NR 509 Final Exam Correct Questions & Answers(GRADED A+)

Appendicitis - ANSWERS 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 - ANSWERS 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 - ANSWERS 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 - ANSWERS --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 - ANSWERS --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 - ANSWERS RUQ pain Murphy Sign Murphy Sign - ANSWERS 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 - ANSWERS Intrapancreatic trypsinogen activation to trypsin and other enzymes, result-ing in autodigestion and inflammation of the pancreas Acute Pancreatitis Location - ANSWERS Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure Acute Pancreatitis Quality - ANSWERS Usually steady Acute PancreatitisTiming - ANSWERS Acute onset, persistent pain Acute Pancreatitis Aggrevating Factors - ANSWERS Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected medications, high triglycerides may exacerbate Acute Pancreatitis Relieving factors - ANSWERS Leaning forward with trunk flexed Acute Pancreatitis Associated Symptoms and Setting - ANSWERS Nausea, vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or gallstones Peptic Ulcer Disease Process - ANSWERS 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 - ANSWERS Epigastric, may radiate straight to the back Peptic Ulcer Disease Quality - ANSWERS Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike No symptoms in up to 20% Peptic Ulcer Disease Timing - ANSWERS 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 - ANSWERS Variable Peptic Ulcer Disease relieving factors - ANSWERS Food and antacids may bring re-lief (less likely in gastric ulcers) Peptic Ulcer Disease associated symptoms and setting - ANSWERS 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 - ANSWERS 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 - ANSWERS Chest or epigastric GERD Quality - ANSWERS Heartburn, regurgitation GERD timing - ANSWERS After meals, especially spicy foods GERD aggravating factors - ANSWERS Lying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter GERD : relieving factors - ANSWERS Antacids, proton pump inhibi-tors; avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, cal-cium channel blockers GERD associated symptoms and setting - ANSWERS Wheezing, 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 - ANSWERS Acute inflammation of colonic diver-ticula, outpouchings 5-10 mm in di-ameter, usually in sigmoid or descend-ing colon Diverticulitis location - ANSWERS Left lower quadrant Diverticulitis quality - ANSWERS May be cramping at first, then steady Diverticulitis timing - ANSWERS Often gradual onset Diverticulitis aggravating factors - ANSWERS -- Diverticulitis relieving factors - ANSWERS Analgesia, bowel rest, antibiotics Diverticulitis associated symptoms and setting - ANSWERS Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness Hepatitis - ANSWERS -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 - ANSWERS -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. IBS patterns - ANSWERS 1. diarrhea—predominant 2. constipation—predominant 3. mixed. --Symptoms present ≥6 mo and abdominal pain for ≥3 mo plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance) IBS: process - ANSWERS Altered motility or secretion from luminal and mucosal irritants that change mucosal permeability, immune activation, and colonic transit, including maldigested carbohydrates, fats, excess bile acids, gluten intolerance, entero-endocrine signaling, and changes in microbiomes IBS characteristics of stool - ANSWERS Loose; ∼50% with mucus; small to mod-erate volume. Small, hard stools with constipation. May be mixed pattern. IBS timing - ANSWERS Worse in the morning; rarely at night. IBS associated symptoms - ANSWERS Crampy lower ab-dominal pain, ab-dominal disten-tion, flatulence, nausea; urgency, pain relieved with defecation IBS setting, persons at risk - ANSWERS Young and middle-aged adults, especially women Stress Incontinence problem - ANSWERS The urethral sphincter is weakened so that transient increases in intra-abdominal pressure raise the bladder pressure to levels that exceed urethral resistance. Stress Incontinence mechanisms - ANSWERS In women, pelvic floor weakness and inadequate muscular and ligamentous support of the bladder neck and proximal urethra change the angle between the bladder and the urethra (see Chapter 14, pp. 592-593). Causes include childbirth and surgery. Local conditions affecting the internal urethral sphincter, such as postmenopausal atrophy of the mucosa and urethral infection, may also contribute. In men, stress incontinence may follow prostate surgery. Stress Incontinence symptoms - ANSWERS Momentary leakage of small amounts of urine with coughing, laughing, and sneezing while the person is in an upright position. Urine loss is unrelated to a conscious urge to urinate. Stress Incontinence Physical signs - ANSWERS Stress incontinence may be demonstrable, especially if the patient is examined before voiding and in a standing position. Atrophic vaginitis may be evident. Bladder distention is absent. Urge incontinence problem - ANSWERS Detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small. Urge incontinence mechanism - ANSWERS Decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above the sacral level. Hyperexcitability of sensory pathways, as in bladder infections, tumors, and fecal impaction. Deconditioning of voiding reflexes, as in frequent voluntary voiding at low bladder volumes. Urge incontinence symptoms - ANSWERS Involuntary urine loss preceded by an urge to void. The volume tends to be moderate. Urgency, frequency, and nocturia with small to moderate volumes. If acute inflammation is present, pain on urination. Possibly "pseudo-stress incontinence"—voiding 10-20 sec after stresses such as a change of position, going up-or downstairs, and possibly coughing, laughing, or sneezing. Urge incontinence physical signs - ANSWERS The small bladder is not detectable on abdominal examination. When cortical inhibition is decreased, mental deficits or motor signs of central nervous system disease are often present. When sensory pathways are hyperexcitable, signs of local pelvic problems or a fecal impaction may be present. Overflow incontinence problem - ANSWERS Detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. The bladder is typically flaccid and large, even after an effort to void. Overflow incontinence mechanisms - ANSWERS Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor. Weakness of the detrusor muscle associated with peripheral nerve disease at S2-4 level. Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy. Overflow incontinence symptoms - ANSWERS When intravesicular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues. Decreased force of the urinary stream. Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present. Overflow incontinence physical signs - ANSWERS Examination often reveals an enlarged, sometimes tender, bladder. Other signs include prostatic enlargement, motor signs of peripheral nerve disease, a decrease in sensation (including perineal sensation), and diminished to absent reflexes. Functional incontinence problem - ANSWERS The patient is functionally unable to reach the toilet in time because of impaired health or environmental conditions. Functional incontinence mechanisms - ANSWERS Problems in mobility resulting from weakness, arthritis, poor vision, or other conditions. Environmental factors such as an unfamiliar setting, distant bathroom facilities, bed rails, or physical restraints. Functional incontinence symptoms - ANSWERS Incontinence on the way to the toilet or only in the early morning. Functional incontinence physical signs - ANSWERS The bladder is not detectable on examination. Look for physical or environmental clues as the likely cause. Incontinence secondary to medications problem - ANSWERS Drugs may contribute to any type of incontinence listed. Incontinence secondary to medications mechanisms - ANSWERS Sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics. Incontinence secondary to medications symptoms - ANSWERS Variable. A careful history and chart review are important. Incontinence secondary to medications physical signs - ANSWERS Variable. Colorectal cancer screening - ANSWERS Adults ages 50 to 75 years—options (grade A recommendation) 1. Hi-sens fecal occult blood testing annually 2. Sigmoidoscopy every 5 years w/ high-sensitivity FOBT every 3 years 3. Screening colonoscopy every 10 years B: Adults 76-85 1. Screening not advised because the benefits are small in comparison to the risks 2. Use individual decision making if screening an adult for the first time C. Adults older than age 85 years—do not screen (grade D recommendation) 1. Screening not advised because "competing causes of mortality preclude a mortality benefit that outweighs harms" Colorectal cancer screening tests - ANSWERS 1. Stool tests that detect occult fecal blood: a. fecal immunochemical tests, b. high-sensitivity guaiac-based tests, c. tests that detect abnormal DNA. 2. Endoscopic tests: a. colonoscopy, which visualizes the entire colon and can remove polyps, b. flexible sigmoidoscopy, which visualizes the distal 60 cm of the bowel. --Colonoscopy is the most commonly used and gold standard, though people may prefer other tests like FOBTs because they are safer and easier to perform. Colorectal cancer epidemiology - ANSWERS --Third most frequently diagnosed cancer among both men and women (over 140,000 new cases) and the third leading cause of cancer death (nearly 50,000 deaths) each year in the United States. --The lifetime risk of diagnosis with colorectal cancer is about 5%, while the lifetime risk for dying from colorectal cancer is about 2%. Colorectal cancer risk factors - ANSWERS 1. Increasing age 2. personal history of colorectal cancer 3. adenomatous polyps, or long-standing inflammatory bowel disease 4. family history of colorectal neoplasia—particularly multiple first-degree relatives, a single first-degree relative diagnosed before age 60 years, or a hereditary colorectal cancer syndrome. Weaker risk factors: 1. male sex 2. African American race 3. tobacco use 4. excessive alcohol use 5. red meat consumption 6. obesity. Colorectal cancer prevention - ANSWERS Primary prevention: 1. screen for and 2. remove pre-cancerous adenomatous polyps Also associated with decreased risk 1. Physical activity 2. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) 3. Postmenopausal combined hormone replacement therapy (estrogen and progestin) Abdominal insepction - ANSWERS Abnormal: purple striae: cushing syndrome Dilated veins: portal HTN from cirrhosis or ICV obstruction Ecchymosis: intraperitoneal or retroperitoneal hemorrhage