NR 509 ABDOMEN EXAM QUESTIONS WITH
COMPLETE SOLUTION
An overweight 26-year-old 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 B-human chorionic
gonadotropin (B-hCG) is positive at triage. She reports that her last
period was 10 weeks ago. Her vital signs at triage are pulse - 118, BP -
86/68, RR - 20/min, O2 sat - 99%, and temp 37.3 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 appendix
b.) acute cholecystitis
c.) ruptured ovarian cysts
d.) ruptured tubal (or ectopic) pregnancy
e.) perforated bowel wall
d.) ruptured tubal (or ectopic) pregnancy
Explanation: The constellation of abdominal pain, syncope, tachycardia,
hypotension, positive B-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
B-hCG testing and her unstable vital signs make ruptured ectopic
pregnancy more likely.
A 63-year-old 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, y-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?
a.) Dullness to percussion over a span of 8 cm at the midsternal line
b.) Liver palpable 3 cm below the right costal margin, mid-clavicular,
on expiration
c.) Liver span of 11 cm at the mid-clavicular
d.) Dullness to percussion over a span of 11 cm at the mid-clavicular
line
e.) Liver span of 8 cm at the midsternal line
b.) Liver palpable 3 cm below the right costal margin, mid-clavicular, on
expiration
Explanation: The liver being palpable 3 cm below the right costal margin,
mid-clavicular 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 mid-
clavicular 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.
A 63-year-old underweight administrative clerk w 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. Her vital
signs are pulse - 86, BP - 148/92, RR - 16, O2 -95%, and temp - 36.2.
Her body mass index is 17.6. On exam, her abdominal aorta is
prominent, which is concerning for an AAA. Which of the following is
her most significant risk factor for AAA?
a.) Family history of ruptured aneurysm
b.) History of smoking
c.) Female gender
COMPLETE SOLUTION
An overweight 26-year-old 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 B-human chorionic
gonadotropin (B-hCG) is positive at triage. She reports that her last
period was 10 weeks ago. Her vital signs at triage are pulse - 118, BP -
86/68, RR - 20/min, O2 sat - 99%, and temp 37.3 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 appendix
b.) acute cholecystitis
c.) ruptured ovarian cysts
d.) ruptured tubal (or ectopic) pregnancy
e.) perforated bowel wall
d.) ruptured tubal (or ectopic) pregnancy
Explanation: The constellation of abdominal pain, syncope, tachycardia,
hypotension, positive B-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
B-hCG testing and her unstable vital signs make ruptured ectopic
pregnancy more likely.
A 63-year-old 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, y-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?
a.) Dullness to percussion over a span of 8 cm at the midsternal line
b.) Liver palpable 3 cm below the right costal margin, mid-clavicular,
on expiration
c.) Liver span of 11 cm at the mid-clavicular
d.) Dullness to percussion over a span of 11 cm at the mid-clavicular
line
e.) Liver span of 8 cm at the midsternal line
b.) Liver palpable 3 cm below the right costal margin, mid-clavicular, on
expiration
Explanation: The liver being palpable 3 cm below the right costal margin,
mid-clavicular 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 mid-
clavicular 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.
A 63-year-old underweight administrative clerk w 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. Her vital
signs are pulse - 86, BP - 148/92, RR - 16, O2 -95%, and temp - 36.2.
Her body mass index is 17.6. On exam, her abdominal aorta is
prominent, which is concerning for an AAA. Which of the following is
her most significant risk factor for AAA?
a.) Family history of ruptured aneurysm
b.) History of smoking
c.) Female gender
