Advanced Assessment Interpreting

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Chapter 10. Abdomen

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. When performing abdominal assessment, the clinician should perform examination techniques in
the following order:
A. Inspection, palpation, percussion, and auscultation
B. Inspection, percussion, palpation, and auscultation
C. Inspection, auscultation, percussion, and palpation
D. Auscultation, palpation, percussion, and inspection
____ 2. The clinician should auscultate the abdomen to listen for possible bruits of the:
A. Aorta
B. Renal artery
C. Iliac artery
D. All of the above
____ 3. On abdominal examination, which of the following is assessed using percussion?
A. Liver
B. Kidneys
C. Pancreas
D. Esophagus
____ 4. In abdominal assessment, a digital rectal examination is performed to assess for:
A. Hemorrhoids
B. Prostate size
C. Blood in stool
D. Ureteral stenosis
____ 5. Rebound tenderness of the abdomen is a sign of:
A. Constipation
B. Peritoneal inflammation
C. Elevated venous pressure
D. Peritoneal edema
____ 6. While assessing the abdomen, the clinician deeply palpates the left lower quadrant of the abdomen,
and this causes pain in the patient’s right lower abdomen. This is most commonly indicative of:
A. Constipation
B. Diverticulitis
C. Appendicitis
D. Hepatitis
____ 7. Your patient complains of severe right lower quadrant abdominal pain. To assess the patient for
peritoneal inflammation, the examiner should:
A. Percuss the right lower quadrant of the abdomen
B. Deeply palpate the right lower quadrant of the abdomen
C. Auscultate the right lower quadrant for hyperactive bowel sounds
 D. Strike the plantar surface of the patient’s heel while the patient is supine
____ 8. Your patient is lying supine and you ask him to raise his leg while you place resistance against the
thigh. The examiner is testing the patient for:
A. Psoas sign
B. Obturator sign
C. Rovsing’s sign
D. Murphys’ sign
____ 9. A patient is lying supine and the clinician deeply palpates the right upper quadrant of the abdomen
while the patient inhales. The examiner is testing the patient for:
A. Psoas sign
B. Obturator sign
C. Rovsing’s sign
D. Murphys’ sign
____ 10. Your patient has abdominal pain, and it is worsened when the examiner rotates the patient’s right
hip inward with the knee bent and the obturator internus muscle is stretched. This is a sign of:
A. Diverticulitis
B. Cholecystitis
C. Appendicitis
D. Mesenteric adenitis
____ 11. On abdominal examination as the clinician presses on the right upper quadrant to assess liver size,
jugular vein distension becomes obvious. Hepatojugular reflux is indicative of:
A. Acute hepatitis
B. Right ventricular failure
C. Cholecystitis
D. Left ventricular failure
____ 12. Your patient demonstrates positive shifting dullness on percussion of the abdomen. This is
indicative of:
A. Cholecystitis
B. Appendicitis
C. Ascites
D. Hepatitis
____ 13. Your 44-year-old female patient complains of right upper quadrant pain. Her skin and sclera are
yellow, and she has hyperbilirubinemia and elevated liver enzymes. The clinician should suspect:
A. Acute pancreatitis
B. Biliary duct obstruction
C. Acute hepatitis
D. Atypical appendicitis
____ 14. The most common cause of acute pancreatitis is:
A. Trauma
B. Hepatitis virus A
C. Hyperlipidemia
D. Alcohol abuse
____ 15. Your patient with pancreatitis has a Ranson rule score of 8. The clinician should recognize that this
is a risk of:
A. Pleural involvement
B. Alcoholism
C. High mortality
D. Bile duct obstruction
____ 16. Your patient complains of left upper quadrant pain, fever, extreme fatigue, and spontaneous
bruising. The clinician should recognize that these symptoms are often related to:
A. Hematopoetic disorders
B. Hepatomegaly
C. Esophageal varices
D. Pleural effusion
____ 17. A 16-year-old patient presents with sore throat, cervical lymphadenopathy, fever, extreme fatigue,
and left upper quadrant pain. The physical examination reveals splenomegaly. The clinician should
recognize the probability of:
A. Bacterial endocarditis
B. Infectious mononucleosis
C. Pneumonia with pleural effusion
D. Pancreatic cancer
____ 18. Your patient complains of lower abdominal pain, anorexia, extreme fatigue, unintentional weight
loss of 10 pounds in last 3 weeks, and you find a positive hemoccult on digital rectal examination.
Laboratory tests show iron deficiency anemia. The clinician needs to consider:
A. Diverticulitis
B. Appendicitis
C. Colon cancer
D. Peptic ulcer disease
____ 19. Which of the following is the most common cause of heartburn-type epigastric pain?
A. Decreased lower esophageal sphincter tone
B. Helicobacteria pylori infection of stomach
C. Esophageal spasm
D. Excess use of NSAIDs
____ 20. A 22-year-old female enters the emergency room with complaints of right lower quadrant
abdominal pain, which has been worsening over the last 24 hours. On examination of the
abdomen, there is a palpable mass and rebound tenderness over the right lower quadrant. The
clinician should recognize the importance of:
A. Digital rectal examination
B. Endoscopy
C. Ultrasound
D. Pelvic examination
____ 21. The major sign of ectopic pregnancy is:
A. Sudden onset of severe epigastric pain
B. Amenorrhea with unilateral lower quadrant pain
 C. Lower back and rectal pain
D. Palpable abdominal mass
____ 22. When ruptured ectopic pregnancy is suspected, the following procedure is most important:
A. Culdocentesis
B. CT scan
C. Abdominal x-ray
D. Digital rectal examination
____ 23. The majority of colon cancers are located in the:
A. Transverse colon
B. Cecum
C. Rectosigmoid region
D. Ascending colon
____ 24. The following symptom(s) in the patient’s history should raise the clinician’s suspicion of colon
cancer:
A. Alternating constipation and diarrhea
B. Narrowed caliber of stool
C. Hematochezia
D. All of the above
____ 25. A patient presents to the emergency department with nausea and severe, colicky back pain that
radiates into the groin. When asked to locate the pain, he points to the right costovertebral angle
region. His physical examination is unremarkable. Which of the following lab tests is most
important for the diagnosis?
A. Urinalysis
B. Serum electrolyte levels
C. Digital rectal exam
D. Lumbar x-ray
____ 26. Your 34-year-old female patient complains of a feeling of “heaviness” in the right lower quadrant,
achiness, and bloating. On pelvic examination, there is a palpable mass in the right lower quadrant.
Urine and serum pregnancy tests are negative. The diagnostic tool that would be most helpful is:
A. Digital rectal exam
B. Transvaginal ultrasound
C. Pap smear
D. Urinalysis
____ 27. Your 54-year-old male patient complains of a painless “lump” in his lower left abdomen that
comes and goes for the past couple of weeks. When examining the abdomen, you should have the
patient:
A. Lie flat and take a deep breath
B. Stand and bear down against your hand
C. Prepare for a digital rectal examination
D. Lie in a left lateral recumbent position
____ 28. A nurse practitioner reports that your patient’s abdominal x-ray demonstrates multiple air-fluid
levels in the bowel. This is a diagnostic finding found in:
 A. Appendicitis
B. Cholecystitis
C. Bowel obstruction
D. Diverticulitis
____ 29. A 76-year-old patient presents to the emergency department with severe left lower quadrant
abdominal pain, diarrhea, and fever. On physical examination, you note the patient has a positive
heel strike, and left lower abdominal rebound tenderness. These are typical signs and symptoms of
which of the following conditions?
A. Diverticulitis
B. Salpingitis
C. Inflammatory bowel disease
D. Irritable bowel syndrome
____ 30. Which of the following conditions is the most common cause of nausea, vomiting, and diarrhea?
A. Viral gastroenteritis
B. Staphylococcal food poisoning
C. Acute hepatitis A
D. E.coli gastroenteritis
____ 31. A patient presents to the emergency department with complaints of vomiting and abdominal pain.
You note that the emesis contains bile. On physical examination, there is diffuse tenderness,
abdominal distension, and rushing, high-pitched bowel sounds. Which of the following diagnoses
would be most likely?
A. Gastric outlet obstruction
B. Small bowel obstruction
C. Distal intestinal blockage
D. Colonic obstruction
____ 32. Your 5-year-old female patient presents to the emergency department with sore throat, vomiting,
ear ache, 103 degree fever, photophobia, and nuchal rigidity. She has an episode of projectile
vomiting while you are examining her. The clinician should recognize that the following should be
done:
A. Abdominal x-ray
B. Fundoscopic examination
C. Lumbar puncture
D. Analysis of vomitus
____ 33. A 9-year-old boy accompanied by his mother reports that since he came home from summer camp,
he has had fever, nausea, vomiting, severe abdominal cramps and watery stools that contain blood
and mucus. The clinician should recognize the importance of:
A. Stool for ova and parasites
B. Abdominal x-ray
C. Stool for clostridium
D. Fecal occult blood test
____ 34. A 56-year-old male complains of anorexia, changes in bowel habits, extreme fatigue, and
unintentional weight loss. At times he is constipated and other times he has episodes of diarrhea.
His physical examination is unremarkable. It is important for the clinician to recognize the
importance of:
A. CBC with differential
B. Stool culture and sensitivity
C. Abdominal x-ray
D. Colonoscopy
____ 35. A 20-year-old engineering student complains of episodes of abdominal discomfort, bloating, and
episodes of diarrhea. The symptoms usually occur after eating, and pain is frequently relieved with
bowel movement. She is on a “celiac diet” and the episodic symptoms persist. Physical
examination and diagnostic tests are negative. Colonoscopy is negative for any abnormalities. This
is a history and physical consistent with:
A. Inflammatory bowel disease
B. Irritable bowel syndrome
C. Laxative abuse
D. Norovirus gastroenteritis
____ 36. A 78-year-old female patient is suffering from heart failure, GERD, diabetes, and depression. She
presents with complaints of frequent episodes of constipation. Her last bowel movement was 1
week ago. Upon examination, you palpate a hard mass is the left lower quadrant of the abdomen.
You review her list of medications. Which of the following of her medications cause constipation?
A. Digitalis (Lanoxin)
B. Amlodipine (Norvasc)
C. Sertraline (Zoloft)
D. Metformin (Glucophage)
____ 37. You are examining a 55-year-old female patient with a history of alcohol abuse. She complains of
anorexia, nausea, pruritus, and weight loss over the last month. On physical examination, you note
yellow hue of the skin and sclera. Which of the following physical examination techniques is most
important?
A. Scratch test
B. Heel strike
C. Digital rectal examination
D. Pelvic examination
____ 38. You observe Charcot’s triad of sign and symptoms in a patient under your care. This is commonly
seen in which of the following disorders?
A. Cirrhosis
B. Pancreatitis
C. Cholangitis
D. Portal hypertension
____ 39. A 59-year-old patient with history of alcohol abuse is admitted for hematemesis. On physical
examination, you note ascites and caput medusa. A likely cause for the hematemesis is:
A. Peptic ulcer disease
B. Barrett’s esophagus
 C. Pancreatitis
D. Esophageal varices
____ 40. A 16-year-old female with anorexia and bulimia is admitted for hematemesis. She admits to
inducing vomiting often. On physical examination, you note pallor, BMI less than 15, and
hypotension. A likely reason for hematemesis is:
A. Mallory-Weiss tear
B. Cirrhosis
C. Peptic ulcer disease
D. Esophageal varies
____ 41. An 82-year-old female presents to the emergency department with epigastric pain and weakness.
She admits to having dark, tarry stools for the last few days. She reports a long history of pain due
to osteoarthritis. She self-medicates daily with ibuprofen, naprosyn, and aspirin for joint pain. On
physical examination, she has orthostatic hypotension and pallor. Fecal occult blood test is
positive. A likely etiology of the patient’s problem is:
A. Mallory-Weiss tear
B. Esophageal varices
C. Gastric ulcer
D. Colon cancer
____ 42. A 48-year-old male presents to the clinic with complaints of anorexia, nausea, weakness, and
unintentional weight loss over the last few weeks. On physical examination, the patient has
jaundice of the skin as well as sclera and a palpable mass in the epigastric region. In addition to
CBC and bilirubin levels, all of the following tests would be helpful except:
A. Liver enzymes
B. Amylase
C. Lipase
D. Uric acid
____ 43. Your 66-year-old male patient complains of weakness, fatigue, chronic constipation for the last
month, and dark stools. On CBC, his results show iron deficiency anemia. Colon cancer is
diagnosed. Which of the following laboratory tests is used to follow progress of colon cancer?
A. Alpha fetoprotein (AFP)
B. Carcinogenic embryonic antigen (CEA)
C. Carcinoma antigen 125 (CA-125)
D. Beta-human chorionic gonadotropin (beta HCG)
____ 44. Your patient is a 33-year-old female gave birth last week. She complains of constipation, rectal
pain, and itching. She reports bright red blood on the toilet tissue. The clinician should recognize
the need for:
A. Digital rectal exam
B. CEA blood test
C. Colonoscopy
D. Fecal occult blood test
Chapter 10. Abdomen
Answer Section

MULTIPLE CHOICE

1. ANS: C
The abdominal examination begins with inspection, followed by auscultation, percussion, and
palpation. Light palpation should precede deep palpation. Auscultating before percussion or
palpation allows the examiner to listen to the abdominal sounds undisturbed. Moreover, if pain is
present, it is best to leave palpation until last and to gather other data before possibly causing the
patient discomfort.

PTS: 1
2. ANS: D
Perform auscultation before palpation so as to hear unaltered bowel sounds. Listen for bruits over
the aorta and the iliac, renal, and femoral arteries.

PTS: 1
3. ANS: A
The purpose of liver percussion is to measure the liver size. The technique used to percuss the liver
is as follows:
1. Starting in the midclavicular line at about the 3rd intercostal space, lightly percuss and move
down.
2. Percuss inferiorly until dullness denotes the liver's upper border (usually at fifth intercostal
space in MCL).
3. Resume percussion from below the umbilicus on the midclavicular line in an area of tympany.
4. Percuss superiorly until dullness indicates the liver's inferior border.
5. Measure span in centimeters. Normal liver span: clinically estimated at midclavicular line: 6-12
cm and midsternal line: 4-8 cm.

PTS: 1
4. ANS: D
A digital rectal examination is included in the abdominal examination. Note skin changes or
lesions in the perianal region or the presence of external hemorrhoids. Insert the gloved index
finger into the anus with the patient either leaning over or side-lying on the examination table, and
note any internal hemorrhoids or fissures. Check the stool for occult blood. For males, the rectal
examination is necessary for direct examination of the prostate. Ureteral stenosis is detected by
angiographt.

PTS: 1
5. ANS: B
Rebound tenderness is tested by slowly pressing over the abdomen with your fingertips, holding
the position until pain subsides or the patient adjusts to the discomfort, and then quickly removing
the pressure. Rebound pain, a sign of peritoneal inflammation, is present if the patient experiences
a sharp discomfort over the inflamed site when pressure is released.
 PTS: 1
6. ANS: C
Appendicitis is suggested by a positive Rovsing’s sign. This sign is positive when there is referred
rebound pain in the right lower quadrant when the examiner presses deeply in the left lower
quadrant and then quickly releases the pressure.

PTS: 1
7. ANS: D
Ask the patient to stand with straight legs and to raise up on toes. Then ask the patient to relax,
allowing the heel to strike the floor, thus jarring the body. A positive heel strike is indicative of
appendicitis and peritoneal irritation. Alternatively, strike the plantar surface of the heel with your
fist while the patient rests supine on the examination table.

PTS: 1
8. ANS: A
To examine the patient for appendicitis, the clinician can test the patient for psoas sign. This is
done in the following manner: Place a hand on the patient’s thigh just above the knee and ask the
patient to raise the thigh against your hand. This contracts the psoas muscle and produces pain in
patients with an inflamed appendix.

PTS: 1
9. ANS: D
Murphy’s Sign is elicited by deeply palpating the right upper quadrant of the abdomen. Pain is
present on deep inspiration when an inflamed gallbladder is palpated by pressing the fingers under
the rib cage. Murphy’s sign is positive in cholecystitis.

PTS: 1
10. ANS: C
A positive obturator sign indicates appendicitis. Pain is elicited by inward rotation of the right hip
with the knee bent so that the obturator internus muscle is stretched.

PTS: 1
11. ANS: B
Hepatojugular reflux is elicited by applying firm, sustained hand pressure to the abdomen in the
midepigastric region while the patient breathes regularly. Observe the neck for elevation of the
jugular venous pressure (JVP) with pressure of the hand and a sudden drop of the JVP when the
hand pressure is released. Hepatojugular reflux is exaggerated in right heart failure.

PTS: 1
12. ANS: C
To assess the patient for ascites, test for shifting of the peritoneal fluid to the dependent side by
rolling the patient side to side and percussing for dullness on the dependent side of the abdomen.

PTS: 1
13. ANS: B
 In cholecystitis, acute colicky pain is localized in the RUQ and is often accompanied by nausea
and vomiting. Murphy’s sign is frequently present. Fever is low grade, and the increase in
neutrophilic leukocytes in the blood is slight. Acute cholecystitis improves in 2 to 3 days and
resolves within a week; however, recurrences are common. If acute cholecystitis is accompanied
by jaundice and cholestasis (arrest of bile excretion), suspect common duct obstruction.

PTS: 1
14. ANS: D
Biliary tract disease and alcoholism account for 80% or more of the pancreatitis admissions. Other
causes include hyperlipidemia, drugs, toxins, infection, structural abnormalities, surgery, vascular
disease, trauma, hyperparathyroidism and hypercalcemia, renal transplantation, and hereditary
pancreatitis. The most common cause of pancreatitis is alcohol abuse.

PTS: 1
15. ANS: C
The Ranson rule uses a score determined by MRI results, with an index possible range of 0 to 10.
A categorization of patients indicates the risk of both mortality and complication from pancreatitis.
Patients at the low end of the index (1–3) are predicted to have a low risk of mortality (3%) and
complications (8%), whereas patients scoring at the high end (7–10) of the index are predicted to
have a higher incidence of mortality (17%) and/or complications (92%).

PTS: 1
16. ANS: A
LUQ pain can be associated with stomach or spleen disorders; however, it is often associated with
causes that are outside the abdomen. Hematopoietic malignancies, such as lymphomas and
leukemias, and other hematologic disorders, such as thrombocytopenia, polycythemia,
myelofibrosis, and hemolyticanemia, often cause enlargement of the spleen, leading to LUQ pain.
In addition to questions about the specific characteristics of the pain, it is important to ask the
patient about fever, unusual bleeding or bruising, recent diagnosis of mononucleosis, fatigue,
malaise, lymphadenopathy, cough, arthralgias, anorexia, weight loss, jaundice, high blood
pressure, and headache.

PTS: 1
17. ANS: B
Hypersplenism is secondary to other primary disorders, most commonly cytopenic hematologic
disorders, such as lymphoma, leukemia, thrombocytopenia, polycythemia, myelofibrosis, and
haemolytic anemias. With the sore throat and cervical lymphadenopathy, infection due to
Epstein-Barr virus is common in adolescents. Infectious mononucleosis is an important disorder to
consider. Splenomegaly often occurs in infectious mononucleosis.

PTS: 1
18. ANS: C
A positive hemoccult on rectal examination may indicate an upper GI bleed or malignancy.
Malignancy should also be suspected if there is weight loss and/or a palpable abdominal mass.

PTS: 1
19. ANS: A
GERD is the most common organic cause of heartburn. GERD is caused by decreased lower
esophageal sphincter (LES) tone. LES control can be decreased by several medications (e.g.,
theophylline, dopamine, diazepam, calcium-channel blockers), foods and/or beverages (caffeine,
alcohol, chocolate, fatty foods), and tobacco use. When LES tone is lower than normal, secretions
are allowed to reflux into the esophagus, causing discomfort.

PTS: 1
20. ANS: D
A female with abdominal pain can have a GI or GU disorder or gynecologic problem. It is
imperative to ask about the last menstrual period (LMP) and about birth control methods in order
to rule out ectopic pregnancy. A history of miscarriages and/or sexually transmitted diseases
(STDs) can give more clues for the risk of ectopic pregnancy. Safe sex practices and the number of
sexual partners can alert the practitioner to the risk for pelvic inflammatory disease. No complaint
of lower abdominal pain in a female should be evaluated without performing a pelvic examination.

PTS: 1
21. ANS: B
The most obvious sign of ectopic pregnancy is amenorrhea followed by spotting and sudden onset
of severe lower quadrant pain. A stat pregnancy test should be performed. There is tenderness on
pelvic examination, and a pelvic mass may be palpated. Blood is present in the cul-de-sac. Shock
and hemorrhage occur if the pregnancy ruptures. Abdominal distention with peritoneal signs will
ensue. Immediate laparoscopy or laparotomy is indicated because this condition is life threatening.

PTS: 1
22. ANS: A
The most obvious sign of ectopic pregnancy is amenorrhea followed by spotting and sudden onset
of severe lower quadrant pain. A stat pregnancy test should be performed. The diagnosis of ectopic
pregnancy can be made with urine human chorionic gonadotropin (hCG) or stat serum hCG, pelvic
ultrasound, and, if necessary, culdocentesis to detect blood in the cul-de-sac. There is tenderness
on pelvic examination, and a pelvic mass may be palpated. Blood is present in the cul-de-sac.
Shock and hemorrhage occur if the pregnancy ruptures. Abdominal distension with peritoneal
signs will ensue. Immediate laparoscopy or laparotomy is indicated because this condition is life
threatening.

PTS: 1
23. ANS: C
Colorectal cancer is the second leading cause of death from malignancies in the United States.
Over half are located in the rectosigmoid region and are typically adenocarcinomas. Risk factors
include a history of polyps, positive family history of colon cancer or familial polyposis, ulcerative
colitis, granulomatous colitis, and a diet low in fiber and high in animal protein, fat, and refined
carbohydrates.

PTS: 1
24. ANS: D
 Colon cancer may be present for several years before symptoms appear. Complaints include
fatigue, weakness, weight loss, alternating constipation and diarrhea, a change in the caliber of
stool, tenesmus, urgency, and hematochezia. Physical examination is usually normal except in
advanced disease, when the tumor can be palpated or hepatomegaly is present, owing to metastatic
disease.

PTS: 1
25. ANS: A
Urinary calculi can occur anywhere in the urinary tract; therefore, pain can originate in the flank or
kidney area and radiate into the RLQ or LLQ and then to the suprapubic area as the stone attempts
to move down the tract. The pain is severe, acute, and colicky and may be accompanied by nausea
and vomiting. If the stone becomes lodged at the ureterovesical junction, the patient will complain
of urgency and frequency. Blood will be present in the urine.

PTS: 1
26. ANS: B
Ovarian masses are often asymptomatic, but symptoms may include pressure-type pain, heaviness,
aching, and bloating. Masses are typically detected on pelvic examination. In advanced
malignancies, ascites is often present. An elevated cancer antigen 125 (CA-125) result indicates
the likelihood that the mass is malignant. A transvaginal pelvic ultrasound has a higher diagnostic
sensitivity than transabdominal ultrasound. If diagnosis is unclear, CT, MRI, or PET scan can be
performed. A laparoscopy or exploratory laparotomy is necessary for staging, tumor debulking,
and resection.

PTS: 1
27. ANS: B
In the majority of hernia cases, a history of heavy physical labor or heavy lifting can be elicited.
Right or left lower quadrant pain that may radiate into the groin or testicle is typical. The pain is
usually dull or aching unless strangulated, in which case the pain is more severe. The pain
increases with straining, lifting, or movement of the lower extremities. Physical examination
includes palpating the femoral area and inguinal ring for bulging or tenderness. Ask the patient to
bear down against your hand.

PTS: 1
28. ANS: C
The most common causes of mechanical obstruction are adhesions, almost exclusively in patients
with previous abdominal surgery, hernias, tumors, volvulus, inflammatory bowel disease (Crohn’s
disease, colitis), Hirschsprung’s disease, fecal impaction, and radiation enteritis. Initially, the
patient complains of a cramping periumbilical pain that eventually becomes constant. Physical
examination reveals mild, diffuse tenderness without peritoneal signs, and possibly visible
peristaltic waves. In early obstruction, tinkles, rushes, and borborygmi can be heard. In late
obstruction, bowel sounds may be absent. The diagnosis can be made with flat and upright
abdominal films looking for bowel distension and the presence of multiple air-fluid levels. CT or
MRI may be necessary for confirmation.

PTS: 1
29. ANS: A
Diverticular disease is prevalent in patients over 60 years of age. Since the sigmoid colon has the
smallest diameter of any portion of the colon, it is the most common site for the development of
diverticula. Although the pain can be generalized, it is typically localized to the left lower
abdomen and is accompanied by tenderness, fever, and leukocytosis. Other symptoms can include
constipation or loose stools, nausea, vomiting, and positive stool occult blood. With diverticulitis,
there is an increased risk of perforation, which presents with a more dramatic clinical picture as a
result of peritonitis. Look for signs of peritonitis, such as a positive heel strike test and/or rebound
tenderness.

PTS: 1
30. ANS: A
Viral gastroenteritis is the most common cause of nausea, vomiting, and diarrhea. At least 50% of
cases of gastroenteritis as foodborne illness are due to norovirus. Another 20% of cases, and the
majority of severe cases in children, are due to rotavirus. Other significant viral agents include
adenovirus and astrovirus.

PTS: 1
31. ANS: B
The contents of the vomitus commonly vary according to the level of obstruction. Gastric outlet
obstruction is associated with emesis containing undigested food. Proximal small intestinal
blockage is likely to be bile-stained. Distal intestinal blockage is more likely to contain fecal
matter. The degree of cramping and pain is often related to the proximity of the obstruction, so that
obstructions of the lower intestines may have less severe cramping, vomiting, and/or pain. Bowel
sounds often are high pitched and metallic sounding but may later become absent. Tenderness may
be localized or diffuse. Distention as well as a succussion splash may be present.

PTS: 1
32. ANS: C
The range of neurologic disorders that result in nausea and/or vomiting is broad. Included are
meningitis, increased intracranial pressure (ICP), migraines, a space-occupying lesion, and
Ménière’s disorder. Central nervous system-related vomiting is often projectile and may not be
preceded by nausea. Papilledema may accompany increased ICP. Neurological deficits may be
evident with increased ICP, space-occupying lesions, and meningitis. Nuchal rigidity is a classic
finding for meningitis.

PTS: 1
33. ANS: A
Parasites causing diarrhea usually enter the body through the mouth. They are swallowed and can
remain in the intestine or burrow through the intestinal wall and invade other organs. Certain
parasites, most commonly Giardia lamblia, transmitted by fecally contaminated water or food, can
cause diarrhea, bloating, flatulence, cramps, nausea, anorexia, weight loss, greasy stools because of
its interference with fat absorption, and occasionally fever. Symptoms usually occur about 2 weeks
after exposure and can last 2 to 3 months. Often, the symptoms are vague and intermittent, which
makes diagnosis more difficult. Serial stool samples for O&P should be ordered because a single
sample may not reveal the offending parasite.
 PTS: 1
34. ANS: D
The symptoms and severity of the diarrhea vary according to the underlying cause. The symptoms
of carcinomas are generally insidious. The diarrhea is mild and intermittent. Often malignancies
are found on routine hemoccults, sigmoidoscopy, or colonoscopy. There should be a high index of
suspicion with unexplained weight loss or new-onset iron-deficiency anemia in a patient over 40
years old.

PTS: 1
35. ANS: B
Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by mild to severe
abdominal pain, discomfort, bloating, and alteration of bowel habits. The exact cause is unknown.
In some cases, the symptoms are relieved by bowel movements. Diarrhea or constipation may
predominate, or they may be mixed (classified as IBS-D, IBS-C, or IBS-M, respectively). IBS may
begin after an infection (postinfectious, IBS-PI) or a stressful life event. IBS is a motility disorder
involving the upper and lower GI tracts that causes intermittent nausea, abdominal pain and
distention, flatulence, pain relieved by defecation, diarrhea, and/or constipation. Symptoms usually
occur in the waking hours and may be worsened or triggered by meals. It is three times more
prevalent in women, accounts for more than half of all GI referrals, and is highly correlated with
emotional factors, particularly anxiety and stress.

PTS: 1
36. ANS: B
Medications that frequently cause constipation include:
- Analgesics/narcotics
- Antacids containing aluminum
- Anticonvulsants
- Antidepressants
- Antihypertensives (calcium-channel blockers, beta blockers)
- Antiparkinsonism agents
- Antispasmodics
- Calcium supplements
- Diuretics
- Iron supplements
- Sedatives/tranquilizers

PTS: 1
37. ANS: A
 Cirrhosis develops with the replacement of normal liver tissue by regenerative, fibrotic nodules
and may occur in the late phase of a variety of disorders that damage the liver, such as alcohol
toxicity. A patient may present with jaundice and describe an associated, progressive pattern of
pruritus, weakness, anorexia, nausea, and weight loss. Determine the size and consistency of the
liver as well as any tenderness. The scratch test is a method used to ascertain the location and size
of a patient's liver during a physical assessment. The scratch test uses auscultation to detect the
differences in sound transmission through the abdominal cavity over solid and hollow organs and
spaces. After placing a stethoscope over the approximate location of a patient's liver, the examiner
will then scratch the skin of the patient's abdomen lightly, moving laterally along the liver border.
When the liver is encountered, the scratching sound heard in the stethoscope will increase
significantly. In this manner, the size and shape of a patient's liver can be ascertained.

PTS: 1
38. ANS: C
Occlusion of the common bile duct may occur with disorders of the gallbladder and/or bile duct,
such as cholecystitis, cholelithiasis, and cholangitis. All three conditions are generally
accompanied by RUQ discomfort, anorexia, and nausea. Charcot’s triad, which includes jaundice,
RUQ pain, and fever/chills, is common to problems resulting in obstructions of the bile duct.

PTS: 1
39. ANS: D
Patients with portal hypertension may develop GI bleeding from varices of the esophagus,
stomach, intestines, or other sites. Portal hypertension is most commonly associated with cirrhosis,
usually caused by alcohol abuse or hepatitis. Check for signs of liver disease, including jaundice,
cirrhosis, telangiectasia, hepatomegaly, and RUQ tenderness. Ascites occurs due to venous
congestion. Caput medusa is the distension of paraumbilical veins due to portal hypertension.

PTS: 1
40. ANS: A
Upper GI hemorrhage may result from a tear at the gastroesophageal junction, known as a
Mallory-Weiss tear. A patient may develop more than one tear. These tears are most common in
alcoholic or bulimic patients following repeated episodes of vomiting or severe retching. If a
laceration/tear of the mucosa causes GI bleeding, the patient may demonstrate alterations in
hemodynamic status.

PTS: 1
41. ANS: C
Bleeding occurs after an area of gastric mucosal injury has ulcerated. Explore symptoms of
epigastric and/or periumbilical discomfort. Identify potential causes of gastric mucosal injury—the
most common being NSAID use and stress. Many elderly individuals self-medicate with
over-the-counter aspirin preparations and various NSAIDs. Commonly, they use too many
medications that have side effects of gastric irritation.

PTS: 1
42. ANS: D
 Primary or metastatic cancers of the liver and/or pancreas can cause obstructive
hyperbilirubinemia and jaundice. Jaundice may be the initial sign of a malignancy or may follow
the development of other symptoms. Ask about associated symptoms, such as RUQ discomfort,
nausea, fever, back pain, weight loss, fatigue/weakness, and pruritus. None of these symptoms are
specific to malignancy; however, other causes of jaundice are less likely to be associated with
weight loss. During the abdominal examination, carefully palpate the area of the liver and the
remainder of the abdomen, checking for masses or unexpected findings. In addition to a CBC, liver
functions, amylase, lipase, and bilirubin levels, abdominal CT and/or ultrasound should be ordered
promptly.

PTS: 1
43. ANS: B
AFP can help diagnose and guide the treatment of liver cancer (hepatocellular carcinoma). CA-125
is the standard tumor marker used to follow women during or after treatment for epithelial ovarian
cancer (the most common type of ovarian cancer) as well as fallopian tube cancer and primary
peritoneal cancer. Serum beta HCG is a pregnancy marker. CEA is not used to diagnose or screen
for colorectal cancer, but it’s the preferred tumor marker to help predict outlook in patients with
colorectal cancer. The higher the CEA level at the time colorectal cancer is detected, the more
likely it is that the cancer is advanced.

PTS: 1
44. ANS: A
The most common cause of lower GI bleeding is hemorrhoids. The bleeding associated with
hemorrhoids is usually evident as red blood on the formed stool, in the toilet bowl, or on the toilet
tissue following a bowel movement. Patients with hemorrhoids often complain of rectal discomfort
as well as the contributing factors for hemorrhoid development, including constipation. Inspect the
perianal rectal tissue. Anoscopy may be indicated. Perform a digital rectal examination to assess
internal haemorrhoids.

PTS: 1