NR509 / NR 509 w eek 5 Exam - |! |! |! |! |! |!
Abdom en an d GU Qu estion s w ith |! |! |! |! |!
answ er s & r ationales |! |!
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 period 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 appendix
|! |!
d. Perf - Correct answer ✔Good!
|! |! |! |! |!
a. 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.
|! |! |! |! |! |! |! |!
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 span of 11 cm at the midclavicular line
|! |! |! |! |! |! |! |! |!
b. Liver span of 8 cm at the midsternal line
|! |! |! |! |! |! |! |! |!
c. Dullness to percussion over a span of 11 cm at the midclavicular line
|! |! |! |! |! |! |! |! |! |! |! |! |!
d. Dullness to percussion over a span of 8 cm at the midsternal line
|! |! |! |! |! |! |! |! |! |! |! |! |!
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
expi - Correct answer ✔e. 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. |! |! |! |!
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. Female gender
|! |!
b. History of smoking
|! |! |!
c. Underweight
|!
d. Family history of ruptured aneurysm
|! |! |! |! |!
e. Hypertension - Correct answer ✔b. 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. |!
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. Do not screen routinely
|! |! |! |!
b. Continue annual FOBT screening until age 80 years
|! |! |! |! |! |! |! |!
c. Continue annual FOBT screening until age 85 years
|! |! |! |! |! |! |! |!
d. Repeat colonoscopy this year
|! |! |! |!
Abdom en an d GU Qu estion s w ith |! |! |! |! |!
answ er s & r ationales |! |!
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 period 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 appendix
|! |!
d. Perf - Correct answer ✔Good!
|! |! |! |! |!
a. 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.
|! |! |! |! |! |! |! |!
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 span of 11 cm at the midclavicular line
|! |! |! |! |! |! |! |! |!
b. Liver span of 8 cm at the midsternal line
|! |! |! |! |! |! |! |! |!
c. Dullness to percussion over a span of 11 cm at the midclavicular line
|! |! |! |! |! |! |! |! |! |! |! |! |!
d. Dullness to percussion over a span of 8 cm at the midsternal line
|! |! |! |! |! |! |! |! |! |! |! |! |!
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
expi - Correct answer ✔e. 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. |! |! |! |!
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. Female gender
|! |!
b. History of smoking
|! |! |!
c. Underweight
|!
d. Family history of ruptured aneurysm
|! |! |! |! |!
e. Hypertension - Correct answer ✔b. 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. |!
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. Do not screen routinely
|! |! |! |!
b. Continue annual FOBT screening until age 80 years
|! |! |! |! |! |! |! |!
c. Continue annual FOBT screening until age 85 years
|! |! |! |! |! |! |! |!
d. Repeat colonoscopy this year
|! |! |! |!
