin, neck, and/or anogenital region. ▶ Looks like dirty skin. ▶Angioma A 45-year-old white male presents [Date] with a “red mole” which appeared 6 months ago and has increased in size. It is not tender and has not bled. ▶ Cherry angiomas Cherry angioma Majority of people get these starting around age 30 Highest concentration on the trunk ▶ Solar Lentigo The solar lentigo, AKA “sun spot”, “age spot”, or “liver spot” is due to sun damage, but is not cancerous or precancerous No treatment required, however… [Date] Extensive solar lentigines reflect history of UV exposure, and therefore can identify patients at risk for skin cancer ▶ How can I tell the difference between one of these lentigines and melanoma? Look for the ugly duckling Consider biopsy or referral to a dermatologist for any lesion that stands out as different Recall the ABCDE’s Asymmetry Border (irregular) Color (multiple, variegated) Diameter (>6mm) [Date] glands [Date] Debris (dead skin cells, oil, etc.) collects within a sack May discharge foul smelling cheesy white material ▶ Pilar cysts Compared to an EIC, less likely to rupture or get inflamed Nearly always on the scalp Slowly enlarging over months to years Firm, mobile subcutaneous nodules, lacking punctum Do not discharge any material “This lump has been slowly enlarging for years. It doesn’t bother me, but my wife wants it checked [Date] out.” You palpate a mobile, soft, subcutaneous nodule, lacking any overlying skin change On exam, he has a few other similar soft to rubbery mobile subcutaneous nodules on his arms and legs Skin Cancers Basal cell carcinoma Comprises 80% of skin cancers Shiny and translucent, they grow slowly and rarely metastasize [Date] Regular dermatologist absent Mole changing Male gender Additional Risk Factors ≥50 common moles ≥1-4 atypical or unusual moles (especially if dysplastic) Red or light hair Actinic lentigo, macular brown or tan spots (usually on sun exposed areas) Heavy sun exposure (especially [Date] severe childhood sunburns) Light eye or skin color (especially freckles/burns easily) Family history of melanoma Screening for Melanoma ADCDE A for asymmetry B for irregular borders, especially ragged, notched, or blurred C for variation or change in color, especially blue or black D for diameter ≥6 mm or different [Date] from other moles, especially changing, itching, or bleeding E for elevation or enlargement Basal cell carcinoma (BCC) Risk factors Skin types I, II (fairer skin types)* History of intense or prolonged ultraviolet light exposure History of ionizing radiation exposure or arsenic ingestion Immune suppression (transplant patients, systemic [Date] Commonly located on the head, neck, forearms, and dorsal hands (sun- exposed areas) SCC has increased associated mortality compared to basal cell carcinoma, mostly due to a higher rate of metastasis SCC: Clinical manifestations Various morphologies Papule, plaque, or nodule Pink, red, or skin-colored Scale Exophytic (grows outward) [Date] Indurated (dermal thickening, lesion feels thick, firm) May present as a cutaneous horn Friable – may bleed with minimal trauma and then crust Usually asymptomatic; may be pruritic Recording the Physical Examination ▶ Initially you may use sentences to describe findings; later you will use phrases ▶Examples: “Color good. Skin warm and moist. Nails without clubbing or cyanosis. [Date] No suspicious nevi. No rash, petechiae, or ecchymoses.” “Marked facial pallor, with circumoral cyanosis. Palms cold and moist. Cyanosis in nailbeds of fingers and toes. One raised blue-black nevus, 1x2 cm, with irregular border on right forearm. No rash.” Evaluating the Bedbound Patient [Date] KNOW YOUR PATIENT BEFORE YOU ENTER ROOM. READ CHART!!!! MAKE SURE YOU LOOK AT B/P (statistics show providers don’t look at B/P readings) Well-Woman Care Basic history Menstrual history Obstetric history Sexual history Type of contraception, past and current Current symptoms or history of pelvic, vaginal, or vulvar infections Cervical cytology (Pap test) history History of other gynecologic [Date] problems  the shorthand for menstrual history is age at menarche x cycle length x number of days of bleeding (eg, 13x28x5)  the shorthand for obstetric history is gravida (number of pregnancies) para (number of term births; number of births from 20 to <37 weeks of [Date] gestation; number of failed or terminated pregnancies at <20 weeks; living children) (eg, G2P112) [Date] NURSING FINAL EXAMINATION AL 2023 WITH CORRECTLY ANSWERED QUESTION Chapter 12 [Date] The Peripheral Vascular System Anatomy and Physiology - Arteries Arteries must respond to the variations that cardiac systole and diastole generate in cardiac output Anatomy and size vary according to their distance from the heart Arterial pulses are palpable when artery lies close to body surface Arms [Date] Subcutaneous with poor tissue support Include great saphenous and small saphenous veins Anastomotic veins connect two saphenous veins Perforating veins connect superficial (saphenous) system with deep system Deep, superficial, and perforating veins have one-way valves [Date] Propel blood toward heart, preventing pooling, venous stasis, and backward flow Anatomy and Physiology – Lymphatic System Extensive vascular network that drains lymph from body tissues and returns it to venous circulation [Date] Lymph nodes Round, oval, or bean-shaped structures Vary in size according to location Important role in body’s immune system Cells in lymph nodes engulf cellular debris/bacteria and produce antibodies Only superficial lymph nodes accessible to physical examination [Date] Swelling of feet and legs Ask about ulcers on lower legs, often near ankles Health Promotion and Counseling Most patients with peripheral arterial disease (PAD) have no symptoms or non-specific symptoms Triad of exercise-induced calf pain that causes patient to stop exercise and experience relief of pain in 10 minutes is present in only 10% of affected patients [Date] Screen for subclinical PAD Aggressive risk factor intervention Ankle-Brachial Index (ABI) Detects stenosis of 50% or more in major vessels of legs Measure systolic blood pressure (with Doppler ultrasonography) in each arm and in pedal pulses Calculate reading for right and left Divide arm pressure by ankle pressure [Date] ABI 0.90-1.30: normal ABI 0.41-.90: mild to moderate disease ABI 0.00-0.40: severe disease with critical stenosis Techniques of Examination Important areas of examination Arms Size, symmetry, skin color Radial pulse, brachial pulse [Date] Use finger pads on flexor surface of wrist Partially flex patient’s wrist Compare pulse in both arms Palpate brachial pulse Flex elbow slightly Palpate artery medial to biceps tendon in antecubital crease Epitrochlear nodes [Date] Flex elbow 90° Support forearm Feel in groove between biceps and triceps muscle, 3 cm above medial epicondyle Techniques of Examination - Legs Patient should lay down, draped so external genitalia is covered and legs are fully exposed MUST remove patient’s stockings or socks Inspect both legs from groin and [Date] buttocks to feet Note the following: Size, symmetry, and any swelling Venous pattern/venous enlargement Pigmentation, rashes, scars, or ulcers Color and texture of skin, color of nail beds, distribution of hair on lower legs, feet, and toes Palpate superficial inguinal nodes [Date]  •  3 Bounding  •  2 Brisk, expected (normal)  •  1 Diminish ed, weaker than expected  •  0 Absent, unable to palpate Techniques of Examination - Edema [Date] Compare one foot and leg with the other Note relative size and prominence of veins, tendons, and bones Check for pitting edema Press firmly with thumb for 5 seconds over dorsum of each foot, behind medial malleolus and shins Severity of edema graded on four- point scale (slight to very marked) If edema is present, look for causes [Date] Recent deep venous thrombosis Chronic venous insufficiency Lymphedema Note color of skin Local area of redness Brownish areas near ankles Ulcers and where Thickness of skin Special Techniques [Date] the lower calf area Ulceration is present on the medial side of the ankle Affected leg feels warm to the touch All the above Answer e. All the above Question A patient you are seeing complains of severe pain in her right foot. Based on examination findings, you suspect arterial insufficiency. Which of the clinical findings below would [Date] suggest arterial insufficiency as the cause of her problem? Brisk posterior tibial and dorsalis pedis pulses Pallor of the foot upon elevation Pitting edema of the lower leg Warmth of the right foot Answer b. Pallor of the foot upon elevation [Date] Decreased posterior tribal and dorsalis pedis pulses No edema of the lower leg Cool right foot [Date] posterior surfaces of body, palms and soles, and webspaces ▶ Inspect entire skin surface in good light Preferably in natural light (or artificial light that resembles natural) o Artificial light often distorts colors ▶Hair Inspect and palpate Note quantity, distribution, and texture ▶Nails Inspect and palpate fingernails/toenails Note color and shape Note lesions [Date] Longitudinal bands of pigment may be a normal finding in people with darker skin ▶ Inspect and palpate skin ▶ Note characteristics of: Color Moisture Temperature Texture Mobility and turgor Lesions ▶Color Patients often notice change in color before physician [Date] Look for increased pigmentation, loss of pigmentation Look for redness, pallor, cyanosis, and yellowing Red color of oxyhemoglobin best assessed at fingertips, lips, and mucous membranes In dark-skinned people, palms and soles For central cyanosis, look in lips, oral mucosa, and tongue Jaundice - sclera ▶Moisture Dryness, sweating, and oiliness ▶Temperature [Date] ▶Plaque ▶Patch ▶Wheel ▶ Vesicle – clear or cloudy fluid? ▶Bulla ▶Pustule ▶Cyst ▶Crust ▶Erosion ▶Ulcer ▶Fissure ▶Excoriation ▶Scar ▶Scale ▶Telangiectasias ▶Burrow [Date] ▶Comedo ▶ Petechial – assess for blanching ▶Purpura ▶Hypopigmented ▶Hyperpigmented ▶ Erythematous – mild, moderate, marked ▶Annular ▶Linear ▶Dermatomal ▶Grouped ▶Lichenified ▶Coalesced [Date] Incisions – sutures intact? erythema? drainage? all edges approximated? *Tattoos ▶ Skin lesions in context Whenever you see a skin lesion, look it up in a well-illustrated textbook of dermatology To arrive at a dermatologic diagnosis, consider the type of lesions, location, and distribution, along with the patient’s history and physical [Date] ▶ Skin tags (acrochordons) Acrochordons : fleshy papules arise in axillae, neck, groin, and eyelids Skin colored to brown Often pedunculated ▶ Acanthosis Nigricans ▶ An eruption of velvety, hyperpigmented plaques and warty- papules in the axillae, groin, neck, and/or anogenital region. ▶ Looks like dirty skin. ▶Angioma A 45-year-old white male presents [Date] with a “red mole” which appeared 6 months ago and has increased in size. It is not tender and has not bled. ▶ Cherry angiomas Cherry angioma Majority of people get these starting around age 30 Highest concentration on the trunk ▶ Solar Lentigo The solar lentigo, AKA “sun spot”, “age spot”, or “liver spot” is due to sun damage, but is not cancerous or precancerous No treatment required, however… [Date] Extensive solar lentigines reflect history of UV exposure, and therefore can identify patients at risk for skin cancer ▶ How can I tell the difference between one of these lentigines and melanoma? Look for the ugly duckling Consider biopsy or referral to a dermatologist for any lesion that stands out as different Recall the ABCDE’s Asymmetry Border (irregular) Color (multiple, variegated) Diameter (>6mm) [Date] glands [Date] Debris (dead skin cells, oil, etc.) collects within a sack May discharge foul smelling cheesy white material ▶ Pilar cysts Compared to an EIC, less likely to rupture or get inflamed Nearly always on the scalp Slowly enlarging over months to years Firm, mobile subcutaneous nodules, lacking punctum Do not discharge any material “This lump has been slowly enlarging for years. It doesn’t bother me, but my wife wants it checked [Date] out.” You palpate a mobile, soft, subcutaneous nodule, lacking any overlying skin change On exam, he has a few other similar soft to rubbery mobile subcutaneous nodules on his arms and legs Skin Cancers Basal cell carcinoma Comprises 80% of skin cancers Shiny and translucent, they grow slowly and rarely metastasize [Date] Regular dermatologist absent Mole changing Male gender Additional Risk Factors ≥50 common moles ≥1-4 atypical or unusual moles (especially if dysplastic) Red or light hair Actinic lentigo, macular brown or tan spots (usually on sun exposed areas) Heavy sun exposure (especially [Date] severe childhood sunburns) Light eye or skin color (especially freckles/burns easily) Family history of melanoma Screening for Melanoma ADCDE A for asymmetry B for irregular borders, especially ragged, notched, or blurred C for variation or change in color, especially blue or black D for diameter ≥6 mm or different [Date] from other moles, especially changing, itching, or bleeding E for elevation or enlargement Basal cell carcinoma (BCC) Risk factors Skin types I, II (fairer skin types)* History of intense or prolonged ultraviolet light exposure History of ionizing radiation exposure or arsenic ingestion Immune suppression (transplant patients, systemic [Date] Commonly located on the head, neck, forearms, and dorsal hands (sun- exposed areas) SCC has increased associated mortality compared to basal cell carcinoma, mostly due to a higher rate of metastasis SCC: Clinical manifestations Various morphologies Papule, plaque, or nodule Pink, red, or skin-colored Scale Exophytic (grows outward) [Date] Indurated (dermal thickening, lesion feels thick, firm) May present as a cutaneous horn Friable – may bleed with minimal trauma and then crust Usually asymptomatic; may be pruritic Recording the Physical Examination ▶ Initially you may use sentences to describe findings; later you will use phrases ▶Examples: “Color good. Skin warm and moist. Nails without clubbing or cyanosis. [Date] No suspicious nevi. No rash, petechiae, or ecchymoses.” “Marked facial pallor, with circumoral cyanosis. Palms cold and moist. Cyanosis in nailbeds of fingers and toes. One raised blue-black nevus, 1x2 cm, with irregular border on right forearm. No rash.” Evaluating the Bedbound Patient [Date] KNOW YOUR PATIENT BEFORE YOU ENTER ROOM. READ CHART!!!! MAKE SURE YOU LOOK AT B/P (statistics show providers don’t look at B/P readings) Well-Woman Care Basic history Menstrual history Obstetric history Sexual history Type of contraception, past and current Current symptoms or history of pelvic, vaginal, or vulvar infections Cervical cytology (Pap test) history History of other gynecologic [Date] problems  the shorthand for menstrual history is age at menarche x cycle length x number of days of bleeding (eg, 13x28x5)  the shorthand for obstetric history is gravida (number of pregnancies) para (number of term births; number of births from 20 to <37 weeks of [Date] gestation; number of failed or terminated pregnancies at <20 weeks; living children) (eg, G2P112) [Date] pelvic examination is not included unless indicated due to symptoms or for screening for a sexually transmitted infection Pelvic Examination [Date] Timing  indicated in any patient with genital or pelvic symptoms and in other patients for preventive care Well- Woman Care Indications and frequency Routine pelvic examinations in asymptomatic women (controversy) ACOG (asymptomatic adolescents and women ) – should be performed only when indicated by the medical history for patients younger than 21 years For women ≥21 years-old, an annual pelvic examination [Date] Well-Woman Care American College of Physicians (ACP) guidelines advise against performing screening pelvic examinations in asymptomatic, nonpregnant, adult women Well-Woman Care Cervical Cancer Screening  initiated at age 21 years [Date] Patient positioning Dorsal lithotomy position Elevating the head of the table 30 to 45 degrees Well-Woman Care Equipment An examining table with stirrups Good light source [Date] We ll-Woman Care [Date] Spe cul um of app rop riat e size Mat eria ls to obt ain cer vical cytology Materials to test for common infections – chlamydia, gonorrhea, herpes simplex virus Cotton swabs for obtaining samples of vaginal discharge pH indicator paper Dropper bottles of saline and potassium hydroxide for performing wet preps Large cotton swabs to absorb excess vaginal discharge or blood Test kits for fecal occult blood Water soluble lubricant, [Date] Consistency Well-Woman Care Adnexal Size Mobility of ovaries Tenderness Well-Woman Care Other Important Components of Exam Constitutional Ears Eyes Thyroid Respiratory Cardiovascular Lymphatic Skin Neurologic/Psychiatric Well-Woman [Date] Care Routine Orders MAMMOGRAPHY – BASELINE 40 DEXA SCAN – MENOPAUSE STARTING AT AGE 65, EARLIER IF RISK FACTORS INDICTATE COLONOSCOPY –AGE 50, EARLIER IF SYMPTOMS OR FAMILY HISTORY INDICTATES Well-Woman Care Routine Labs LIPID PROFILE Every 5 years starting at age 65 TSH [Date] Every 5 years starting at age 50 GLUCOSE/HGB A1C Fasting glucose at age 45 then every 3 years after Well-Woman Care Additional Screenings Hypertension Obesity Well-Woman Care Visit Summary INFORM PATIENT OF EXAM RESULTS RESOLVE ANY QUESTIONS OR CONCERNS INFORM PATIENTS WHEN RESULTS CAN BE EXPECTED [Date] function begins with an evaluation of urinary function and symptoms. This assessment includes a focus an sexual function as well as manifestations of sexual dysfunction. Male Reproductive Examination The patient is asked about his usual state of health and any recent change in general, physical and sexual activity. Male Reproductive Examination Any symptoms or changes in function are explored fully and described in detail. These symptoms, collectively referred to as prostatism, may include [Date] those associated with an obstruction caused by an enlarged prostate gland, increased urinary frequency, decreased force of urinary stream, double or triple voiding. The patient also assessed for dysuria, hematuria and hematospermia (blood in the ejaculation) Male Reproductive Examination Assessment of sexual function and dysfunction is an essential part of every health history. The extent of history depends on the patient presenting symptoms and the presence of factors that may affect the sexual function. Chronic illness [Date] (DM, HTN, Multiple sclerosis, stroke & cardiac disease.) Male Reproductive Examination Use of medications that affects the sexual function (anti hypertensive, antipsychotics, OTC etc) [Date] Examination of the testicles and penis A swab from the urethra, anus or throat A urine or blood sample DIAGNOSIS EVALUATION Prostate – specific antigen test (PSA) Ultrasonagraphy Prostate fluid and tissue analysis Test of male sexual function Male Reproductive Examination [Date] Recommendations to screen for testicular cancer American Cancer Society recommends a testicular exam be performed routinely USPSTF’s guidelines have evolved to a recommendation “against routine screening for testicular cancer in asymptomatic adolescent and adult males” [Date] Anato my and Physio logy Hormo nal change s Pregnant Woman Assessment Shawana S. Moore, DNP, CRNP, WHNP-BC Lead to extensive anatomical and physiologic changes in every major [Date] Increased vascularity Hyperplasia of glandular tissue Become more nodular by 3rd month of pregnancy From mid-to-late pregnancy Colostrum may be expressed Areolae darken Montgomery’s glands are more pronounced e Venous pattern increasingly visible e Pelvic changes e Uterus [Date] Most easily palpable beyond 12 to 14 weeks when it straightens (from early anteverted position) and rises up out of the pelvis As uterus enlarges, it rotates to the right to accommodate the rectosigmoid structures on the left side of the pelvis Vagina Walls appear thicker and deeply rugated Vaginal secretions are thick, white, and more profuse [Date] gestation with protein in the urine Weight and BMI (body mass index) are very important for educating the patient on proper weight gain and nutrition Head: look for mask of pregnancy (chloasma) and edema Hair: often dry and thinning Eyes: examine conjunctiva; pallor often means anemia Nose: edema causing congestion is normal [Date] Mouth: examine gums and teeth; periodontal disease is common in pregnancy [Date] Thorax and lungs: patients complain of shortness of breath Heart: listen for venous hums which are common in pregnancy Breasts: look for symmetry and color; veins are often prominent Examination of the Pregnant Woman Abdominal exam Inspect for scars (from earlier C- sections), striae, and the linea nigra