NR 509 Final week 5 Abdomen and GU
103 quizzes and Approved Answers.
NR 509 Final week 5 Abdomen and GU
103 quizzes and Approved Answers.
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 - 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
,NR 509 Final week 5 Abdomen and GU
103 quizzes and Approved Answers.
e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expi -
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 - 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.
, NR 509 Final week 5 Abdomen and GU
103 quizzes and Approved Answers.
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
e. Sigmoidoscopy every 5 years with FOBT every 3 years - ANSWER- a. 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.
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. A large, firm fecal mass in the rectum
b. Decreased fecal bulk
c. Functional change in bowel movement
d. Spasm of the external sphincter
