NR 509 FINAL EXAM /NR509 ADVANCED
PHYSICAL ASSESSMENT FINAL EXAM
Appendicitis - ANSWER1. McBurney point tenderness
2. Rovsing sign
3. the psoas sign
4. the obturator sign
--Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign,
and the psoas sign
--The pain of appendicitis classically begins near the umbilicus, then migrates to the
RLQ. Older adults are less likely to report this pattern.
--Localized tenderness anywhere in the RLQ, even in the right flank, suggests
appendicitis.
McBurney Point - ANSWER1. McBurney point lies 2 inches from the anterior
superior spinous process of ilium on a line drawn from that process to the umbilicus
2. Appendicitis is three times more likely if there is McBurney point tenderness.
Rovsing sign - ANSWERPress deeply and evenly in the LLQ. Then quickly withdraw
your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
Psoas Sign - ANSWER--Place your hand just above the patient's right knee and ask
the patient to raise that thigh against your hand. Alternatively, ask the patient to turn
onto the left side. Then extend the patient's right leg at the hip. Flexion of the leg at
the hip makes the psoas muscle contract; extension stretches it.
--Increased abdominal pain on either maneuver is a positive psoas sign, sug-gesting
irritation of the psoas muscle by an inflamed appendix.
Obturator Sign - ANSWER--Less helpful
--Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg
internally at the hip. This maneuver stretches the internal obturator muscle.
--Right hypogastric pain is a positive obturator sign, from irritation of the obturator
muscle by an inflamed appendix. This sign has very low sensitivity.
Acute Cholecystits - ANSWERRUQ pain
Murphy Sign
Murphy Sign - ANSWERHook your left thumb or the fingers of your right hand under
the costal margin at the point where the lateral border of the rectus muscle intersects
with the costal margin. Alternatively, palpate the RUQ with the fingers of your right
hand near the costal margin. If the liver is enlarged, hook your thumb or fingers
under the liver edge at a comparable point. Ask the patient to take a deep breath,
which forces the liver and gallbladder down toward the examining fingers. Watch the
patient's breathing and note the degree of tenderness.
--A sharp increase in tenderness with inspiratory effort is a positive Murphy sign.
When positive, Murphy sign triples the likelihood of acute cholecystitis.
,Acute Pancreatitis Process - ANSWERIntrapancreatic trypsinogen activation to
trypsin and other enzymes, result-ing in autodigestion and inflammation of the
pancreas
Acute Pancreatitis Location - ANSWEREpigastric, may radiate straight to the back or
other areas of the abdomen; 20% with severe sequelae of organ failure
Acute Pancreatitis Quality - ANSWERUsually steady
Acute PancreatitisTiming - ANSWERAcute onset, persistent pain
Acute Pancreatitis Aggrevating Factors - ANSWERLying supine; dyspnea if pleural
effusions from capillary leak syn-drome; selected medications, high triglycerides may
exacerbate
Acute Pancreatitis Relieving factors - ANSWERLeaning forward with trunk flexed
Acute Pancreatitis Associated Symptoms and Setting - ANSWERNausea, vomiting,
abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or
gallstones
Peptic Ulcer Disease Process - ANSWERMucosal ulcer in stomach or duode-num
>5 mm, covered with fibrin, ex-tending through the muscularis mu-cosa; H. pylori
infection present in 90% of peptic ulcers
Peptic Ulcer Disease Location - ANSWEREpigastric, may radiate straight to the back
Peptic Ulcer Disease Quality - ANSWERVariable: epigastric gnawing or burning
(dyspepsia); may also be boring, aching, or hungerlike
No symptoms in up to 20%
Peptic Ulcer Disease Timing - ANSWERIntermittent; duodenal ulcer is more likely
than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and
(2) occurs intermittently over a few wks, disappears for months, then recurs
Peptic Ulcer Disease aggravating factors - ANSWERVariable
Peptic Ulcer Disease relieving factors - ANSWERFood and antacids may bring re-lief
(less likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting - ANSWERNausea,
vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight
loss (more common in gastric ulcer); dyspepsia is more com-mon in the young (20-
29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in those 30-60 yrs
GERD Process - ANSWERProlonged exposure of esophagus to gastric acid due to
impaired esopha-geal motility or excess relaxations of the lower esophageal
sphincter; Helico-bacter pylori may be present
, GERD Location - ANSWERChest or epigastric
GERD Quality - ANSWERHeartburn, regurgitation
GERD timing - ANSWERAfter meals, especially spicy foods
GERD aggravating factors - ANSWERLying down, bending over; physical activity;
diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower
esophageal sphincter
GERD : relieving factors - ANSWERAntacids, proton pump inhibi-tors; avoiding
alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, cal-
cium channel blockers
GERD associated symptoms and setting - ANSWERWheezing, chronic cough, short-
ness of breath, hoarseness, choking sensation, dysphagia, regurgitation, halitosis,
sore throat; increases risk of Barrett esophagus and esopha-geal cancer
Diverticulitis process - ANSWERAcute inflammation of colonic diver-ticula,
outpouchings 5-10 mm in di-ameter, usually in sigmoid or descend-ing colon
Diverticulitis location - ANSWERLeft lower quadrant
Diverticulitis quality - ANSWERMay be cramping at first, then steady
Diverticulitis timing - ANSWEROften gradual onset
Diverticulitis aggravating factors - ANSWER--
Diverticulitis relieving factors - ANSWERAnalgesia, bowel rest, antibiotics
Diverticulitis associated symptoms and setting - ANSWERFever, constipation. Also
nausea, vomiting, abdominal mass with rebound tenderness
Hepatitis - ANSWER-Tenderness over liver (liver inflammation)
--Hep A and B prevention: Vaccination
Hep A: spread through fecal matter and asymptomatic children
Hep B: 1% fatality, 15-25% of chronic infection die from cirrhosis or liver cancer
(usually asymptomatic until onset of advanced liver disease).
Hep C: Mainly percutaneous exposure.
Hepatitis B high risk - ANSWER-Sexual contact: w/ partners infected, more than one
parter in prior 6 mos, people seeing eval of treatment for STD, men with men
-Perc and Mucosal exposure to blod: drugs, household contacts, residents and staff
of facilties of DD, Health care, dialysis
-Others: Travel to endemic areas, chronic liver disease and HIV, people seeking
protection from Hep B.
--All adults in high risk-settings: STD clinics, HIV programs, Drug programs,
correctional facilities, programs for gay men, chronic hemodialysis facilities, facilities
for people with Developmental Delays.
PHYSICAL ASSESSMENT FINAL EXAM
Appendicitis - ANSWER1. McBurney point tenderness
2. Rovsing sign
3. the psoas sign
4. the obturator sign
--Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign,
and the psoas sign
--The pain of appendicitis classically begins near the umbilicus, then migrates to the
RLQ. Older adults are less likely to report this pattern.
--Localized tenderness anywhere in the RLQ, even in the right flank, suggests
appendicitis.
McBurney Point - ANSWER1. McBurney point lies 2 inches from the anterior
superior spinous process of ilium on a line drawn from that process to the umbilicus
2. Appendicitis is three times more likely if there is McBurney point tenderness.
Rovsing sign - ANSWERPress deeply and evenly in the LLQ. Then quickly withdraw
your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
Psoas Sign - ANSWER--Place your hand just above the patient's right knee and ask
the patient to raise that thigh against your hand. Alternatively, ask the patient to turn
onto the left side. Then extend the patient's right leg at the hip. Flexion of the leg at
the hip makes the psoas muscle contract; extension stretches it.
--Increased abdominal pain on either maneuver is a positive psoas sign, sug-gesting
irritation of the psoas muscle by an inflamed appendix.
Obturator Sign - ANSWER--Less helpful
--Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg
internally at the hip. This maneuver stretches the internal obturator muscle.
--Right hypogastric pain is a positive obturator sign, from irritation of the obturator
muscle by an inflamed appendix. This sign has very low sensitivity.
Acute Cholecystits - ANSWERRUQ pain
Murphy Sign
Murphy Sign - ANSWERHook your left thumb or the fingers of your right hand under
the costal margin at the point where the lateral border of the rectus muscle intersects
with the costal margin. Alternatively, palpate the RUQ with the fingers of your right
hand near the costal margin. If the liver is enlarged, hook your thumb or fingers
under the liver edge at a comparable point. Ask the patient to take a deep breath,
which forces the liver and gallbladder down toward the examining fingers. Watch the
patient's breathing and note the degree of tenderness.
--A sharp increase in tenderness with inspiratory effort is a positive Murphy sign.
When positive, Murphy sign triples the likelihood of acute cholecystitis.
,Acute Pancreatitis Process - ANSWERIntrapancreatic trypsinogen activation to
trypsin and other enzymes, result-ing in autodigestion and inflammation of the
pancreas
Acute Pancreatitis Location - ANSWEREpigastric, may radiate straight to the back or
other areas of the abdomen; 20% with severe sequelae of organ failure
Acute Pancreatitis Quality - ANSWERUsually steady
Acute PancreatitisTiming - ANSWERAcute onset, persistent pain
Acute Pancreatitis Aggrevating Factors - ANSWERLying supine; dyspnea if pleural
effusions from capillary leak syn-drome; selected medications, high triglycerides may
exacerbate
Acute Pancreatitis Relieving factors - ANSWERLeaning forward with trunk flexed
Acute Pancreatitis Associated Symptoms and Setting - ANSWERNausea, vomiting,
abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or
gallstones
Peptic Ulcer Disease Process - ANSWERMucosal ulcer in stomach or duode-num
>5 mm, covered with fibrin, ex-tending through the muscularis mu-cosa; H. pylori
infection present in 90% of peptic ulcers
Peptic Ulcer Disease Location - ANSWEREpigastric, may radiate straight to the back
Peptic Ulcer Disease Quality - ANSWERVariable: epigastric gnawing or burning
(dyspepsia); may also be boring, aching, or hungerlike
No symptoms in up to 20%
Peptic Ulcer Disease Timing - ANSWERIntermittent; duodenal ulcer is more likely
than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and
(2) occurs intermittently over a few wks, disappears for months, then recurs
Peptic Ulcer Disease aggravating factors - ANSWERVariable
Peptic Ulcer Disease relieving factors - ANSWERFood and antacids may bring re-lief
(less likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting - ANSWERNausea,
vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight
loss (more common in gastric ulcer); dyspepsia is more com-mon in the young (20-
29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in those 30-60 yrs
GERD Process - ANSWERProlonged exposure of esophagus to gastric acid due to
impaired esopha-geal motility or excess relaxations of the lower esophageal
sphincter; Helico-bacter pylori may be present
, GERD Location - ANSWERChest or epigastric
GERD Quality - ANSWERHeartburn, regurgitation
GERD timing - ANSWERAfter meals, especially spicy foods
GERD aggravating factors - ANSWERLying down, bending over; physical activity;
diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower
esophageal sphincter
GERD : relieving factors - ANSWERAntacids, proton pump inhibi-tors; avoiding
alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, cal-
cium channel blockers
GERD associated symptoms and setting - ANSWERWheezing, chronic cough, short-
ness of breath, hoarseness, choking sensation, dysphagia, regurgitation, halitosis,
sore throat; increases risk of Barrett esophagus and esopha-geal cancer
Diverticulitis process - ANSWERAcute inflammation of colonic diver-ticula,
outpouchings 5-10 mm in di-ameter, usually in sigmoid or descend-ing colon
Diverticulitis location - ANSWERLeft lower quadrant
Diverticulitis quality - ANSWERMay be cramping at first, then steady
Diverticulitis timing - ANSWEROften gradual onset
Diverticulitis aggravating factors - ANSWER--
Diverticulitis relieving factors - ANSWERAnalgesia, bowel rest, antibiotics
Diverticulitis associated symptoms and setting - ANSWERFever, constipation. Also
nausea, vomiting, abdominal mass with rebound tenderness
Hepatitis - ANSWER-Tenderness over liver (liver inflammation)
--Hep A and B prevention: Vaccination
Hep A: spread through fecal matter and asymptomatic children
Hep B: 1% fatality, 15-25% of chronic infection die from cirrhosis or liver cancer
(usually asymptomatic until onset of advanced liver disease).
Hep C: Mainly percutaneous exposure.
Hepatitis B high risk - ANSWER-Sexual contact: w/ partners infected, more than one
parter in prior 6 mos, people seeing eval of treatment for STD, men with men
-Perc and Mucosal exposure to blod: drugs, household contacts, residents and staff
of facilties of DD, Health care, dialysis
-Others: Travel to endemic areas, chronic liver disease and HIV, people seeking
protection from Hep B.
--All adults in high risk-settings: STD clinics, HIV programs, Drug programs,
correctional facilities, programs for gay men, chronic hemodialysis facilities, facilities
for people with Developmental Delays.
