Week 8 NR 509 Advanced Health Assessment
Final Updated 2024
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?
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?
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. 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?
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?
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
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?
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?
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
Final Updated 2024
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?
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?
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. 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?
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?
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
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?
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?
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
