Weeksd8sdNRsd509sdAdvancedsdHealthsdAssessmentsdFinal
CHAPTERsd19:sdAbdomen
Ansdoverweightsd26-year-
oldsdpublicsdservantsdpresentssdtosdthesdEmergencysdDepartmentsdwithsd12sdho
urssdofsdintensesdabdominalsdpain,sdlight-
headedness,sdandsdasdfaintingsdepisodesdthatsdfinallysdpromptedsdhersdtosdseeksd
medicalsdattention.sdShesdhassdasdstrongsdfamilysdhistorysdofsdgallstonessdandsdi
ssdconcernedsdaboutsdthissdpossibility.sdShesdhassdnotsdhadsdanysdvomitingsdorsdd
iarrhea.sdShesdhadsdasdnormalsdbowelsdmovementsdthissdmorning.sdHersdβ-
humansdchorionicsdgonadotropinsd(β-
hCG)sdissdpositivesdatsdtriage.sdShesdreportssdthatsdhersdlastsdperiterm-
12odsdwassd10sdweekssdago.sdHersdvitalsdsignssdatsdtriagesdaresdpulse,sd118;sdblo
odsdpressure,sd86/68;sdrespiratorysdrate,sd20/min;sdoxygensdsaturation,sd99%;sd
andsdtemperature,sd37.3ºCsdorally.sdThesdcliniciansdperformssdansdabdominalsd
examsdpriorsdtosdhersdpelvicsdexamsdand,sdonsdpalpationsdofsdhersdabdomen,sdfin
dssdinvoluntarysdrigiditysdandsdreboundsdtenderness.sdWhatsdissdthesdmostsdlike
lysddiagnosis?sd-sdcorrectsdanswer✔ ✔
Rupturedsdtubalsd(orsdectopic)sdpregnancy
Rationale:sdThesdconstellationsdofsdabdominalsdpain,sdsyncope,sdtachycardia,s
dhypotension,sdpositivesdβ-
hCG,sdandsdfindingssdsuggestivesdofsdperitonealsdinflammation/irritationsdstr
onglysdsuggestsdasdrupturedsdectopicsdpregnancysdwithsdsignificantsdintra-
abdominalsdbleedingsdleadingsdtosdperitonealsdsigns.sdThissdcasesdissdemergents
dandsdrequiressdimmediatesdtreatmentsdofsdhersdhypotensionsdandsdpresumedsdb
,loodsdlosssdassdwellsdassdgynecologicalsdconsultsdforsdemergentsdsurgery.sdRupt
uredsdectopicsdpregnanciessdcansdleadsdtosdlife-threateningsdintra-
abdominalsdbleeding.sdAlthoughsdacutesdcholecystitis,sdrupturedsdappendix,sd
bowelsdwallsdperforation,sdandsdrupturedsdovariansdcystsdaresdallsdpossibilities,s
dthesdpositivesdβ-
hCGsdtestingsdandsdhersdunstablesdvitalsdsignssdmakesdrupturedsdectopicsdpregn
ancysdmoresdlikely.
CHAPTERsd19:sdAbdomen
Asd63-year-
oldsdjanitorsdwithsdasdhistorysdofsdadenomatoussdcolonicsdpolypssdpresentssdfors
dasdwellsdvisit.sdBasicsdlabssdaresdperformedsdtosdscreensdforsddiabetessdmellitussd
andsddyslipidemia.sdElectrolytessdandsdliversdenzymessdweresdalsosdmeasured.
sdHissdlabssdaresdallsdnormalsdexpectsdforsdmoderatesdelevationssdofsdaspartatesda
minotransferase,sdalaninesdaminotransferase,sdγ-
glutamylsdtransferase,sdandsdalkalinesdphosphatasesdassdwellsdassdasdmildlysdele
vatedsdtotalsdbilirubin.sdHesdpresentssdforsdasdfollow-
upsdappointmentsdandsdthesdcliniciansdperformssdansdabdominalsdexamsdtosdass
esssdhissdliver.sdWhichsdofsdthesdfollowingsdfindingssdwouldsdbesdmostsdconsiste
ntsdwithsdhepatomegaly?sd-sdcorrectsdanswer✔ ✔
Liversdpalpablesd3sdcmsdbelowsdthesdrightsdcostalsdmargin,sdmidsdclavicularsdl
ine,sdonsdexpiration
Rationale:sdThesdliversdbeingsdpalpablesd3sdcmsdbelowsdthesdrightsdcostalsdmarg
in,sdmidclavicularsdline,sdwouldsdbesdconsideredsdnormalsdonsdinspirationsdwh
ensdthesdliversdissdpushedsddownsdintosdthesdabdominalsdcavitysdonsdinspiration,s
dbutsdissdabnormalsdonsdexpiration.sdFindingssdtosdsupportsdhepatomegalysdwo
uldsdbesdmoresdconvincingsdif,sdbysdpercussion,sdthesdliversdspansdwassd>12sdcms
,atsdthesdmidclavicularsdline.sdForsdpatientssdwithsdobstructivesdlungsddisease,sd
d
airsdtrappingsdinsdthesdlungssdmaysddisplacesdthesdliversddownwardssdintosdthesda
bdominalsdcavity.sdThesdliversdspansdandsddullnesssdtosdpercussionsdrefersdtosdth
esdsamesdmeasurement.sdMeasurementssdofsd6-12sdcmsdatsdthesdmid-
clavicularsdlinesdandsd4-
8sdcmsdatsdthesdmidsternalsdlinesdaresdconsideredsdnormal.
CHAPTERsd19:sdAbdomen
Asd63-year-oldsdunderweightsdadministrativesdclerksdwithsdasd50-pack-
yearsdsmokingsdhistorysdpresentssdwithsdasdseveralsdmonthsdhistorysdofsdrecurre
ntsdepigastricsdabdominalsddiscomfort.sdShesdfeelssdfairlysdwellsdotherwisesdan
dsddeniessdanysdnausea,sdvomiting,sddiarrhea,sdorsdconstipation.sdShesdreportssd
thatsdasdfirstsdcousinsddiedsdfromsdasdrupturedsdaneurysmsdatsdagesd68sdyears.sdHe
rsdvitalsdsignssdaresdpulse,sd86;sdbloodsdpressure,sd148/92;sdrespiratorysdrate,sd1
6;sdoxygensdsaturation,sd95%;sdandsdtemperature,sd36.2ºC.sdHersdbodysdmasssdi
ndexsdissd17.6.sdOnsdexam,sdhersdabdominalsdaortasdissdprominent,sdwhichsdissdc
oncerningsdforsdansdabdominalsdaorticsdaneurysmsd(AAA).sdWhichsdofsdthesdfo
llowingsdissdhersdmostsdsignificantsdrisksdfactorsdforsdansdAAA?sd-
sdcorrectsdanswer✔ ✔ Historysdofsdsmoking
Rationale:sdHistorysdofsdsmokingsdissdhersdmostsdsignificantsdrisksdfactorsdforsda
nsdAAA.sdMalesdgender,sdnotsdfemalesdgender,sdissdconsideredsdassdrisksdfactor.
sdUnderweightsdissdnotsdasdrisksdfactorsdforsdAAA.sdFamilysdhistorysdofsdrupture
dsdaneurysmsdissdvaguesdandsdcouldsdbesdasdcerebralsdaneurysm.sdFurther,sdhersd
familysdhistorysdissdinsdasdfirst-degreesdcousinsdnotsdasdfirst-
degreesdrelativesd(biologicsdparents,sdsiblings,sdandsdchildren).sdHypertension
sdcouldsdcontributesdtosdatherosclerosis,sdwhichsdissdasdrisksdfactor.sdFurther,sdasd
, diagnosissdofsdhypertensionsdissdnotsdbasedsdonsdonesdelevatedsdbloodsdpressur
esdreading.
CHAPTERsd19:sdAbdomen
Asd76-year-
oldsdretiredsdmansdwithsdasdhistorysdofsdprostatesdcancersdandsdhypertensionsdha
ssdbeensdscreenedsdannuallysdforsdcolonsdcancersdusingsdhighsdsensitivitysdfecal
sdoccultsdbloodsdtestingsd(FOBT).sdHesdpresentssdforsdfollow-
upsdofsdhissdhypertension,sdduringsdwhichsdthesdcliniciansdscanssdhissdchartsdtosd
ensuresdhesdissdupsdtosddatesdwithsdhissdpreventivesdhealthsdcare.sdHesdhassdasdposi
tivesdFOBTsdonsdonesdoccasionsdatsdagesd66sdyearssdandsdsubsequentlysdwentsdf
orsdasdcolonoscopy.sdInternalsdhemorrhoidssdandsdsigmoidsddiverticulisdweresd
foundsdonsdcolonoscopy.sdHesdhassdnosdfirst-
degreesdrelativessdwithsdasdhistorysdofsdcolorectalsdcancersdorsdadenomatoussdp
olyps.sdWhatsdaresdthesdU.S.sdPreventivesdServicessdTasksdForcesd(USPSTF)sds
creeningsdrecommendationssdforsdthissdpatient?sd-sdcorrectsdanswer✔ ✔
Dosdnotsdscreensdroutinely
Rationale:sdThesdUSPSTFsdrecommendssdnotsdscreeningsdroutinely.sdForsdmo
stsdadultssdagessd76-
85sdyears,sdthesdgainsdinsdlifesdyearssdissdsmallsdcomparedsdtosdcolonoscopysdris
ks.sdItsdissdadvisedsdtosddiscusssdindividualizedsdriskssdandsdbenefitssdwithsdthesd
patient.sdAnnualsdFOBTsdscreeningsdmaysdcontinuesduntilsdagesd80-
85sdyearssdifsdbenefitssdtosddoingsdsosdoutweighsdriskssdforsdthesdindividualsdpati
ent;sdhowever,sdscreeningsdshouldsdnotsdbesdroutinelysdcontinued.sdInsdgeneral,
sdasdlifesdexpectancysd>7sdyearssdissdnecessarysdforsdscreeningsdtosdbesdpotentiall
ysdbeneficial.sdTheresdissdnosdindicationsdtosdrepeatsdasdcolonoscopysdgivensdthe
sdabsencesdofsdanysdcanceroussdorsdprecanceroussdfindingssdonsdhissdcolonosco
CHAPTERsd19:sdAbdomen
Ansdoverweightsd26-year-
oldsdpublicsdservantsdpresentssdtosdthesdEmergencysdDepartmentsdwithsd12sdho
urssdofsdintensesdabdominalsdpain,sdlight-
headedness,sdandsdasdfaintingsdepisodesdthatsdfinallysdpromptedsdhersdtosdseeksd
medicalsdattention.sdShesdhassdasdstrongsdfamilysdhistorysdofsdgallstonessdandsdi
ssdconcernedsdaboutsdthissdpossibility.sdShesdhassdnotsdhadsdanysdvomitingsdorsdd
iarrhea.sdShesdhadsdasdnormalsdbowelsdmovementsdthissdmorning.sdHersdβ-
humansdchorionicsdgonadotropinsd(β-
hCG)sdissdpositivesdatsdtriage.sdShesdreportssdthatsdhersdlastsdperiterm-
12odsdwassd10sdweekssdago.sdHersdvitalsdsignssdatsdtriagesdaresdpulse,sd118;sdblo
odsdpressure,sd86/68;sdrespiratorysdrate,sd20/min;sdoxygensdsaturation,sd99%;sd
andsdtemperature,sd37.3ºCsdorally.sdThesdcliniciansdperformssdansdabdominalsd
examsdpriorsdtosdhersdpelvicsdexamsdand,sdonsdpalpationsdofsdhersdabdomen,sdfin
dssdinvoluntarysdrigiditysdandsdreboundsdtenderness.sdWhatsdissdthesdmostsdlike
lysddiagnosis?sd-sdcorrectsdanswer✔ ✔
Rupturedsdtubalsd(orsdectopic)sdpregnancy
Rationale:sdThesdconstellationsdofsdabdominalsdpain,sdsyncope,sdtachycardia,s
dhypotension,sdpositivesdβ-
hCG,sdandsdfindingssdsuggestivesdofsdperitonealsdinflammation/irritationsdstr
onglysdsuggestsdasdrupturedsdectopicsdpregnancysdwithsdsignificantsdintra-
abdominalsdbleedingsdleadingsdtosdperitonealsdsigns.sdThissdcasesdissdemergents
dandsdrequiressdimmediatesdtreatmentsdofsdhersdhypotensionsdandsdpresumedsdb
,loodsdlosssdassdwellsdassdgynecologicalsdconsultsdforsdemergentsdsurgery.sdRupt
uredsdectopicsdpregnanciessdcansdleadsdtosdlife-threateningsdintra-
abdominalsdbleeding.sdAlthoughsdacutesdcholecystitis,sdrupturedsdappendix,sd
bowelsdwallsdperforation,sdandsdrupturedsdovariansdcystsdaresdallsdpossibilities,s
dthesdpositivesdβ-
hCGsdtestingsdandsdhersdunstablesdvitalsdsignssdmakesdrupturedsdectopicsdpregn
ancysdmoresdlikely.
CHAPTERsd19:sdAbdomen
Asd63-year-
oldsdjanitorsdwithsdasdhistorysdofsdadenomatoussdcolonicsdpolypssdpresentssdfors
dasdwellsdvisit.sdBasicsdlabssdaresdperformedsdtosdscreensdforsddiabetessdmellitussd
andsddyslipidemia.sdElectrolytessdandsdliversdenzymessdweresdalsosdmeasured.
sdHissdlabssdaresdallsdnormalsdexpectsdforsdmoderatesdelevationssdofsdaspartatesda
minotransferase,sdalaninesdaminotransferase,sdγ-
glutamylsdtransferase,sdandsdalkalinesdphosphatasesdassdwellsdassdasdmildlysdele
vatedsdtotalsdbilirubin.sdHesdpresentssdforsdasdfollow-
upsdappointmentsdandsdthesdcliniciansdperformssdansdabdominalsdexamsdtosdass
esssdhissdliver.sdWhichsdofsdthesdfollowingsdfindingssdwouldsdbesdmostsdconsiste
ntsdwithsdhepatomegaly?sd-sdcorrectsdanswer✔ ✔
Liversdpalpablesd3sdcmsdbelowsdthesdrightsdcostalsdmargin,sdmidsdclavicularsdl
ine,sdonsdexpiration
Rationale:sdThesdliversdbeingsdpalpablesd3sdcmsdbelowsdthesdrightsdcostalsdmarg
in,sdmidclavicularsdline,sdwouldsdbesdconsideredsdnormalsdonsdinspirationsdwh
ensdthesdliversdissdpushedsddownsdintosdthesdabdominalsdcavitysdonsdinspiration,s
dbutsdissdabnormalsdonsdexpiration.sdFindingssdtosdsupportsdhepatomegalysdwo
uldsdbesdmoresdconvincingsdif,sdbysdpercussion,sdthesdliversdspansdwassd>12sdcms
,atsdthesdmidclavicularsdline.sdForsdpatientssdwithsdobstructivesdlungsddisease,sd
d
airsdtrappingsdinsdthesdlungssdmaysddisplacesdthesdliversddownwardssdintosdthesda
bdominalsdcavity.sdThesdliversdspansdandsddullnesssdtosdpercussionsdrefersdtosdth
esdsamesdmeasurement.sdMeasurementssdofsd6-12sdcmsdatsdthesdmid-
clavicularsdlinesdandsd4-
8sdcmsdatsdthesdmidsternalsdlinesdaresdconsideredsdnormal.
CHAPTERsd19:sdAbdomen
Asd63-year-oldsdunderweightsdadministrativesdclerksdwithsdasd50-pack-
yearsdsmokingsdhistorysdpresentssdwithsdasdseveralsdmonthsdhistorysdofsdrecurre
ntsdepigastricsdabdominalsddiscomfort.sdShesdfeelssdfairlysdwellsdotherwisesdan
dsddeniessdanysdnausea,sdvomiting,sddiarrhea,sdorsdconstipation.sdShesdreportssd
thatsdasdfirstsdcousinsddiedsdfromsdasdrupturedsdaneurysmsdatsdagesd68sdyears.sdHe
rsdvitalsdsignssdaresdpulse,sd86;sdbloodsdpressure,sd148/92;sdrespiratorysdrate,sd1
6;sdoxygensdsaturation,sd95%;sdandsdtemperature,sd36.2ºC.sdHersdbodysdmasssdi
ndexsdissd17.6.sdOnsdexam,sdhersdabdominalsdaortasdissdprominent,sdwhichsdissdc
oncerningsdforsdansdabdominalsdaorticsdaneurysmsd(AAA).sdWhichsdofsdthesdfo
llowingsdissdhersdmostsdsignificantsdrisksdfactorsdforsdansdAAA?sd-
sdcorrectsdanswer✔ ✔ Historysdofsdsmoking
Rationale:sdHistorysdofsdsmokingsdissdhersdmostsdsignificantsdrisksdfactorsdforsda
nsdAAA.sdMalesdgender,sdnotsdfemalesdgender,sdissdconsideredsdassdrisksdfactor.
sdUnderweightsdissdnotsdasdrisksdfactorsdforsdAAA.sdFamilysdhistorysdofsdrupture
dsdaneurysmsdissdvaguesdandsdcouldsdbesdasdcerebralsdaneurysm.sdFurther,sdhersd
familysdhistorysdissdinsdasdfirst-degreesdcousinsdnotsdasdfirst-
degreesdrelativesd(biologicsdparents,sdsiblings,sdandsdchildren).sdHypertension
sdcouldsdcontributesdtosdatherosclerosis,sdwhichsdissdasdrisksdfactor.sdFurther,sdasd
, diagnosissdofsdhypertensionsdissdnotsdbasedsdonsdonesdelevatedsdbloodsdpressur
esdreading.
CHAPTERsd19:sdAbdomen
Asd76-year-
oldsdretiredsdmansdwithsdasdhistorysdofsdprostatesdcancersdandsdhypertensionsdha
ssdbeensdscreenedsdannuallysdforsdcolonsdcancersdusingsdhighsdsensitivitysdfecal
sdoccultsdbloodsdtestingsd(FOBT).sdHesdpresentssdforsdfollow-
upsdofsdhissdhypertension,sdduringsdwhichsdthesdcliniciansdscanssdhissdchartsdtosd
ensuresdhesdissdupsdtosddatesdwithsdhissdpreventivesdhealthsdcare.sdHesdhassdasdposi
tivesdFOBTsdonsdonesdoccasionsdatsdagesd66sdyearssdandsdsubsequentlysdwentsdf
orsdasdcolonoscopy.sdInternalsdhemorrhoidssdandsdsigmoidsddiverticulisdweresd
foundsdonsdcolonoscopy.sdHesdhassdnosdfirst-
degreesdrelativessdwithsdasdhistorysdofsdcolorectalsdcancersdorsdadenomatoussdp
olyps.sdWhatsdaresdthesdU.S.sdPreventivesdServicessdTasksdForcesd(USPSTF)sds
creeningsdrecommendationssdforsdthissdpatient?sd-sdcorrectsdanswer✔ ✔
Dosdnotsdscreensdroutinely
Rationale:sdThesdUSPSTFsdrecommendssdnotsdscreeningsdroutinely.sdForsdmo
stsdadultssdagessd76-
85sdyears,sdthesdgainsdinsdlifesdyearssdissdsmallsdcomparedsdtosdcolonoscopysdris
ks.sdItsdissdadvisedsdtosddiscusssdindividualizedsdriskssdandsdbenefitssdwithsdthesd
patient.sdAnnualsdFOBTsdscreeningsdmaysdcontinuesduntilsdagesd80-
85sdyearssdifsdbenefitssdtosddoingsdsosdoutweighsdriskssdforsdthesdindividualsdpati
ent;sdhowever,sdscreeningsdshouldsdnotsdbesdroutinelysdcontinued.sdInsdgeneral,
sdasdlifesdexpectancysd>7sdyearssdissdnecessarysdforsdscreeningsdtosdbesdpotentiall
ysdbeneficial.sdTheresdissdnosdindicationsdtosdrepeatsdasdcolonoscopysdgivensdthe
sdabsencesdofsdanysdcanceroussdorsdprecanceroussdfindingssdonsdhissdcolonosco
