WEEK 8 NR 509 ADVANCED HEALTH
ASSESSMENT FINAL
CHAPTER6519:65Abdomen
An65overweight6526-year-
old65public65servant65presents65to65the65Emergency65Department65with651265hours65of65i
ntense65abdominal65pain,65light-
headedness,65and65a65fainting65episode65that65finally65prompted65her65to65seek65medica
l65attention.65She65has65a65strong65family65history65of65gallstones65and65is65concerned65
about65this65possibility.65She65has65not65had65any65vomiting65or65diarrhea.65She65had65a
65normal65bowel65movement65this65morning.65Her65β-
human65chorionic65gonadotropin65(β-
hCG)65is65positive65at65triage.65She65reports65that65her65last65periterm-
12od65was651065weeks65ago.65Her65vital65signs65at65triage65are65pulse,65118;65blood65pr
essure,6586/68;65respiratory65rate,6520/
min;65oxygen65saturation,6599%;65and65temperature,6537.3ºC65orally.65The65clinician65pe
rforms65an65abdominal65exam65prior65to65her65pelvic65exam65and,65on65palpation65of65he
r65abdomen,65finds65involuntary65rigidity65and65rebound65tenderness.65What65is65the65m
ost65likely65diagnosis?65-65answer--Ruptured65tubal65(or65ectopic)65pregnancy
Rationale:65The65constellation65of65abdominal65pain,65syncope,65tachycardia,65hypotens
ion,65positive65β-hCG,65and65findings65suggestive65of65peritoneal65inflammation/
irritation65strongly65suggest65a65ruptured65ectopic65pregnancy65with65significant65intra-
abdominal65bleeding65leading65to65peritoneal65signs.65This65case65is65emergent65and65r
equires65immediate65treatment65of65her65hypotension65and65presumed65blood65loss65as6
5well65as65gynecological65consult65for65emergent65surgery.65Ruptured65ectopic65pregna
ncies65can65lead65to65life-threatening65intra-
abdominal65bleeding.65Although65acute65cholecystitis,65ruptured65appendix,65bowel65wal
l65perforation,65and65ruptured65ovarian65cyst65are65all65possibilities,65the65positive65β-
hCG65testing65and65her65unstable65vital65signs65make65ruptured65ectopic65pregnancy65
more65likely.
CHAPTER6519:65Abdomen
A6563-year-
old65janitor65with65a65history65of65adenomatous65colonic65polyps65presents65for65a65well6
5visit.65Basic65labs65are65performed65to65screen65for65diabetes65mellitus65and65dyslipide
mia.65Electrolytes65and65liver65enzymes65were65also65measured.65His65labs65are65all65n
,ormal65expect65for65moderate65elevations65of65aspartate65aminotransferase,65alanine65a
minotransferase,65γ-
glutamyl65transferase,65and65alkaline65phosphatase65as65well65as65a65mildly65elevated65t
otal65bilirubin.65He65presents65for65a65follow-
up65appointment65and65the65clinician65performs65an65abdominal65exam65to65assess65his
65liver.65Which65of65the65following65findings65would65be65most65consistent65with65hepato
megaly?65-65answer--
Liver65palpable65365cm65below65the65right65costal65margin,65mid65clavicular65line,65on65e
xpiration
Rationale:65The65liver65being65palpable65365cm65below65the65right65costal65margin,65mid
clavicular65line,65would65be65considered65normal65on65inspiration65when65the65liver65is65
pushed65down65into65the65abdominal65cavity65on65inspiration,65but65is65abnormal65on65e
xpiration.65Findings65to65support65hepatomegaly65would65be65more65convincing65if,65by6
5percussion,65the65liver65span65was65>1265cm65at65the65midclavicular65line.65For65patient
s65with65obstructive65lung65disease,65air65trapping65in65the65lungs65may65displace65the65l
iver65downwards65into65the65abdominal65cavity.65The65liver65span65and65dullness65to65p
ercussion65refer65to65the65same65measurement.65Measurements65of656-
1265cm65at65the65mid-clavicular65line65and654-
865cm65at65the65midsternal65line65are65considered65normal.
CHAPTER6519:65Abdomen
A6563-year-old65underweight65administrative65clerk65with65a6550-pack-
year65smoking65history65presents65with65a65several65month65history65of65recurrent65epig
astric65abdominal65discomfort.65She65feels65fairly65well65otherwise65and65denies65any65n
ausea,65vomiting,65diarrhea,65or65constipation.65She65reports65that65a65first65cousin65die
d65from65a65ruptured65aneurysm65at65age656865years.65Her65vital65signs65are65pulse,6586
;65blood65pressure,65148/92;65respiratory65rate,6516;65oxygen65saturation,6595%;65and65t
emperature,6536.2ºC.65Her65body65mass65index65is6517.6.65On65exam,65her65abdominal6
5aorta65is65prominent,65which65is65concerning65for65an65abdominal65aortic65aneurysm65(
AAA).65Which65of65the65following65is65her65most65significant65risk65factor65for65an65AAA?
65-65answer--History65of65smoking
Rationale:65History65of65smoking65is65her65most65significant65risk65factor65for65an65AAA.6
5Male65gender,65not65female65gender,65is65considered65as65risk65factor.65Underweight65i
s65not65a65risk65factor65for65AAA.65Family65history65of65ruptured65aneurysm65is65vague65
and65could65be65a65cerebral65aneurysm.65Further,65her65family65history65is65in65a65first-
degree65cousin65not65a65first-
degree65relative65(biologic65parents,65siblings,65and65children).65Hypertension65could65c
ontribute65to65atherosclerosis,65which65is65a65risk65factor.65Further,65a65diagnosis65of65hy
pertension65is65not65based65on65one65elevated65blood65pressure65reading.
CHAPTER6519:65Abdomen
A6576-year-
old65retired65man65with65a65history65of65prostate65cancer65and65hypertension65has65been
65screened65annually65for65colon65cancer65using65high65sensitivity65fecal65occult65blood6
,5testing65(FOBT).65He65presents65for65follow-
up65of65his65hypertension,65during65which65the65clinician65scans65his65chart65to65ensure6
5he65is65up65to65date65with65his65preventive65health65care.65He65has65a65positive65FOBT6
5on65one65occasion65at65age656665years65and65subsequently65went65for65a65colonoscop
y.65Internal65hemorrhoids65and65sigmoid65diverticuli65were65found65on65colonoscopy.65H
e65has65no65first-
degree65relatives65with65a65history65of65colorectal65cancer65or65adenomatous65polyps.65
What65are65the65U.S.65Preventive65Services65Task65Force65(USPSTF)65screening65reco
mmendations65for65this65patient?65-65answer--Do65not65screen65routinely
Rationale:65The65USPSTF65recommends65not65screening65routinely.65For65most65adults
65ages6576-
8565years,65the65gain65in65life65years65is65small65compared65to65colonoscopy65risks.65It65
is65advised65to65discuss65individualized65risks65and65benefits65with65the65patient.65Annu
al65FOBT65screening65may65continue65until65age6580-
8565years65if65benefits65to65doing65so65outweigh65risks65for65the65individual65patient;65ho
wever,65screening65should65not65be65routinely65continued.65In65general,65a65life65expect
ancy65>765years65is65necessary65for65screening65to65be65potentially65beneficial.65There65
is65no65indication65to65repeat65a65colonoscopy65given65the65absence65of65any65cancerou
s65or65precancerous65findings65on65his65colonoscopy651065years65ago.65Sigmoidoscopy6
5every65565years65with65FOBT65every65365years65is65a65valid65screening65option,65but65a
gain65screening65is65not65routinely65recommended65for65patients65age65>7565years.
CHAPTER6519:65Abdomen
An65otherwise65healthy6531-year-
old65accountant65presents65to65an65outpatient65clinic65with65a653-
year65history65of65recurrent65crampy65abdominal65pain65that65lasts65for65about651-
265weeks65each65episode65and65is65associated65with65onset65of65constipation.65She65de
scribes65infrequent,65small65hard65stool65that65she65finds65very65difficult65to65pass.65She
65has65tried65to65increase65dietary65fiber65and65water65intake,65but65usually65this65is65not
65sufficient65and65she65resorts65to65over-the-
counter65laxatives,65which65she65finds65upset65her65stomach65but65do65resolve65the65co
nstipation.65Symptoms65typically65gradually65resolve65with65bowel65movements.65Which
65of65the65following65is65the65most65likely65physiological65mechanism65for65her65constipat
ion?65-65answer--Functional65change65in65bowel65movement
Rationale:65Functional65change65in65bowel65movement65is65characteristic65of65irritable65
bowel65syndrome65(IBS).65IBS65is65characterized65by65three65patterns:65diarrhea65predo
minant,65constipation65predominant,65or65mixed.65Other65functional65causes65for65her65c
onstipation65should65be65excluded65prior65to65making65this65diagnosis.65A65large65firm65f
ecal65mass65in65the65rectum65is65characteristic65of65fecal65impaction,65which65is65comm
on65in65debilitated,65bedridden65individuals.65Decreased65fecal65bulk65is65characteristic65
of65a65diet65low65in65fiber.65This65patient65had65not65found65that65increasing65fiber65helps
65her65constipation.65Spasm65of65the65external65sphincter65is65associated65with65painful6
5anal65lesions,65which65this65patient65does65not65report.65Impairment65of65autonomic65in
nervations65is65characteristic65of65patients65with65multiple65sclerosis,65spinal65cord65injur
, ies,65and65Hirschsprung65disease.65She65has65no65known65diagnosis65that65would65incr
ease65suspicion65of65neurological65impairment.
CHAPTER6519:65Abdomen
A6523-year-old65woman65comes65to65the65respirology65clinic65for65follow-
up65of65her65chronic65sinusitis65and65bronchiectasis65that65is65associated65with65a65rare6
5congenital65condition65called65Kartagener65syndrome.65The65preceptor65notes65that65sh
e65has65situs65inversus65and65asks65for65a65physical65exam.65Which65of65the65following6
5descriptions65best65fits65with65findings65on65the65abdominal65exam?65-65answer--
Tympany65to65percussion65in65the65right65upper65quadrant,65dullness65to65percussion65o
f65the65left65upper65quadrant
Rationale:65Situs65inversus65is65a65rare65condition65in65which65organs65are65reversed65a
nd65is65associated65with65Kartagener65syndrome.65Thus,65the65stomach65and65gastric65
air65bubble65are65on65the65right65and65liver65dullness65is65on65the65left.65A65protuberant65
abdomen65with65scattered65areas65of65dullness65and65tympany65and65stool65on65palpati
on65is65likely65constipation.65None65of65these65findings65suggest65organ65reversal.65Live
r65dullness65will65occur65in65the65left65upper65quadrant65with65organ65reversal.65Findings
65given65in65the65remaining65answer65choices65are65both65associated65with65splenomeg
aly65with65the65spleen65located65in65the65left65upper65quadrant,65which65would65not65be65
the65case65for65sinus65inversus65totalis.
CHAPTER6519:65Abdomen
An65otherwise65healthy6528-year-
old65lawyer65presents65to65the65Emergency65Department65with65a651-
day65history65of65severe65abdominal65pain.65The65emergency65physician65suspects65ap
pendicitis65and65general65surgery65is65consulted.65The65resident65believes65the65patient6
5has65signs65of65peritonitis65on65exam.65Which65of65the65following65physical65exam65findi
ngs65supports65peritonitis?65-65answer--
Pressing65down65onto65the65abdomen65firmly65and65slowly65and65withdrawing65the65han
d65quickly65produces65pain
Rationale:65Pressing65down65onto65the65abdomen65firmly65and65slowly65and65withdrawin
g65the65hand65quickly65producing65pain65describes65rebound65tenderness,65which,65alon
g65with65guarding65and65rigidity,65is65suggestive65of65peritonitis.65Involuntary65contractio
n65rather65than65voluntary65contraction65of65the65abdominal65wall65that65persists65over65
several65examinations65describes65rigidity.65Abdominal65pain65that65increases65with65hip
65flexion65is65not65suggestive65of65peritonitis.65In65fact,65patients65with65peritonitis65tend6
5to65keep65hips65flexed65to65reduce65stretch65and65irritation65of65the65parietal65peritoneu
m.65They65often65walk65bent65forward65at65the65hips65for65this65reason.65Localized65pain
65over65McBurney65point65is65certainly65suggestive65of65appendicitis,65but65not65suggesti
ve65of65peritonitis.65Similarly65pain65with65internal65rotation65of65the65right65hip,65or65a65p
ositive65obturator65sign,65suggests65irritation65of65the65psoas65muscle65due65to65an65infla
med65appendix,65but65not65peritonitis.
CHAPTER6519:65Abdomen
ASSESSMENT FINAL
CHAPTER6519:65Abdomen
An65overweight6526-year-
old65public65servant65presents65to65the65Emergency65Department65with651265hours65of65i
ntense65abdominal65pain,65light-
headedness,65and65a65fainting65episode65that65finally65prompted65her65to65seek65medica
l65attention.65She65has65a65strong65family65history65of65gallstones65and65is65concerned65
about65this65possibility.65She65has65not65had65any65vomiting65or65diarrhea.65She65had65a
65normal65bowel65movement65this65morning.65Her65β-
human65chorionic65gonadotropin65(β-
hCG)65is65positive65at65triage.65She65reports65that65her65last65periterm-
12od65was651065weeks65ago.65Her65vital65signs65at65triage65are65pulse,65118;65blood65pr
essure,6586/68;65respiratory65rate,6520/
min;65oxygen65saturation,6599%;65and65temperature,6537.3ºC65orally.65The65clinician65pe
rforms65an65abdominal65exam65prior65to65her65pelvic65exam65and,65on65palpation65of65he
r65abdomen,65finds65involuntary65rigidity65and65rebound65tenderness.65What65is65the65m
ost65likely65diagnosis?65-65answer--Ruptured65tubal65(or65ectopic)65pregnancy
Rationale:65The65constellation65of65abdominal65pain,65syncope,65tachycardia,65hypotens
ion,65positive65β-hCG,65and65findings65suggestive65of65peritoneal65inflammation/
irritation65strongly65suggest65a65ruptured65ectopic65pregnancy65with65significant65intra-
abdominal65bleeding65leading65to65peritoneal65signs.65This65case65is65emergent65and65r
equires65immediate65treatment65of65her65hypotension65and65presumed65blood65loss65as6
5well65as65gynecological65consult65for65emergent65surgery.65Ruptured65ectopic65pregna
ncies65can65lead65to65life-threatening65intra-
abdominal65bleeding.65Although65acute65cholecystitis,65ruptured65appendix,65bowel65wal
l65perforation,65and65ruptured65ovarian65cyst65are65all65possibilities,65the65positive65β-
hCG65testing65and65her65unstable65vital65signs65make65ruptured65ectopic65pregnancy65
more65likely.
CHAPTER6519:65Abdomen
A6563-year-
old65janitor65with65a65history65of65adenomatous65colonic65polyps65presents65for65a65well6
5visit.65Basic65labs65are65performed65to65screen65for65diabetes65mellitus65and65dyslipide
mia.65Electrolytes65and65liver65enzymes65were65also65measured.65His65labs65are65all65n
,ormal65expect65for65moderate65elevations65of65aspartate65aminotransferase,65alanine65a
minotransferase,65γ-
glutamyl65transferase,65and65alkaline65phosphatase65as65well65as65a65mildly65elevated65t
otal65bilirubin.65He65presents65for65a65follow-
up65appointment65and65the65clinician65performs65an65abdominal65exam65to65assess65his
65liver.65Which65of65the65following65findings65would65be65most65consistent65with65hepato
megaly?65-65answer--
Liver65palpable65365cm65below65the65right65costal65margin,65mid65clavicular65line,65on65e
xpiration
Rationale:65The65liver65being65palpable65365cm65below65the65right65costal65margin,65mid
clavicular65line,65would65be65considered65normal65on65inspiration65when65the65liver65is65
pushed65down65into65the65abdominal65cavity65on65inspiration,65but65is65abnormal65on65e
xpiration.65Findings65to65support65hepatomegaly65would65be65more65convincing65if,65by6
5percussion,65the65liver65span65was65>1265cm65at65the65midclavicular65line.65For65patient
s65with65obstructive65lung65disease,65air65trapping65in65the65lungs65may65displace65the65l
iver65downwards65into65the65abdominal65cavity.65The65liver65span65and65dullness65to65p
ercussion65refer65to65the65same65measurement.65Measurements65of656-
1265cm65at65the65mid-clavicular65line65and654-
865cm65at65the65midsternal65line65are65considered65normal.
CHAPTER6519:65Abdomen
A6563-year-old65underweight65administrative65clerk65with65a6550-pack-
year65smoking65history65presents65with65a65several65month65history65of65recurrent65epig
astric65abdominal65discomfort.65She65feels65fairly65well65otherwise65and65denies65any65n
ausea,65vomiting,65diarrhea,65or65constipation.65She65reports65that65a65first65cousin65die
d65from65a65ruptured65aneurysm65at65age656865years.65Her65vital65signs65are65pulse,6586
;65blood65pressure,65148/92;65respiratory65rate,6516;65oxygen65saturation,6595%;65and65t
emperature,6536.2ºC.65Her65body65mass65index65is6517.6.65On65exam,65her65abdominal6
5aorta65is65prominent,65which65is65concerning65for65an65abdominal65aortic65aneurysm65(
AAA).65Which65of65the65following65is65her65most65significant65risk65factor65for65an65AAA?
65-65answer--History65of65smoking
Rationale:65History65of65smoking65is65her65most65significant65risk65factor65for65an65AAA.6
5Male65gender,65not65female65gender,65is65considered65as65risk65factor.65Underweight65i
s65not65a65risk65factor65for65AAA.65Family65history65of65ruptured65aneurysm65is65vague65
and65could65be65a65cerebral65aneurysm.65Further,65her65family65history65is65in65a65first-
degree65cousin65not65a65first-
degree65relative65(biologic65parents,65siblings,65and65children).65Hypertension65could65c
ontribute65to65atherosclerosis,65which65is65a65risk65factor.65Further,65a65diagnosis65of65hy
pertension65is65not65based65on65one65elevated65blood65pressure65reading.
CHAPTER6519:65Abdomen
A6576-year-
old65retired65man65with65a65history65of65prostate65cancer65and65hypertension65has65been
65screened65annually65for65colon65cancer65using65high65sensitivity65fecal65occult65blood6
,5testing65(FOBT).65He65presents65for65follow-
up65of65his65hypertension,65during65which65the65clinician65scans65his65chart65to65ensure6
5he65is65up65to65date65with65his65preventive65health65care.65He65has65a65positive65FOBT6
5on65one65occasion65at65age656665years65and65subsequently65went65for65a65colonoscop
y.65Internal65hemorrhoids65and65sigmoid65diverticuli65were65found65on65colonoscopy.65H
e65has65no65first-
degree65relatives65with65a65history65of65colorectal65cancer65or65adenomatous65polyps.65
What65are65the65U.S.65Preventive65Services65Task65Force65(USPSTF)65screening65reco
mmendations65for65this65patient?65-65answer--Do65not65screen65routinely
Rationale:65The65USPSTF65recommends65not65screening65routinely.65For65most65adults
65ages6576-
8565years,65the65gain65in65life65years65is65small65compared65to65colonoscopy65risks.65It65
is65advised65to65discuss65individualized65risks65and65benefits65with65the65patient.65Annu
al65FOBT65screening65may65continue65until65age6580-
8565years65if65benefits65to65doing65so65outweigh65risks65for65the65individual65patient;65ho
wever,65screening65should65not65be65routinely65continued.65In65general,65a65life65expect
ancy65>765years65is65necessary65for65screening65to65be65potentially65beneficial.65There65
is65no65indication65to65repeat65a65colonoscopy65given65the65absence65of65any65cancerou
s65or65precancerous65findings65on65his65colonoscopy651065years65ago.65Sigmoidoscopy6
5every65565years65with65FOBT65every65365years65is65a65valid65screening65option,65but65a
gain65screening65is65not65routinely65recommended65for65patients65age65>7565years.
CHAPTER6519:65Abdomen
An65otherwise65healthy6531-year-
old65accountant65presents65to65an65outpatient65clinic65with65a653-
year65history65of65recurrent65crampy65abdominal65pain65that65lasts65for65about651-
265weeks65each65episode65and65is65associated65with65onset65of65constipation.65She65de
scribes65infrequent,65small65hard65stool65that65she65finds65very65difficult65to65pass.65She
65has65tried65to65increase65dietary65fiber65and65water65intake,65but65usually65this65is65not
65sufficient65and65she65resorts65to65over-the-
counter65laxatives,65which65she65finds65upset65her65stomach65but65do65resolve65the65co
nstipation.65Symptoms65typically65gradually65resolve65with65bowel65movements.65Which
65of65the65following65is65the65most65likely65physiological65mechanism65for65her65constipat
ion?65-65answer--Functional65change65in65bowel65movement
Rationale:65Functional65change65in65bowel65movement65is65characteristic65of65irritable65
bowel65syndrome65(IBS).65IBS65is65characterized65by65three65patterns:65diarrhea65predo
minant,65constipation65predominant,65or65mixed.65Other65functional65causes65for65her65c
onstipation65should65be65excluded65prior65to65making65this65diagnosis.65A65large65firm65f
ecal65mass65in65the65rectum65is65characteristic65of65fecal65impaction,65which65is65comm
on65in65debilitated,65bedridden65individuals.65Decreased65fecal65bulk65is65characteristic65
of65a65diet65low65in65fiber.65This65patient65had65not65found65that65increasing65fiber65helps
65her65constipation.65Spasm65of65the65external65sphincter65is65associated65with65painful6
5anal65lesions,65which65this65patient65does65not65report.65Impairment65of65autonomic65in
nervations65is65characteristic65of65patients65with65multiple65sclerosis,65spinal65cord65injur
, ies,65and65Hirschsprung65disease.65She65has65no65known65diagnosis65that65would65incr
ease65suspicion65of65neurological65impairment.
CHAPTER6519:65Abdomen
A6523-year-old65woman65comes65to65the65respirology65clinic65for65follow-
up65of65her65chronic65sinusitis65and65bronchiectasis65that65is65associated65with65a65rare6
5congenital65condition65called65Kartagener65syndrome.65The65preceptor65notes65that65sh
e65has65situs65inversus65and65asks65for65a65physical65exam.65Which65of65the65following6
5descriptions65best65fits65with65findings65on65the65abdominal65exam?65-65answer--
Tympany65to65percussion65in65the65right65upper65quadrant,65dullness65to65percussion65o
f65the65left65upper65quadrant
Rationale:65Situs65inversus65is65a65rare65condition65in65which65organs65are65reversed65a
nd65is65associated65with65Kartagener65syndrome.65Thus,65the65stomach65and65gastric65
air65bubble65are65on65the65right65and65liver65dullness65is65on65the65left.65A65protuberant65
abdomen65with65scattered65areas65of65dullness65and65tympany65and65stool65on65palpati
on65is65likely65constipation.65None65of65these65findings65suggest65organ65reversal.65Live
r65dullness65will65occur65in65the65left65upper65quadrant65with65organ65reversal.65Findings
65given65in65the65remaining65answer65choices65are65both65associated65with65splenomeg
aly65with65the65spleen65located65in65the65left65upper65quadrant,65which65would65not65be65
the65case65for65sinus65inversus65totalis.
CHAPTER6519:65Abdomen
An65otherwise65healthy6528-year-
old65lawyer65presents65to65the65Emergency65Department65with65a651-
day65history65of65severe65abdominal65pain.65The65emergency65physician65suspects65ap
pendicitis65and65general65surgery65is65consulted.65The65resident65believes65the65patient6
5has65signs65of65peritonitis65on65exam.65Which65of65the65following65physical65exam65findi
ngs65supports65peritonitis?65-65answer--
Pressing65down65onto65the65abdomen65firmly65and65slowly65and65withdrawing65the65han
d65quickly65produces65pain
Rationale:65Pressing65down65onto65the65abdomen65firmly65and65slowly65and65withdrawin
g65the65hand65quickly65producing65pain65describes65rebound65tenderness,65which,65alon
g65with65guarding65and65rigidity,65is65suggestive65of65peritonitis.65Involuntary65contractio
n65rather65than65voluntary65contraction65of65the65abdominal65wall65that65persists65over65
several65examinations65describes65rigidity.65Abdominal65pain65that65increases65with65hip
65flexion65is65not65suggestive65of65peritonitis.65In65fact,65patients65with65peritonitis65tend6
5to65keep65hips65flexed65to65reduce65stretch65and65irritation65of65the65parietal65peritoneu
m.65They65often65walk65bent65forward65at65the65hips65for65this65reason.65Localized65pain
65over65McBurney65point65is65certainly65suggestive65of65appendicitis,65but65not65suggesti
ve65of65peritonitis.65Similarly65pain65with65internal65rotation65of65the65right65hip,65or65a65p
ositive65obturator65sign,65suggests65irritation65of65the65psoas65muscle65due65to65an65infla
med65appendix,65but65not65peritonitis.
CHAPTER6519:65Abdomen
