Week 8 NR 509 Advanced Health
Assessment Final
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? - 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? - 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? - 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? - 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? - 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 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.
Assessment Final
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? - 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? - 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? - 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? - 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? - 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 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.
