NR 509 Final Exam
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2026
,Appendicitis
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
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
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
--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
--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
RUQ pain
Murphy Sign
Murphy Sign
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
Intrapancreatic trypsinogen activation to trypsin and other enzymes, result-ing in
autodigestion and inflammation of the pancreas
Acute Pancreatitis Location
Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with
severe sequelae of organ failure
Acute Pancreatitis Quality
Usually steady
Acute PancreatitisTiming
Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors
Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected
medications, high triglycerides may exacerbate
Questions Verified and
Provided with A+ Graded
Answers| Latest Updated
2026
,Appendicitis
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
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
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
--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
--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
RUQ pain
Murphy Sign
Murphy Sign
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
Intrapancreatic trypsinogen activation to trypsin and other enzymes, result-ing in
autodigestion and inflammation of the pancreas
Acute Pancreatitis Location
Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with
severe sequelae of organ failure
Acute Pancreatitis Quality
Usually steady
Acute PancreatitisTiming
Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors
Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected
medications, high triglycerides may exacerbate
