NR 509 FINAL EXAM|WITH COMPLETE SOLUTIONS|ALREADY GRADED A|DOWNLOAD TO PASS

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 Acute Pancreatitis Relieving factors Leaning forward with trunk flexed Acute Pancreatitis Associated Symptoms and Setting Nausea, vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or gallstones Peptic Ulcer Disease Process 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 Epigastric, may radiate straight to the back Peptic Ulcer Disease Quality Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike No symptoms in up to 20% Peptic Ulcer Disease Timing 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 Variable Peptic Ulcer Disease relieving factors Food and antacids may bring re-lief (less likely in gastric ulcers) Peptic Ulcer Disease associated symptoms and setting 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 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 Chest or epigastric GERD Quality Heartburn, regurgitation GERD timing After meals, especially spicy foods GERD aggravating factors Lying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter GERD : relieving factors 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 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 Acute inflammation of colonic diver-ticula, outpouchings 5-10 mm in di-ameter, usually in sigmoid or descend-ing colon Diverticulitis location Left lower quadrant Diverticulitis quality May be cramping at first, then steady Diverticulitis timing Often gradual onset Diverticulitis aggravating factors -- Diverticulitis relieving factors Analgesia, bowel rest, antibiotics Diverticulitis associated symptoms and setting Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness Hepatitis -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 -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.