NR 509 / NR509 W eek 8 Advanced Health
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Assessm ent Exam w ith solu tions w ell |! |! |! |! |!
explained
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? - Correct answer ✔Ruptured tubal (or ectopic)
|! |! |! |! |! |! |! |! |! |!
pregnancy
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.
CHAPTER 19: Abdomen |! |!
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? - Correct answer ✔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. |! |! |! |! |! |! |! |! |! |! |!
CHAPTER 19: Abdomen |! |!
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?
|! |! |! |! |! |! |! |! |! |! |! |! |!
- Correct answer ✔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. |!
CHAPTER 19: Abdomen |! |!
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? - Correct answer ✔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 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. |! |! |! |! |!
CHAPTER 19: Abdomen |! |!
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? - Correct answer ✔Functional |! |! |! |! |! |! |! |! |!
change in bowel movement |! |! |!
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
|! |! |! |! |! |! |! |! |! |!
|! |! |! |! |! |! |! |!
Assessm ent Exam w ith solu tions w ell |! |! |! |! |!
explained
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? - Correct answer ✔Ruptured tubal (or ectopic)
|! |! |! |! |! |! |! |! |! |!
pregnancy
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.
CHAPTER 19: Abdomen |! |!
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? - Correct answer ✔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. |! |! |! |! |! |! |! |! |! |! |!
CHAPTER 19: Abdomen |! |!
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?
|! |! |! |! |! |! |! |! |! |! |! |! |!
- Correct answer ✔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. |!
CHAPTER 19: Abdomen |! |!
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? - Correct answer ✔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 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. |! |! |! |! |!
CHAPTER 19: Abdomen |! |!
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? - Correct answer ✔Functional |! |! |! |! |! |! |! |! |!
change in bowel movement |! |! |!
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
|! |! |! |! |! |! |! |! |! |!
