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NR 509 Final week 5 Abdomen and GU.
Exam Questions And Correct Answers
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 period 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?
a. Ruptured tubal (or ectopic) pregnancy
b. Acute cholecystitis
c. Ruptured appendix
d. Perf - answer✔Good!
a. Ruptured tubal (or ectopic) pregnancy
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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.
2. 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?
a. Liver span of 11 cm at the midclavicular line
b. Liver span of 8 cm at the midsternal line
c. Dullness to percussion over a span of 11 cm at the midclavicular line
d. Dullness to percussion over a span of 8 cm at the midsternal line
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e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expi - answer✔e.
Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration
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.
3. 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
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abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for
an AAA?
a. Female gender
b. History of smoking
c. Underweight
d. Family history of ruptured aneurysm
e. Hypertension - answer✔b. 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).
