1|Page
NR 509 Advanced Physical Assessment Abdominal
Pain (Esther Park Shadow Health) Study
Guide||Verified Exam!!||, 2026/2027-Question
Examination with Verified Solutions
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
,2|Page
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
,3|Page
would be most consistent with hepatomegaly? - Answer-
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.
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.
, 4|Page
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
NR 509 Advanced Physical Assessment Abdominal
Pain (Esther Park Shadow Health) Study
Guide||Verified Exam!!||, 2026/2027-Question
Examination with Verified Solutions
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
,2|Page
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
,3|Page
would be most consistent with hepatomegaly? - Answer-
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.
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.
, 4|Page
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
