Chamberlain NR 509 Week 8 Final Exam
Advanced Physical Assessment | Questions, Correct Answers & Expert Rationales
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 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?
A. Ruptured tubal (or ectopic) pregnancy
B. Acute cholecystitis
C. Ruptured appendicitis
D. Ruptured ovarian cyst
Correct Answer: Ruptured tubal (or ectopic) pregnancy
Expert 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.
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, 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?
A. Liver palpable 3 cm below the right costal margin only on deep inspiration
B. Liver span of 6 cm at the midsternal line
C. Liver span of 8 cm at the midclavicular line
D. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration
Correct Answer: Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration
Expert 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
NR 509 Week 8 Final Exam • Page 1
,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. 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. Low body mass index
B. Female sex
C. History of smoking
D. A single elevated office blood pressure reading
Correct Answer: History of smoking
Expert 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. Schedule routine colonoscopy every 5 years
B. Continue annual fecal occult blood testing routinely regardless of age
C. Perform routine sigmoidoscopy every 5 years with FOBT every 3 years
D. Do not screen routinely
Correct Answer: Do not screen routinely
Expert 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.
NR 509 Week 8 Final Exam • Page 2
,5. 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?
A. Decreased fecal bulk from inadequate dietary fiber
B. Functional change in bowel movement
C. Impaired autonomic innervation of the bowel
D. A large firm fecal mass in the rectum
Correct Answer: Functional change in bowel movement
Expert 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.
6. 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?
A. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant
B. Left upper-quadrant splenic dullness with a normal right-sided gastric air bubble
C. Dullness to percussion in the right upper quadrant with tympany in the left upper quadrant
D. Diffuse abdominal dullness with palpable stool throughout the colon
Correct Answer: Tympany to percussion in the right upper quadrant, dullness to percussion of the
left upper quadrant
Expert 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 dullness and tympany and stool on palpation is likely
constipation. None of these findings suggest organ reversal. Liver dullness will occur in the left upper quadrant
with organ reversal. Findings given in the remaining answer choices are both associated with splenomegaly
with the spleen located in the left upper quadrant, which would not be the case for sinus inversus totalis.
7. An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-
day history of severe abdominal pain. The emergency physician suspects appendicitis and
NR 509 Week 8 Final Exam • Page 3
, general surgery is consulted. The resident believes the patient has signs of peritonitis on
exam. Which of the following physical exam findings supports peritonitis?
A. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain
B. Pain with internal rotation of the right hip
C. Localized tenderness at McBurney point
D. Abdominal pain that increases with hip flexion
Correct Answer: Pressing down onto the abdomen firmly and slowly and withdrawing the hand
quickly produces pain
Expert Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly
producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of
peritonitis. Involuntary contraction rather than voluntary contraction of the abdominal wall that persists over
several examinations describes rigidity. Abdominal pain that increases with hip flexion is not suggestive of
peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of the parietal
peritoneum. They often walk bent forward at the hips for this reason. Localized pain over McBurney point is
certainly suggestive of appendicitis, but not suggestive of peritonitis. Similarly pain with internal rotation of the
right hip, or a positive obturator sign, suggests irritation of the psoas muscle due to an inflamed appendix, but
not peritonitis.
8. A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the
last 10 months. He presents with a 4-month history of increasing weakness, recurrent
epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight
loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis?
A. Reduced mesenteric blood flow
B. Fibrosis of the pancreas
C. Helicobacter pylori infection
D. Inflammation of a colonic diverticulum
Correct Answer: Fibrosis of the pancreas
Expert Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to
fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency and
diabetes mellitus. H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not usually
associated with diarrhea. Inflammation of the colonic diverticulum is diverticulitis and typically causes left-lower-
quadrant pain, fever, constipation, and sometimes diarrhea. It is typically an acute disease. Reduced blood
supply to the bowel characterizes mesenteric ischemia. It can be acute or chronic in presentation and causes
diffuse abdominal pain, vomiting, diarrhea, or constipation. It is associated with older age and vascular risk
factors such as coronary artery disease.
9. A 46-year-old executive who is obese and otherwise healthy presents to a family medicine
clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its
own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated
that she has had to leave or miss work on three separate occasions. She would like a
NR 509 Week 8 Final Exam • Page 4
Advanced Physical Assessment | Questions, Correct Answers & Expert Rationales
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 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?
A. Ruptured tubal (or ectopic) pregnancy
B. Acute cholecystitis
C. Ruptured appendicitis
D. Ruptured ovarian cyst
Correct Answer: Ruptured tubal (or ectopic) pregnancy
Expert 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.
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, 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?
A. Liver palpable 3 cm below the right costal margin only on deep inspiration
B. Liver span of 6 cm at the midsternal line
C. Liver span of 8 cm at the midclavicular line
D. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration
Correct Answer: Liver palpable 3 cm below the right costal margin, mid clavicular line, on
expiration
Expert 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
NR 509 Week 8 Final Exam • Page 1
,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. 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. Low body mass index
B. Female sex
C. History of smoking
D. A single elevated office blood pressure reading
Correct Answer: History of smoking
Expert 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. Schedule routine colonoscopy every 5 years
B. Continue annual fecal occult blood testing routinely regardless of age
C. Perform routine sigmoidoscopy every 5 years with FOBT every 3 years
D. Do not screen routinely
Correct Answer: Do not screen routinely
Expert 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.
NR 509 Week 8 Final Exam • Page 2
,5. 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?
A. Decreased fecal bulk from inadequate dietary fiber
B. Functional change in bowel movement
C. Impaired autonomic innervation of the bowel
D. A large firm fecal mass in the rectum
Correct Answer: Functional change in bowel movement
Expert 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.
6. 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?
A. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant
B. Left upper-quadrant splenic dullness with a normal right-sided gastric air bubble
C. Dullness to percussion in the right upper quadrant with tympany in the left upper quadrant
D. Diffuse abdominal dullness with palpable stool throughout the colon
Correct Answer: Tympany to percussion in the right upper quadrant, dullness to percussion of the
left upper quadrant
Expert 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 dullness and tympany and stool on palpation is likely
constipation. None of these findings suggest organ reversal. Liver dullness will occur in the left upper quadrant
with organ reversal. Findings given in the remaining answer choices are both associated with splenomegaly
with the spleen located in the left upper quadrant, which would not be the case for sinus inversus totalis.
7. An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-
day history of severe abdominal pain. The emergency physician suspects appendicitis and
NR 509 Week 8 Final Exam • Page 3
, general surgery is consulted. The resident believes the patient has signs of peritonitis on
exam. Which of the following physical exam findings supports peritonitis?
A. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain
B. Pain with internal rotation of the right hip
C. Localized tenderness at McBurney point
D. Abdominal pain that increases with hip flexion
Correct Answer: Pressing down onto the abdomen firmly and slowly and withdrawing the hand
quickly produces pain
Expert Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly
producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of
peritonitis. Involuntary contraction rather than voluntary contraction of the abdominal wall that persists over
several examinations describes rigidity. Abdominal pain that increases with hip flexion is not suggestive of
peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of the parietal
peritoneum. They often walk bent forward at the hips for this reason. Localized pain over McBurney point is
certainly suggestive of appendicitis, but not suggestive of peritonitis. Similarly pain with internal rotation of the
right hip, or a positive obturator sign, suggests irritation of the psoas muscle due to an inflamed appendix, but
not peritonitis.
8. A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the
last 10 months. He presents with a 4-month history of increasing weakness, recurrent
epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight
loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis?
A. Reduced mesenteric blood flow
B. Fibrosis of the pancreas
C. Helicobacter pylori infection
D. Inflammation of a colonic diverticulum
Correct Answer: Fibrosis of the pancreas
Expert Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to
fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency and
diabetes mellitus. H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not usually
associated with diarrhea. Inflammation of the colonic diverticulum is diverticulitis and typically causes left-lower-
quadrant pain, fever, constipation, and sometimes diarrhea. It is typically an acute disease. Reduced blood
supply to the bowel characterizes mesenteric ischemia. It can be acute or chronic in presentation and causes
diffuse abdominal pain, vomiting, diarrhea, or constipation. It is associated with older age and vascular risk
factors such as coronary artery disease.
9. A 46-year-old executive who is obese and otherwise healthy presents to a family medicine
clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its
own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated
that she has had to leave or miss work on three separate occasions. She would like a
NR 509 Week 8 Final Exam • Page 4
