NR 509 Final Exam Test Question and Answers
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
GERD : relieving factors
Answer: 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
Answer: 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
Answer: Acute inflammation of colonic diver-ticula, outpouchings 5-10 mm in di-ameter, usually in
sigmoid or descend-ing colon
Diverticulitis location
Answer: Left lower quadrant
Diverticulitis quality
Answer: May be cramping at first, then steady
Diverticulitis timing
Answer: Often gradual onset
Diverticulitis aggravating factors
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
GERD : relieving factors
Answer: 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
Answer: 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
Answer: Acute inflammation of colonic diver-ticula, outpouchings 5-10 mm in di-ameter, usually in
sigmoid or descend-ing colon
Diverticulitis location
Answer: Left lower quadrant
Diverticulitis quality
Answer: May be cramping at first, then steady
Diverticulitis timing
Answer: Often gradual onset
Diverticulitis aggravating factors
