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