NR 509 FINAL EXAM WITH ACCURATE
SOLUTIONS /PASS GUIDE /GRADED A+
Appendicitis - ANSWER-1. 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 - ANSWER-1. 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 - ANSWER-Press 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 - ANSWER-RUQ pain
Murphy Sign
Murphy Sign - ANSWER-Hook 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 - ANSWER-Intrapancreatic trypsinogen
activation to trypsin and other enzymes, result-ing in autodigestion
and inflammation of the pancreas
,Acute Pancreatitis Location - ANSWER-Epigastric, may radiate
straight to the back or other areas of the abdomen; 20% with severe
sequelae of organ failure
Acute Pancreatitis Quality - ANSWER-Usually steady
Acute PancreatitisTiming - ANSWER-Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors - ANSWER-Lying supine;
dyspnea if pleural effusions from capillary leak syn-drome; selected
medications, high triglycerides may exacerbate
Acute Pancreatitis Relieving factors - ANSWER-Leaning forward with
trunk flexed
Acute Pancreatitis Associated Symptoms and Setting - ANSWER-
Nausea, vomiting, abdominal dis-tention, fever; often recurrent;
80% with history of alcohol abuse or gallstones
Peptic Ulcer Disease Process - ANSWER-Mucosal 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 - ANSWER-Epigastric, may radiate
straight to the back
Peptic Ulcer Disease Quality - ANSWER-Variable: epigastric gnawing
or burning (dyspepsia); may also be boring, aching, or hungerlike
No symptoms in up to 20%
, Peptic Ulcer Disease Timing - ANSWER-Intermittent; 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 - ANSWER-Variable
Peptic Ulcer Disease relieving factors - ANSWER-Food and antacids
may bring re-lief (less likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting - ANSWER-
Nausea, 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 - ANSWER-Prolonged 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 - ANSWER-Chest or epigastric
GERD Quality - ANSWER-Heartburn, regurgitation
GERD timing - ANSWER-After meals, especially spicy foods
GERD aggravating factors - ANSWER-Lying down, bending over;
physical activity; diseases such as scleroderma, gastroparesis;
drugs like nicotine that relax the lower esophageal sphincter
SOLUTIONS /PASS GUIDE /GRADED A+
Appendicitis - ANSWER-1. 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 - ANSWER-1. 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 - ANSWER-Press 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 - ANSWER-RUQ pain
Murphy Sign
Murphy Sign - ANSWER-Hook 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 - ANSWER-Intrapancreatic trypsinogen
activation to trypsin and other enzymes, result-ing in autodigestion
and inflammation of the pancreas
,Acute Pancreatitis Location - ANSWER-Epigastric, may radiate
straight to the back or other areas of the abdomen; 20% with severe
sequelae of organ failure
Acute Pancreatitis Quality - ANSWER-Usually steady
Acute PancreatitisTiming - ANSWER-Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors - ANSWER-Lying supine;
dyspnea if pleural effusions from capillary leak syn-drome; selected
medications, high triglycerides may exacerbate
Acute Pancreatitis Relieving factors - ANSWER-Leaning forward with
trunk flexed
Acute Pancreatitis Associated Symptoms and Setting - ANSWER-
Nausea, vomiting, abdominal dis-tention, fever; often recurrent;
80% with history of alcohol abuse or gallstones
Peptic Ulcer Disease Process - ANSWER-Mucosal 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 - ANSWER-Epigastric, may radiate
straight to the back
Peptic Ulcer Disease Quality - ANSWER-Variable: epigastric gnawing
or burning (dyspepsia); may also be boring, aching, or hungerlike
No symptoms in up to 20%
, Peptic Ulcer Disease Timing - ANSWER-Intermittent; 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 - ANSWER-Variable
Peptic Ulcer Disease relieving factors - ANSWER-Food and antacids
may bring re-lief (less likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting - ANSWER-
Nausea, 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 - ANSWER-Prolonged 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 - ANSWER-Chest or epigastric
GERD Quality - ANSWER-Heartburn, regurgitation
GERD timing - ANSWER-After meals, especially spicy foods
GERD aggravating factors - ANSWER-Lying down, bending over;
physical activity; diseases such as scleroderma, gastroparesis;
drugs like nicotine that relax the lower esophageal sphincter
