The advanced practice registered nurse (APRN) is assessing a patient's thyroid gland. The APRN places their hands below which anatomical landmark?

A. Appendicitis is incorrect because appendicitis usually causes pain localized to the right lower quadrant rather than the right upper quadrant. Classic signs include tenderness at McBurney’s point, rebound tenderness, Rovsing’s sign (pain in the right lower quadrant when the left lower quadrant is palpated), and psoas sign (pain on hip extension). Murphy’s sign is specific to gallbladder irritation, so it would not be positive in appendicitis.

B. Pancreatitis is incorrect because pancreatitis typically presents with epigastric or periumbilical pain that may radiate to the back. Additional symptoms include nausea, vomiting, anorexia, and sometimes fever. While patients may have some tenderness in the right upper quadrant if the pancreas head is involved, deep palpation with inspiration does not produce Murphy’s sign, making this maneuver not diagnostic for pancreatitis.

C. Cholecystitis is correct because acute cholecystitis is inflammation of the gallbladder, usually due to gallstones obstructing the cystic duct. During the Murphy’s sign test, the examiner palpates the right upper quadrant beneath the costal margin at the mid-clavicular line and asks the patient to inhale deeply. The descending diaphragm pushes the inflamed gallbladder against the examiner’s fingers, causing abrupt pain and halting inspiration. This is a classic and highly suggestive finding for acute cholecystitis.

D. Gastroenteritis is incorrect because gastroenteritis causes diffuse abdominal cramping, diarrhea, nausea, and sometimes fever, without localized right upper quadrant inflammation. Deep palpation of the right upper quadrant with inspiration does not produce abrupt pain, so Murphy’s sign would be negative in gastroenteritis.

A. Bilateral tympanic membranes erythematous, flat, with good cone of light is incorrect because, although erythema is present, the TM is flat, landmarks are intact, and the cone of light is visible, which suggests no middle ear effusion and does not meet criteria for AOM. This may indicate mild irritation, viral upper respiratory infection, or early inflammation.

B. Left tympanic membrane erythematous, bulging and non-mobile, with loss of landmarks is correct because these findings reflect the classic presentation of acute otitis media. Bulging occurs due to pressure from pus or fluid in the middle ear, and non-mobility on pneumatic testing confirms the presence of middle ear effusion, which differentiates AOM from viral pharyngitis or external ear infections.

C. Bilateral tympanic membranes intact and mobile, with good cone of light is incorrect because these are normal otoscopic findings, indicating no acute infection, normal TM integrity, and proper mobility.

D. Right tympanic membrane erythematous and flat, with blood-tinged discharge is incorrect because the blood-tinged discharge suggests trauma, tympanic membrane perforation, or chronic otitis media with perforation, rather than typical AOM. While erythema is consistent with inflammation, the presence of discharge and flat TM points to a different pathology.