Advanced Health Assessment & Clinical Diagnosis in Primary Care 5th Edition by Joyce E. Dains – Test Bank

Complete Test Bank With Answers

 

Sample Questions Posted Below

 

 

Chapter 3. 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

pregnancy is suspected, the following procedure is most important:

.
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 3. 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. 1. Starting in the midclavicular line at about the 3rd intercostal space, lightly percuss and move down.
2. 2. Percuss inferiorly until dullness denotes the liver’s upper border (usually at fifth intercostal space in MCL).
3. 3. Resume percussion from below the umbilicus on the midclavicular line in an area of tympany.
4. 4. Percuss superiorly until dullness indicates the liver’s inferior border.
5. 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.

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.

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.

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.

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.

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.

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.

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