NR 509 Final week 5 Abdomen and GU
1. 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 ²-human chorionic gonadotropin (²-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. Perforated bowel wall
e. Ruptured ovarian cyst: Good!
a. Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension,
positive ²-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 ²-hCG testing and her
unstable vital signs make ruptured ectopic pregnancy more likely.
2. 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, ³-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
, NR 509 Final week 5 Abdomen and GU
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
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration: 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. 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 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
, NR 509 Final week 5 Abdomen and GU
e. Hypertension: 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).
Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a
diagnosis of hypertension is not based on one elevated blood pressure reading.
4. 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?
a. Do not screen routinely
b. Continue annual FOBT screening until age 80 years
c. Continue annual FOBT screening until age 85 years
d. Repeat colonoscopy this year
e. Sigmoidoscopy every 5 years with FOBT every 3 years: a. 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
1. 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 ²-human chorionic gonadotropin (²-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. Perforated bowel wall
e. Ruptured ovarian cyst: Good!
a. Ruptured tubal (or ectopic) pregnancy
Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension,
positive ²-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 ²-hCG testing and her
unstable vital signs make ruptured ectopic pregnancy more likely.
2. 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, ³-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
, NR 509 Final week 5 Abdomen and GU
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
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration: 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. 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 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
, NR 509 Final week 5 Abdomen and GU
e. Hypertension: 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).
Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a
diagnosis of hypertension is not based on one elevated blood pressure reading.
4. 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?
a. Do not screen routinely
b. Continue annual FOBT screening until age 80 years
c. Continue annual FOBT screening until age 85 years
d. Repeat colonoscopy this year
e. Sigmoidoscopy every 5 years with FOBT every 3 years: a. 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
