NR 509 Final Exam Study Guide Questions and 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
Appendicitis 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.
1. McBurney point lies 2 inches from the anterior superior
McBurney Point 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.
Press deeply and evenly in the LLQ. Then quickly
Rovsing sign
withdraw your fingers. Pain in the RLQ during
left-sided pressure is a positive Rovsing 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.
Psoas Sign
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.
--Less helpful
--Flex the patient's right thigh at the hip, with the knee
Obturator Sign 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.
, RUQ pain
Acute Cholecystits
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.
Murphy Sign 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.
Intrapancreatic trypsinogen activation to trypsin and
Acute Pancreatitis Process
other enzymes, result-ing in autodigestion and
inflammation of the pancreas
Epigastric, may radiate straight to the back or other
Acute Pancreatitis Location
areas of the abdomen; 20% with severe sequelae of
organ failure
Acute Pancreatitis Quality Usually steady
Acute PancreatitisTiming Acute onset, persistent pain
Lying supine; dyspnea if pleural effusions from capillary
Acute Pancreatitis Aggrevating
Factors leak syn-drome; selected medications, high
triglycerides may exacerbate
Acute Pancreatitis Relieving Leaning forward with trunk flexed
factors
Acute Pancreatitis Associated Nausea, vomiting, abdominal dis-tention, fever; often
Symptoms and Setting recurrent; 80% with history of alcohol abuse or
gallstones
Mucosal ulcer in stomach or duode-num >5 mm, covered with
Peptic Ulcer Disease Process
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
Variable: epigastric gnawing or burning (dyspepsia);
Peptic Ulcer Disease Quality may also be boring, aching, or hungerlike
No symptoms in up to 20%
Intermittent; duodenal ulcer is more likely than gastric
Peptic Ulcer Disease Timing 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 Variable
aggravating factors
Peptic Ulcer Disease relieving Food and antacids may bring re-lief (less likely in gastric ulcers)
factors
Nausea, vomiting, belching, bloating; heartburn (more
Peptic Ulcer Disease common in duodenal ulcer); weight loss (more common
associated symptoms and in gastric ulcer); dyspepsia is more com-mon in the
setting young (20-29 yrs), gastric ulcer in those over 50 yrs,
and duodenal ulcer in those 30- 60 yrs
Prolonged exposure of esophagus to gastric acid due
GERD Process 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
Lying down, bending over; physical activity; diseases
GERD aggravating factors
such as scleroderma, gastroparesis; drugs like nicotine
that relax the lower esophageal sphincter
Antacids, proton pump inhibi-tors; avoiding alcohol,
GERD : relieving factors
smoking, fatty meals, chocolate, selected drugs such
as theophylline, cal-cium channel blockers
Wheezing, chronic cough, short-ness of breath,
GERD associated symptoms hoarseness, choking sensation, dysphagia,
and setting
regurgitation, halitosis, sore throat; increases risk of
Barrett esophagus and esopha-geal cancer
Acute inflammation of colonic diver-ticula, outpouchings
Diverticulitis process
5-10 mm in di-ameter, usually in sigmoid or descend-
ing colon
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
Appendicitis 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.
1. McBurney point lies 2 inches from the anterior superior
McBurney Point 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.
Press deeply and evenly in the LLQ. Then quickly
Rovsing sign
withdraw your fingers. Pain in the RLQ during
left-sided pressure is a positive Rovsing 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.
Psoas Sign
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.
--Less helpful
--Flex the patient's right thigh at the hip, with the knee
Obturator Sign 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.
, RUQ pain
Acute Cholecystits
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.
Murphy Sign 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.
Intrapancreatic trypsinogen activation to trypsin and
Acute Pancreatitis Process
other enzymes, result-ing in autodigestion and
inflammation of the pancreas
Epigastric, may radiate straight to the back or other
Acute Pancreatitis Location
areas of the abdomen; 20% with severe sequelae of
organ failure
Acute Pancreatitis Quality Usually steady
Acute PancreatitisTiming Acute onset, persistent pain
Lying supine; dyspnea if pleural effusions from capillary
Acute Pancreatitis Aggrevating
Factors leak syn-drome; selected medications, high
triglycerides may exacerbate
Acute Pancreatitis Relieving Leaning forward with trunk flexed
factors
Acute Pancreatitis Associated Nausea, vomiting, abdominal dis-tention, fever; often
Symptoms and Setting recurrent; 80% with history of alcohol abuse or
gallstones
Mucosal ulcer in stomach or duode-num >5 mm, covered with
Peptic Ulcer Disease Process
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
Variable: epigastric gnawing or burning (dyspepsia);
Peptic Ulcer Disease Quality may also be boring, aching, or hungerlike
No symptoms in up to 20%
Intermittent; duodenal ulcer is more likely than gastric
Peptic Ulcer Disease Timing 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 Variable
aggravating factors
Peptic Ulcer Disease relieving Food and antacids may bring re-lief (less likely in gastric ulcers)
factors
Nausea, vomiting, belching, bloating; heartburn (more
Peptic Ulcer Disease common in duodenal ulcer); weight loss (more common
associated symptoms and in gastric ulcer); dyspepsia is more com-mon in the
setting young (20-29 yrs), gastric ulcer in those over 50 yrs,
and duodenal ulcer in those 30- 60 yrs
Prolonged exposure of esophagus to gastric acid due
GERD Process 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
Lying down, bending over; physical activity; diseases
GERD aggravating factors
such as scleroderma, gastroparesis; drugs like nicotine
that relax the lower esophageal sphincter
Antacids, proton pump inhibi-tors; avoiding alcohol,
GERD : relieving factors
smoking, fatty meals, chocolate, selected drugs such
as theophylline, cal-cium channel blockers
Wheezing, chronic cough, short-ness of breath,
GERD associated symptoms hoarseness, choking sensation, dysphagia,
and setting
regurgitation, halitosis, sore throat; increases risk of
Barrett esophagus and esopha-geal cancer
Acute inflammation of colonic diver-ticula, outpouchings
Diverticulitis process
5-10 mm in di-ameter, usually in sigmoid or descend-
ing colon
