NR 509 Final Exam
Appendicitis - ANS-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 - ANS-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 - ANS-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 - ANS---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 - ANS---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 - ANS-RUQ pain
Murphy Sign
Murphy Sign - ANS-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 - ANS-Intrapancreatic trypsinogen activation to trypsin and
other enzymes, result-ing in autodigestion and inflammation of the pancreas
Acute Pancreatitis Location - ANS-Epigastric, may radiate straight to the back or other
areas of the abdomen; 20% with severe sequelae of organ failure
Acute Pancreatitis Quality - ANS-Usually steady
Acute PancreatitisTiming - ANS-Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors - ANS-Lying supine; dyspnea if pleural effusions
from capillary leak syn-drome; selected medications, high triglycerides may exacerbate
Acute Pancreatitis Relieving factors - ANS-Leaning forward with trunk flexed
Acute Pancreatitis Associated Symptoms and Setting - ANS-Nausea, vomiting,
abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or
gallstones
Peptic Ulcer Disease Process - ANS-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 - ANS-Epigastric, may radiate straight to the back
Peptic Ulcer Disease Quality - ANS-Variable: epigastric gnawing or burning (dyspepsia);
may also be boring, aching, or hungerlike
No symptoms in up to 20%
Peptic Ulcer Disease Timing - ANS-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 - ANS-Variable
Peptic Ulcer Disease relieving factors - ANS-Food and antacids may bring re-lief (less
likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting - ANS-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 - ANS-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 - ANS-Chest or epigastric
GERD Quality - ANS-Heartburn, regurgitation
GERD timing - ANS-After meals, especially spicy foods
GERD aggravating factors - ANS-Lying down, bending over; physical activity; diseases
such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal
sphincter
GERD : relieving factors - ANS-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 - ANS-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 - ANS-Acute inflammation of colonic diver-ticula, outpouchings
5-10 mm in di-ameter, usually in sigmoid or descend-ing colon
Diverticulitis location - ANS-Left lower quadrant
Diverticulitis quality - ANS-May be cramping at first, then steady
Appendicitis - ANS-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 - ANS-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 - ANS-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 - ANS---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 - ANS---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 - ANS-RUQ pain
Murphy Sign
Murphy Sign - ANS-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 - ANS-Intrapancreatic trypsinogen activation to trypsin and
other enzymes, result-ing in autodigestion and inflammation of the pancreas
Acute Pancreatitis Location - ANS-Epigastric, may radiate straight to the back or other
areas of the abdomen; 20% with severe sequelae of organ failure
Acute Pancreatitis Quality - ANS-Usually steady
Acute PancreatitisTiming - ANS-Acute onset, persistent pain
Acute Pancreatitis Aggrevating Factors - ANS-Lying supine; dyspnea if pleural effusions
from capillary leak syn-drome; selected medications, high triglycerides may exacerbate
Acute Pancreatitis Relieving factors - ANS-Leaning forward with trunk flexed
Acute Pancreatitis Associated Symptoms and Setting - ANS-Nausea, vomiting,
abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or
gallstones
Peptic Ulcer Disease Process - ANS-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 - ANS-Epigastric, may radiate straight to the back
Peptic Ulcer Disease Quality - ANS-Variable: epigastric gnawing or burning (dyspepsia);
may also be boring, aching, or hungerlike
No symptoms in up to 20%
Peptic Ulcer Disease Timing - ANS-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 - ANS-Variable
Peptic Ulcer Disease relieving factors - ANS-Food and antacids may bring re-lief (less
likely in gastric ulcers)
Peptic Ulcer Disease associated symptoms and setting - ANS-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 - ANS-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 - ANS-Chest or epigastric
GERD Quality - ANS-Heartburn, regurgitation
GERD timing - ANS-After meals, especially spicy foods
GERD aggravating factors - ANS-Lying down, bending over; physical activity; diseases
such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal
sphincter
GERD : relieving factors - ANS-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 - ANS-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 - ANS-Acute inflammation of colonic diver-ticula, outpouchings
5-10 mm in di-ameter, usually in sigmoid or descend-ing colon
Diverticulitis location - ANS-Left lower quadrant
Diverticulitis quality - ANS-May be cramping at first, then steady
