NR 509 Final Exam
Appendicitis - correct 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 - correct 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 - correct 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 - correct 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 - correct 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 - correct answerRUQ pain
Murphy Sign
Murphy Sign - correct 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
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, NR 509 Final Exam
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 - correct answerIntrapancreatic trypsinogen activation
to trypsin and other enzymes, result-ing in autodigestion and inflammation of the
pancreas
Acute Pancreatitis Location - correct answerEpigastric, may radiate straight to the
back or other areas of the abdomen; 20% with severe sequelae of organ failure
Acute Pancreatitis Quality - correct answerUsually steady
Acute PancreatitisTiming - correct answerAcute onset, persistent pain
Acute Pancreatitis Aggrevating Factors - correct answerLying supine; dyspnea if
pleural effusions from capillary leak syn-drome; selected medications, high
triglycerides may exacerbate
Acute Pancreatitis Relieving factors - correct answerLeaning forward with trunk
flexed
Acute Pancreatitis Associated Symptoms and Setting - correct answerNausea,
vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of
alcohol abuse or gallstones
Peptic Ulcer Disease Process - correct 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 - correct answerEpigastric, may radiate straight to
the back
Peptic Ulcer Disease Quality - correct answerVariable: epigastric gnawing or
burning (dyspepsia); may also be boring, aching, or hungerlike
No symptoms in up to 20%
Peptic Ulcer Disease Timing - correct 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 - correct answerVariable
Peptic Ulcer Disease relieving factors - correct answerFood and antacids may
bring re-lief (less likely in gastric ulcers)
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Peptic Ulcer Disease associated symptoms and setting - correct 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 - correct 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 - correct answerChest or epigastric
GERD Quality - correct answerHeartburn, regurgitation
GERD timing - correct answerAfter meals, especially spicy foods
GERD aggravating factors - correct answerLying down, bending over; physical
activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax
the lower esophageal sphincter
GERD : relieving factors - correct 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 - correct 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 - correct answerAcute inflammation of colonic diver-ticula,
outpouchings 5-10 mm in di-ameter, usually in sigmoid or descend-ing colon
Diverticulitis location - correct answerLeft lower quadrant
Diverticulitis quality - correct answerMay be cramping at first, then steady
Diverticulitis timing - correct answerOften gradual onset
Diverticulitis aggravating factors - correct answer--
Diverticulitis relieving factors - correct answerAnalgesia, bowel rest, antibiotics
Diverticulitis associated symptoms and setting - correct answerFever,
constipation. Also nausea, vomiting, abdominal mass with rebound tenderness
Hepatitis - correct 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.
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