Week 8 NR 509 Advanced Health Assessment Final
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1. CHAPTER 19: Abdomen Ruptured tubal (or ectopic) pregnancy
An overweight 26-year-old Rationale: The constellation of abdominal pain, syncope,
public servant presents to the tachycardia, hypotension, positive β-hCG, and findings sug-
Emergency Department with gestive of peritoneal inflammation/irritation strongly suggest
12 hours of intense abdom- a ruptured ectopic pregnancy with significant intra-abdomi-
inal pain, light-headedness, nal bleeding leading to peritoneal signs. This case is emer-
and a fainting episode that fi- gent and requires immediate treatment of her hypotension
nally prompted her to seek and presumed blood loss as well as gynecological consult
medical attention. She has a for emergent surgery. Ruptured ectopic pregnancies can lead
strong family history of gall- to life-threatening intra-abdominal bleeding. Although acute
stones and is concerned about cholecystitis, ruptured appendix, bowel wall perforation, and
this possibility. She has not ruptured ovarian cyst are all possibilities, the positive β-hCG
had any vomiting or diar- testing and her unstable vital signs make ruptured ectopic
rhea. She had a normal bow- pregnancy more likely.
el movement this morning.
Her β-human chorionic go-
nadotropin (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 satura-
tion, 99%; and temperature,
37.3ºC orally. The clinician per-
forms an abdominal exam pri-
or to her pelvic exam and,
on palpation of her abdomen,
finds involuntary rigidity and
rebound tenderness. What is
the most likely diagnosis?
, Week 8 NR 509 Advanced Health Assessment Final
Study online at https://quizlet.com/_dflx9u
2. CHAPTER 19: Abdomen Liver palpable 3 cm below the right costal margin, mid clavic-
A 63-year-old janitor with a his- ular line, on expiration
tory of adenomatous colonic
polyps presents for a well vis- Rationale: The liver being palpable 3 cm below the right costal
it. Basic labs are performed margin, midclavicular line, would be considered normal on
to screen for diabetes mel- inspiration when the liver is pushed down into the abdominal
litus and dyslipidemia. Elec- cavity on inspiration, but is abnormal on expiration. Findings
trolytes and liver enzymes to support hepatomegaly would be more convincing if, by
were also measured. His labs percussion, the liver span was >12 cm at the midclavicular
are all normal expect for line. For patients with obstructive lung disease, air trapping
moderate elevations of as- in the lungs may displace the liver downwards into the ab-
partate aminotransferase, ala- dominal cavity. The liver span and dullness to percussion
nine aminotransferase, γ-glu- refer to the same measurement. Measurements of 6-12 cm at
tamyl transferase, and alka- the mid-clavicular line and 4-8 cm at the midsternal line are
line phosphatase as well as a considered normal.
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 he-
patomegaly?
3. CHAPTER 19: Abdomen History of smoking
A 63-year-old underweight
administrative clerk with a Rationale: History of smoking is her most significant risk factor
50-pack-year smoking history for an AAA. Male gender, not female gender, is considered
presents with a several month as risk factor. Underweight is not a risk factor for AAA. Family
history of recurrent epigas- history of ruptured aneurysm is vague and could be a cerebral
tric abdominal discomfort. She aneurysm. Further, her family history is in a first-degree cousin
, Week 8 NR 509 Advanced Health Assessment Final
Study online at https://quizlet.com/_dflx9u
feels fairly well otherwise and not a first-degree relative (biologic parents, siblings, and
denies any nausea, vomiting, children). Hypertension could contribute to atherosclerosis,
diarrhea, or constipation. She which is a risk factor. Further, a diagnosis of hypertension is
reports that a first cousin died not based on one elevated blood pressure reading.
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 promi-
nent, which is concerning for
an abdominal aortic aneurysm
(AAA). Which of the following is
her most significant risk factor
for an AAA?
4. CHAPTER 19: Abdomen Do not screen routinely
A 76-year-old retired man with
a history of prostate cancer Rationale: The USPSTF recommends not screening routinely.
and hypertension has been For most adults ages 76-85 years, the gain in life years is
screened annually for colon small compared to colonoscopy risks. It is advised to discuss
cancer using high sensitiv- individualized risks and benefits with the patient. Annual FOBT
ity fecal occult blood test- screening may continue until age 80-85 years if benefits to
ing (FOBT). He presents for doing so outweigh risks for the individual patient; however,
follow-up of his hyperten- screening should not be routinely continued. In general, a life
sion, during which the clin- expectancy >7 years is necessary for screening to be poten-
ician scans his chart to en- tially beneficial. There is no indication to repeat a colonoscopy
sure he is up to date with given the absence of any cancerous or precancerous findings
his preventive health care. on his colonoscopy 10 years ago. Sigmoidoscopy every 5
He has a positive FOBT on years with FOBT every 3 years is a valid screening option, but
, Week 8 NR 509 Advanced Health Assessment Final
Study online at https://quizlet.com/_dflx9u
one occasion at age 66 years again screening is not routinely recommended for patients
and subsequently went for a age >75 years.
colonoscopy. Internal hemor-
rhoids and sigmoid diverticuli
were found on colonoscopy.
He has no first-degree rela-
tives with a history of col-
orectal cancer or adenoma-
tous polyps. What are the
U.S. Preventive Services Task
Force (USPSTF) screening rec-
ommendations for this pa-
tient?
5. CHAPTER 19: Abdomen Functional change in bowel movement
An otherwise healthy
31-year-old accountant pre- Rationale: Functional change in bowel movement is charac-
sents to an outpatient clinic teristic of irritable bowel syndrome (IBS). IBS is character-
with a 3-year history of recur- ized by three patterns: diarrhea predominant, constipation
rent crampy abdominal pain predominant, or mixed. Other functional causes for her con-
that lasts for about 1-2 weeks stipation should be excluded prior to making this diagno-
each episode and is associ- sis. A large firm fecal mass in the rectum is characteristic of
ated with onset of constipa- fecal impaction, which is common in debilitated, bedridden
tion. She describes infrequent, individuals. Decreased fecal bulk is characteristic of a diet
small hard stool that she finds low in fiber. This patient had not found that increasing fiber
very difficult to pass. She has helps her constipation. Spasm of the external sphincter is
tried to increase dietary fiber associated with painful anal lesions, which this patient does
and water intake, but usually not report. Impairment of autonomic innervations is charac-
this is not sufficient and she re- teristic of patients with multiple sclerosis, spinal cord injuries,
sorts to over-the-counter lax- and Hirschsprung disease. She has no known diagnosis that
atives, which she finds upset would increase suspicion of neurological impairment.
her stomach but do resolve
Study online at https://quizlet.com/_dflx9u
1. CHAPTER 19: Abdomen Ruptured tubal (or ectopic) pregnancy
An overweight 26-year-old Rationale: The constellation of abdominal pain, syncope,
public servant presents to the tachycardia, hypotension, positive β-hCG, and findings sug-
Emergency Department with gestive of peritoneal inflammation/irritation strongly suggest
12 hours of intense abdom- a ruptured ectopic pregnancy with significant intra-abdomi-
inal pain, light-headedness, nal bleeding leading to peritoneal signs. This case is emer-
and a fainting episode that fi- gent and requires immediate treatment of her hypotension
nally prompted her to seek and presumed blood loss as well as gynecological consult
medical attention. She has a for emergent surgery. Ruptured ectopic pregnancies can lead
strong family history of gall- to life-threatening intra-abdominal bleeding. Although acute
stones and is concerned about cholecystitis, ruptured appendix, bowel wall perforation, and
this possibility. She has not ruptured ovarian cyst are all possibilities, the positive β-hCG
had any vomiting or diar- testing and her unstable vital signs make ruptured ectopic
rhea. She had a normal bow- pregnancy more likely.
el movement this morning.
Her β-human chorionic go-
nadotropin (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 satura-
tion, 99%; and temperature,
37.3ºC orally. The clinician per-
forms an abdominal exam pri-
or to her pelvic exam and,
on palpation of her abdomen,
finds involuntary rigidity and
rebound tenderness. What is
the most likely diagnosis?
, Week 8 NR 509 Advanced Health Assessment Final
Study online at https://quizlet.com/_dflx9u
2. CHAPTER 19: Abdomen Liver palpable 3 cm below the right costal margin, mid clavic-
A 63-year-old janitor with a his- ular line, on expiration
tory of adenomatous colonic
polyps presents for a well vis- Rationale: The liver being palpable 3 cm below the right costal
it. Basic labs are performed margin, midclavicular line, would be considered normal on
to screen for diabetes mel- inspiration when the liver is pushed down into the abdominal
litus and dyslipidemia. Elec- cavity on inspiration, but is abnormal on expiration. Findings
trolytes and liver enzymes to support hepatomegaly would be more convincing if, by
were also measured. His labs percussion, the liver span was >12 cm at the midclavicular
are all normal expect for line. For patients with obstructive lung disease, air trapping
moderate elevations of as- in the lungs may displace the liver downwards into the ab-
partate aminotransferase, ala- dominal cavity. The liver span and dullness to percussion
nine aminotransferase, γ-glu- refer to the same measurement. Measurements of 6-12 cm at
tamyl transferase, and alka- the mid-clavicular line and 4-8 cm at the midsternal line are
line phosphatase as well as a considered normal.
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 he-
patomegaly?
3. CHAPTER 19: Abdomen History of smoking
A 63-year-old underweight
administrative clerk with a Rationale: History of smoking is her most significant risk factor
50-pack-year smoking history for an AAA. Male gender, not female gender, is considered
presents with a several month as risk factor. Underweight is not a risk factor for AAA. Family
history of recurrent epigas- history of ruptured aneurysm is vague and could be a cerebral
tric abdominal discomfort. She aneurysm. Further, her family history is in a first-degree cousin
, Week 8 NR 509 Advanced Health Assessment Final
Study online at https://quizlet.com/_dflx9u
feels fairly well otherwise and not a first-degree relative (biologic parents, siblings, and
denies any nausea, vomiting, children). Hypertension could contribute to atherosclerosis,
diarrhea, or constipation. She which is a risk factor. Further, a diagnosis of hypertension is
reports that a first cousin died not based on one elevated blood pressure reading.
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 promi-
nent, which is concerning for
an abdominal aortic aneurysm
(AAA). Which of the following is
her most significant risk factor
for an AAA?
4. CHAPTER 19: Abdomen Do not screen routinely
A 76-year-old retired man with
a history of prostate cancer Rationale: The USPSTF recommends not screening routinely.
and hypertension has been For most adults ages 76-85 years, the gain in life years is
screened annually for colon small compared to colonoscopy risks. It is advised to discuss
cancer using high sensitiv- individualized risks and benefits with the patient. Annual FOBT
ity fecal occult blood test- screening may continue until age 80-85 years if benefits to
ing (FOBT). He presents for doing so outweigh risks for the individual patient; however,
follow-up of his hyperten- screening should not be routinely continued. In general, a life
sion, during which the clin- expectancy >7 years is necessary for screening to be poten-
ician scans his chart to en- tially beneficial. There is no indication to repeat a colonoscopy
sure he is up to date with given the absence of any cancerous or precancerous findings
his preventive health care. on his colonoscopy 10 years ago. Sigmoidoscopy every 5
He has a positive FOBT on years with FOBT every 3 years is a valid screening option, but
, Week 8 NR 509 Advanced Health Assessment Final
Study online at https://quizlet.com/_dflx9u
one occasion at age 66 years again screening is not routinely recommended for patients
and subsequently went for a age >75 years.
colonoscopy. Internal hemor-
rhoids and sigmoid diverticuli
were found on colonoscopy.
He has no first-degree rela-
tives with a history of col-
orectal cancer or adenoma-
tous polyps. What are the
U.S. Preventive Services Task
Force (USPSTF) screening rec-
ommendations for this pa-
tient?
5. CHAPTER 19: Abdomen Functional change in bowel movement
An otherwise healthy
31-year-old accountant pre- Rationale: Functional change in bowel movement is charac-
sents to an outpatient clinic teristic of irritable bowel syndrome (IBS). IBS is character-
with a 3-year history of recur- ized by three patterns: diarrhea predominant, constipation
rent crampy abdominal pain predominant, or mixed. Other functional causes for her con-
that lasts for about 1-2 weeks stipation should be excluded prior to making this diagno-
each episode and is associ- sis. A large firm fecal mass in the rectum is characteristic of
ated with onset of constipa- fecal impaction, which is common in debilitated, bedridden
tion. She describes infrequent, individuals. Decreased fecal bulk is characteristic of a diet
small hard stool that she finds low in fiber. This patient had not found that increasing fiber
very difficult to pass. She has helps her constipation. Spasm of the external sphincter is
tried to increase dietary fiber associated with painful anal lesions, which this patient does
and water intake, but usually not report. Impairment of autonomic innervations is charac-
this is not sufficient and she re- teristic of patients with multiple sclerosis, spinal cord injuries,
sorts to over-the-counter lax- and Hirschsprung disease. She has no known diagnosis that
atives, which she finds upset would increase suspicion of neurological impairment.
her stomach but do resolve
