Week 8 NR 509 Advanced Health
Assessment Final 100 approved
answers.
Week 8 NR 509 Advanced Health
Assessment Final 100 approved
answers.
CHAPTER 19: Abdomen
An overweight 26-year-old public servant presents to the Emergency Department with
12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally
prompted her to seek medical attention. She has a strong family history of gallstones
and is concerned about this possibility. She has not had any vomiting or diarrhea. She
had a normal bowel movement this morning. Her β-human chorionic gonadotropin (β-
hCG) is positive at triage. She reports that her last periterm-12od was 10 weeks ago.
Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min;
oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an
abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds
involuntary rigidity and rebound tenderness. What is the most likely diagnosis? -
ANSWER- Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension,
positive β-hCG, and findings suggestive of peritoneal inflammation/irritation strongly
suggest a ruptured ectopic pregnancy with significant intra-abdominal bleeding leading
to peritoneal signs. This case is emergent and requires immediate treatment of her
hypotension and presumed blood loss as well as gynecological consult for emergent
surgery. Ruptured ectopic pregnancies can lead to life-threatening intra-abdominal
bleeding. Although acute cholecystitis, ruptured appendix, bowel wall perforation, and
ruptured ovarian cyst are all possibilities, the positive β-hCG testing and her unstable
vital signs make ruptured ectopic pregnancy more likely.
CHAPTER 19: Abdomen
A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well
visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia.
Electrolytes and liver enzymes were also measured. His labs are all normal expect for
moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ-
glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total
bilirubin. He presents for a follow-up appointment and the clinician performs an
abdominal exam to assess his liver. Which of the following findings would be most
consistent with hepatomegaly? - ANSWER- Liver palpable 3 cm below the right costal
margin, mid clavicular line, on expiration
,Week 8 NR 509 Advanced Health
Assessment Final 100 approved
answers.
Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular
line, would be considered normal on inspiration when the liver is pushed down into the
abdominal cavity on inspiration, but is abnormal on expiration. Findings to support
hepatomegaly would be more convincing if, by percussion, the liver span was >12 cm at
the midclavicular line. For patients with obstructive lung disease, air trapping in the
lungs may displace the liver downwards into the abdominal cavity. The liver span and
dullness to percussion refer to the same measurement. Measurements of 6-12 cm at
the mid-clavicular line and 4-8 cm at the midsternal line are considered normal.
CHAPTER 19: Abdomen
A 63-year-old underweight administrative clerk with a 50-pack-year smoking history
presents with a several month history of recurrent epigastric abdominal discomfort. She
feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation.
She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital
signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation,
95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal
aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which
of the following is her most significant risk factor for an AAA? - ANSWER- History of
smoking
Rationale: History of smoking is her most significant risk factor for an AAA. Male
gender, not female gender, is considered as risk factor. Underweight is not a risk factor
for AAA. Family history of ruptured aneurysm is vague and could be a cerebral
aneurysm. Further, her family history is in a first-degree cousin not a first-degree
relative (biologic parents, siblings, and children). Hypertension could contribute to
atherosclerosis, which is a risk factor. Further, a diagnosis of hypertension is not based
on one elevated blood pressure reading.
CHAPTER 19: Abdomen
A 76-year-old retired man with a history of prostate cancer and hypertension has been
screened annually for colon cancer using high sensitivity fecal occult blood testing
(FOBT). He presents for follow-up of his hypertension, during which the clinician scans
his chart to ensure he is up to date with his preventive health care. He has a positive
FOBT on one occasion at age 66 years and subsequently went for a colonoscopy.
Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no
first-degree relatives with a history of colorectal cancer or adenomatous polyps. What
are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for
this patient? - ANSWER- Do not screen routinely
Rationale: The USPSTF recommends not screening routinely. For most adults ages 76-
85 years, the gain in life years is small compared to colonoscopy risks. It is advised to
discuss individualized risks and benefits with the patient. Annual FOBT screening may
,Week 8 NR 509 Advanced Health
Assessment Final 100 approved
answers.
continue until age 80-85 years if benefits to doing so outweigh risks for the individual
patient; however, screening should not be routinely continued. In general, a life
expectancy >7 years is necessary for screening to be potentially beneficial. There is no
indication to repeat a colonoscopy given the absence of any cancerous or precancerous
findings on his colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT
every 3 years is a valid screening option, but again screening is not routinely
recommended for patients age >75 years.
CHAPTER 19: Abdomen
An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-
year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each
episode and is associated with onset of constipation. She describes infrequent, small
hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and
water intake, but usually this is not sufficient and she resorts to over-the-counter
laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms
typically gradually resolve with bowel movements. Which of the following is the most
likely physiological mechanism for her constipation? - ANSWER- Functional change in
bowel movement
Rationale: Functional change in bowel movement is characteristic of irritable bowel
syndrome (IBS). IBS is characterized by three patterns: diarrhea predominant,
constipation predominant, or mixed. Other functional causes for her constipation should
be excluded prior to making this diagnosis. A large firm fecal mass in the rectum is
characteristic of fecal impaction, which is common in debilitated, bedridden individuals.
Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found
that increasing fiber helps her constipation. Spasm of the external sphincter is
associated with painful anal lesions, which this patient does not report. Impairment of
autonomic innervations is characteristic of patients with multiple sclerosis, spinal cord
injuries, and Hirschsprung disease. She has no known diagnosis that would increase
suspicion of neurological impairment.
CHAPTER 19: Abdomen
A 23-year-old woman comes to the respirology clinic for follow-up of her chronic
sinusitis and bronchiectasis that is associated with a rare congenital condition called
Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a
physical exam. Which of the following descriptions best fits with findings on the
abdominal exam? - ANSWER- Tympany to percussion in the right upper quadrant,
dullness to percussion of the left upper quadrant
Rationale: Situs inversus is a rare condition in which organs are reversed and is
associated with Kartagener syndrome. Thus, the stomach and gastric air bubble are on
the right and liver dullness is on the left. A protuberant abdomen with scattered areas of
, Week 8 NR 509 Advanced Health
Assessment Final 100 approved
answers.
dullness and tympany and stool on palpation is likely constipation. None of these
findings suggest organ reversal. Liver dullness will occur in the left upper quadrant with
organ reversal. Findings given in the remaining answer choices are both associated
with splenomegaly with the spleen located in the left upper quadrant, which would not
be the case for sinus inversus totalis.
CHAPTER 19: Abdomen
An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a
1-day history of severe abdominal pain. The emergency physician suspects appendicitis
and general surgery is consulted. The resident believes the patient has signs of
peritonitis on exam. Which of the following physical exam findings supports peritonitis? -
ANSWER- Pressing down onto the abdomen firmly and slowly and withdrawing the
hand quickly produces pain
Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand
quickly producing pain describes rebound tenderness, which, along with guarding and
rigidity, is suggestive of peritonitis. Involuntary contraction rather than voluntary
contraction of the abdominal wall that persists over several examinations describes
rigidity. Abdominal pain that increases with hip flexion is not suggestive of peritonitis. In
fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of
the parietal peritoneum. They often walk bent forward at the hips for this reason.
Localized pain over McBurney point is certainly suggestive of appendicitis, but not
suggestive of peritonitis. Similarly pain with internal rotation of the right hip, or a positive
obturator sign, suggests irritation of the psoas muscle due to an inflamed appendix, but
not peritonitis.
CHAPTER 19: Abdomen
A 58-year-old man with a history of diabetes and alcohol addiction has been sober for
the last 10 months. He presents with a 4-month history of increasing weakness,
recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times
daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely
diagnosis? - ANSWER- Fibrosis of the pancreas
Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic
pancreatitis leads to fibrosis and decreased pancreatic function, which causes diarrhea
from pancreatic enzyme insufficiency and diabetes mellitus. H. pylori infection may
cause peptic ulcer disease and dyspepsia, which is not usually associated with
diarrhea. Inflammation of the colonic diverticulum is diverticulitis and typically causes
left-lower-quadrant pain, fever, constipation, and sometimes diarrhea. It is typically an
acute disease. Reduced blood supply to the bowel characterizes mesenteric ischemia.
It can be acute or chronic in presentation and causes diffuse abdominal pain, vomiting,
