NR 509 ADVANCED PHYSICAL ASSESSMENT ABDOMINAL PAIN
(ESTHER PARK SHADOW HEALTH) STUDY GUIDE, 2026/2027
QUESTION EXAMINATION WITH VERIFIED SOLUTIONS
**1. A 45-year-old male reports dull, burning epigastric pain 2 hours after meals, relieved by food. What
is the most likely diagnosis?**
- **Answer:** Duodenal ulcer
- **Rationale:** Duodenal ulcers classically cause pain 1–3 hours postprandial, often at night,
relieved by food or antacids. Gastric ulcers worsen with food.
**2. A 60-year-old with history of NSAID use presents with sudden, severe epigastric pain radiating to
the back, with vomiting. Vitals: HR 110, BP 100/70. What must be considered?**
- **Answer:** Acute pancreatitis or perforated ulcer
- **Rationale:** Radiation to back, severe pain, hemodynamic changes + NSAID history raise
concern for pancreatitis or perforated viscus. Immediate imaging (CT) warranted.
**3. A patient describes epigastric pain that worsens after fatty meals, with nausea and belching.
Murphy’s sign is negative. What is the top differential?**
- **Answer:** Chronic cholecystitis or biliary colic
- **Rationale:** Pain after fatty meals suggests biliary origin. Negative Murphy’s does not rule out
cholecystitis; ultrasound is next step.
**4. In a patient with epigastric pain and melena, which finding on abdominal exam is most concerning?
**
- **Answer:** Guaiac-positive stool with epigastric tenderness
- **Rationale:** Melena indicates upper GI bleed. Epigastric tenderness + bleed suggests peptic
ulcer disease or gastritis. Hemodynamically unstable patients need urgent endoscopy.
**5. A patient reports episodic, crampy epigastric pain that migrates to the right lower quadrant over 24
hours. What is the most likely pathophysiology?**
- **Answer:** Appendiceal obstruction and inflammation
- **Rationale:** Classic migration of pain (epigastric to periumbilical to RLQ) is hallmark of acute
appendicitis due to visceral to parietal pain progression.
, **6. Which historical feature differentiates biliary colic from acute cholecystitis?**
- **Answer:** Pain duration >6 hours and fever suggest cholecystitis
- **Rationale:** Biliary colic lasts 1–5 hours; acute cholecystitis pain persists >6 hours with fever,
leukocytosis, and Murphy’s sign.
**7. A 35-year-old pregnant woman in third trimester reports epigastric pain with nausea and
hypertension. What is the priority diagnosis?**
- **Answer:** HELLP syndrome or preeclampsia with liver involvement
- **Rationale:** Epigastric pain in late pregnancy + HTN raises HELLP syndrome (hemolysis,
elevated liver enzymes, low platelets), a life-threatening condition.
**8. Which question best screens for cardiac causes of epigastric pain?**
- **Answer:** “Does the pain worsen with exertion or improve with rest?”
- **Rationale:** Cardiac ischemia can present as epigastric discomfort, especially in
women/diabetics. Exertional pattern suggests angina.
**9. A patient with epigastric pain and dysphagia to solids and liquids suggests what diagnosis?**
- **Answer:** Achalasia or esophageal dysmotility
- **Rationale:** Progressive dysphagia to both solids and liquids points to esophageal motility
disorder, not mechanical obstruction.
**10. What RED flag in epigastric pain warrants immediate referral?**
- **Answer:** Unexplained weight loss, jaundice, or palpable mass
- **Rationale:** These suggest malignancy (e.g., gastric, pancreatic). Urgent imaging/endoscopy
needed.
---
### Questions 11–20: Right Upper Quadrant (RUQ) Pain
(ESTHER PARK SHADOW HEALTH) STUDY GUIDE, 2026/2027
QUESTION EXAMINATION WITH VERIFIED SOLUTIONS
**1. A 45-year-old male reports dull, burning epigastric pain 2 hours after meals, relieved by food. What
is the most likely diagnosis?**
- **Answer:** Duodenal ulcer
- **Rationale:** Duodenal ulcers classically cause pain 1–3 hours postprandial, often at night,
relieved by food or antacids. Gastric ulcers worsen with food.
**2. A 60-year-old with history of NSAID use presents with sudden, severe epigastric pain radiating to
the back, with vomiting. Vitals: HR 110, BP 100/70. What must be considered?**
- **Answer:** Acute pancreatitis or perforated ulcer
- **Rationale:** Radiation to back, severe pain, hemodynamic changes + NSAID history raise
concern for pancreatitis or perforated viscus. Immediate imaging (CT) warranted.
**3. A patient describes epigastric pain that worsens after fatty meals, with nausea and belching.
Murphy’s sign is negative. What is the top differential?**
- **Answer:** Chronic cholecystitis or biliary colic
- **Rationale:** Pain after fatty meals suggests biliary origin. Negative Murphy’s does not rule out
cholecystitis; ultrasound is next step.
**4. In a patient with epigastric pain and melena, which finding on abdominal exam is most concerning?
**
- **Answer:** Guaiac-positive stool with epigastric tenderness
- **Rationale:** Melena indicates upper GI bleed. Epigastric tenderness + bleed suggests peptic
ulcer disease or gastritis. Hemodynamically unstable patients need urgent endoscopy.
**5. A patient reports episodic, crampy epigastric pain that migrates to the right lower quadrant over 24
hours. What is the most likely pathophysiology?**
- **Answer:** Appendiceal obstruction and inflammation
- **Rationale:** Classic migration of pain (epigastric to periumbilical to RLQ) is hallmark of acute
appendicitis due to visceral to parietal pain progression.
, **6. Which historical feature differentiates biliary colic from acute cholecystitis?**
- **Answer:** Pain duration >6 hours and fever suggest cholecystitis
- **Rationale:** Biliary colic lasts 1–5 hours; acute cholecystitis pain persists >6 hours with fever,
leukocytosis, and Murphy’s sign.
**7. A 35-year-old pregnant woman in third trimester reports epigastric pain with nausea and
hypertension. What is the priority diagnosis?**
- **Answer:** HELLP syndrome or preeclampsia with liver involvement
- **Rationale:** Epigastric pain in late pregnancy + HTN raises HELLP syndrome (hemolysis,
elevated liver enzymes, low platelets), a life-threatening condition.
**8. Which question best screens for cardiac causes of epigastric pain?**
- **Answer:** “Does the pain worsen with exertion or improve with rest?”
- **Rationale:** Cardiac ischemia can present as epigastric discomfort, especially in
women/diabetics. Exertional pattern suggests angina.
**9. A patient with epigastric pain and dysphagia to solids and liquids suggests what diagnosis?**
- **Answer:** Achalasia or esophageal dysmotility
- **Rationale:** Progressive dysphagia to both solids and liquids points to esophageal motility
disorder, not mechanical obstruction.
**10. What RED flag in epigastric pain warrants immediate referral?**
- **Answer:** Unexplained weight loss, jaundice, or palpable mass
- **Rationale:** These suggest malignancy (e.g., gastric, pancreatic). Urgent imaging/endoscopy
needed.
---
### Questions 11–20: Right Upper Quadrant (RUQ) Pain
