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Bates’ Guide to Physical Examination and History Taking, 12th Edition

Chapter 11: The Abdomen

Multiple Choice

1. A 52-year-old secretary comes to your office, complaining about accidentally leaking urine
when she coughs or sneezes. She says this has been going on for about a year now. She relates
that she has not had a period for 2 years. She denies any recent illness or injuries. Her past
medical history is significant for four spontaneous vaginal deliveries. She is married and has four
children. She denies alcohol, tobacco, or drug use. During her pelvic examination you note some
atrophic vaginal tissue, but the remainder of her pelvic, abdominal, and rectal examinations are
unremarkable.
Which type of urinary incontinence does she have?
A) Stress incontinence
B) Urge incontinence
C) Overflow incontinence GRADESMORE.COM

Ans: A
Chapter: 11

Feedback: Stress incontinence usually occurs when the intra-abdominal pressure goes up
during coughing, sneezing, or laughing. This is usually due to a weakness of the pelvic floor,
with inadequate muscle support of the bladder. Vaginal deliveries and pelvic surgery are often
associated with these symptoms. Usually female patients are postmenopausal when stress
incontinence begins. Kegel exercises are usually recommended to strengthen the pelvic floor
muscles.

2. A 46-year-old former salesman presents to the ER, complaining of black stools for the past
few weeks. His past medical history is significant for cirrhosis. He has gained weight recently,
especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and
has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and
smoked crack in the past. He denies any recent use. He is currently unemployed and has never
been married. On examination you find a man appearing older than his stated age. His skin has a
yellowish tint and he is thin, with a prominent abdomen. You note multiple “spider angiomas” at
the base of his neck. Otherwise, his heart and lung examinations are normal. On inspection he

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has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation.
Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small
and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his
rectal examination.
What cause of black stools most likely describes his symptoms and signs?
A) Infectious diarrhea
B) Mallory-Weiss tear
C) Esophageal varices

Ans: C
Chapter: 11

Feedback: Varices are often found in alcoholic patients, but only when they have a diagnosis of
significant cirrhosis. This patient has symptoms of cirrhosis, including jaundice, ascites, spider
hemangiomas, and dilated veins on his abdomen (caput medusa).

3. A 21-year-old receptionist comes to your clinic, complaining of frequent diarrhea. She states
that the stools are very loose and there is some cramping beforehand. She states this has occurred
on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool.
Occasionally she has periods of constipation, but that is rare. She thinks the diarrhea is much
worse when she is nervous. Her pastGmedical
RADEShistory
MOREis.not
COMsignificant. She is single and a junior
in college majoring in accounting. She smokes when she drinks alcohol but denies using any
illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable.
What is most likely the etiology of her diarrhea?
A) Secretory infections
B) Inflammatory infections
C) Irritable bowel syndrome
D) Malabsorption syndrome

Ans: C
Chapter: 11

Feedback: Irritable bowel syndrome will cause loose bowel movements with cramps but no
systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely in young
women with alternating symptoms of loose stools and constipation. Stress usually makes the
symptoms worse, as do certain foods.

4. A 42-year-old florist comes to your office, complaining of chronic constipation for the last 6
months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She
denies any recent illnesses or injuries. She denies any changes to her diet or exercise program.

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She is on no new medications. During the review of systems you note that she has felt fatigued,
had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is
significant for one vaginal delivery and two cesarean sections. She is married, has three children,
and owns a flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2
diabetes and her father has coronary artery disease. There is no family history of cancers. On
examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose,
throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are
also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed
in response to a blow with the hammer, especially the Achilles tendons.
What is the best choice for the cause of her constipation?
A) Large bowel obstruction
B) Irritable bowel syndrome
C) Rectal cancer
D) Hypothyroidism

Ans: D
Chapter: 11

Feedback: Many metabolic conditions can interfere with bowel motility. In this case the patient
has many symptoms of hypothyroidism, including cold intolerance, weight gain, fatigue,
constipation, and irregular menstrual cycles. On examination, thyromegaly and delayed reflexes
can help to make the diagnosis. Medication will usually correct these symptoms.

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5. A 22-year-old law student comes to your office, complaining of severe abdominal pain
radiating to his back. He states it began last night after hours of heavy drinking. He has had
abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep
any food or water down, and these symptoms have been going on for almost 12 hours. He has
had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking
or using illegal drugs but admits to drinking 6 to 10 beers per weekend night. He admits that last
night he drank something like 14 drinks. On examination you find a young male appearing his
stated age in some distress. He is leaning over on the examination table and holding his abdomen
with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal
examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and
epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The
remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular
examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood
work is pending.
What etiology of abdominal pain is most likely causing his symptoms?
A) Peptic ulcer disease
B) Biliary colic
C) Acute cholecystitis
D) Acute pancreatitis

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Ans: D
Chapter: 11

Feedback: Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates
into the back. There is often a history of long-standing gallbladder disease or recent alcohol
ingestion. Severe abdominal pain and vomiting are often seen. Medications such as proton pump
inhibitors can also cause pancreatitis in people without these other risk factors. Treatment
includes hydration, pain management, and bowel rest.

6. A 76-year-old retired farmer comes to your office complaining of abdominal pain,

constipation, and a low-grade fever for about 3 days. He denies any nausea, vomiting, or
diarrhea. The only unusual thing he remembers eating is two bags of popcorn at the movies with
his grandson, 3 days before his symptoms began. He denies any other recent illnesses. His past
medical history is significant for coronary artery disease and high blood pressure. He has been
married for over 50 years. He denies any tobacco, alcohol, or drug use. His mother died of colon
cancer and his father had a stroke. On examination he appears his stated age and is in no acute
distress. His temperature is 100.9 degrees and his other vital signs are unremarkable. His head,
cardiac, and pulmonary examinations are normal. He has normal bowel sounds and is tender over
the left lower quadrant. He has no rebound or guarding. His rectal examination is unremarkable
and his fecal occult blood test is negative. His prostate is slightly enlarged but his testicular,
penile, and inguinal examinations areGall
RAnormal.
DESMOBlood
RE.CworkOM is pending.
What diagnosis for abdominal pain best describes his symptoms and signs?
A) Acute diverticulitis
B) Acute cholecystitis
C) Acute appendicitis
D) Mesenteric ischemia

Ans: A
Chapter: 11

Feedback: Diverticulitis is caused by localized infections within the colonic diverticula.

Constipation, fever, and abdominal pain are common. Mesenteric ischemia classically presents in
older people with a history of vascular disease elsewhere. The typical pain is unusual in that it is
not made worse by examination despite being severe. Some mistake this feature to indicate
malingering, with bad results.

7. A 77-year-old retired bus driver comes to your clinic for a physical examination at his wife's
request. He has recently been losing weight and has felt very fatigued. He has had no chest pain,
shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer,
for which he had surgery, and arthritis. He has been married for over 40 years. He denies any

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tobacco or drug use and has not drunk alcohol in over 40 years. His parents both died of cancer
in their 60s. On examination his vital signs are normal. His head, cardiac, and pulmonary
examinations are unremarkable. On abdominal examination you hear normal bowel sounds, but
when you palpate his liver it is abnormal. His rectal examination is positive for occult blood.
What further abnormality of the liver was likely found on examination?
A) Smooth, large, nontender liver
B) Irregular, large liver
C) Smooth, large, tender liver

Ans: B
Chapter: 11

Feedback: With his past history of colon cancer and with recent weight loss and fatigue, a
relapse of his colon cancer would be expected. Colon cancer usually metastasizes to the liver,
creating hard, irregular nodules, which can sometimes be palpated on examination. A smooth,
large liver which is tender is often seen in hepatitis.

8. A 26-year-old sports store manager comes to your clinic, complaining of severe right-sided
abdominal pain for 12 hours. He began having a stomachache yesterday, with a decreased
appetite, but today the pain seems to be just on the lower right side. He has had some nausea and
vomiting but no constipation or diarrhea.
GRAHisDESlast
MObowel
RE.Cmovement
OM was last night and was
normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical
history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six
beers per week. His mother has breast cancer and his father has coronary artery disease. On
examination he appears ill and is lying on his right side. His temperature is 100.4 and his heart
rate is 110. His bowel sounds are decreased and he has rebound and involuntary guarding, one
third of the way between the anterior superior iliac spine and the umbilicus in the right lower
quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal.
What is the most likely cause of his pain?
A) Acute appendicitis
B) Acute mechanical intestinal obstruction
C) Acute cholecystitis
D) Mesenteric ischemia

Ans: A
Chapter: 11

Feedback: Appendicitis is common in the young and usually presents with periumbilical pain
that localizes to the right lower quadrant in an area known as McBurney's Point, described above
as one third of the way between the anterior superior iliac spine and the umbilicus on the right.
Rebound and guarding are common. Remote rebound or Rovsing's sign is also seen commonly
when the course of appendicitis is advanced. Bowel movements are usually unaffected.

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9. A 15-year-old high school freshman is brought to the clinic by his mother because of chronic
diarrhea. The mother states that for the past couple of years her son has had diarrhea after many
meals. The patient states that the diarrhea seems the absolute worst after his school lunches. He
describes his symptoms as cramping abdominal pain and gas followed by diarrhea. His stools are
watery with no specific smell. He denies any nausea, vomiting, constipation, weight loss, or
fatigue. He has had no recent illness, injuries, or foreign travel. His past medical history is
unremarkable. He denies tobacco, alcohol, or drug use. His parents are both healthy. On
examination you see a relaxed young man breathing comfortably. His vital signs are normal and
his head, eyes, ears, throat, neck, cardiac, and pulmonary examinations are normal. His abdomen
is soft and nondistended. His bowel sounds are active and he has no tenderness, no enlarged
organs, and no rebound or guarding. His rectal examination is nontender with no blood on the
glove. You collect a stool sample for further study.
What is the most likely explanation for this patient's chronic diarrhea?
A) Malabsorption syndrome
B) Osmotic diarrhea
C) Secretory diarrhea

Ans: B
Chapter: 11

Feedback: Usually related to lactose

GRintolerance,
ADESMORwatery
E.COdiarrhea
M often follows meal ingestion.
Crampy abdominal pain, distension, and gas often accompany symptoms. Diarrhea is often
provoked by pizza, milkshakes, yogurt, and other lactose-containing foods. This condition is
more common in African-Americans, Latinos, Native Americans, and Asians.

10. A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back
pain radiating down into her groin. It began in the middle of the night and woke her up suddenly.
It hurts in her bladder to urinate but she has no burning on the outside. She has had no frequency
or urgency with urination but she has seen blood in her urine. She has had nausea with the pain
but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history
is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high
blood pressure and her father is healthy. On examination she looks her stated age and is in
obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and
abdominal examinations are unremarkable. She has tenderness just inferior to the left
costovertebral angle. Her urine pregnancy test is negative and her urine analysis shows red blood
cells.
What type of urinary tract pain is she most likely to have?
A) Kidney pain (from pyelonephritis)
B) Ureteral pain (from a kidney stone)
C) Musculoskeletal pain

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D) Ischemic bowel pain

Ans: B
Chapter: 11

Feedback: The pain from a kidney stone causes dramatic, severe, colicky pain at the
costovertebral angle that radiates across the flank and down into the groin.

11. Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at
his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable
position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk,
because any motion makes the pain much worse. It is localized just medial and inferior to his
iliac crest on the right. Which of the following is most likely?
A) Peptic ulcer
B) Cholecystitis
C) Pancreatitis
D) Appendicitis

Ans: D
Chapter: 11
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Feedback: This is a classic history for appendicitis. Notice that the pain has changed from
visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong
consideration.

12. Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or
more at a time and has started recently. Which of the following should be considered?
A) Peptic ulcer
B) Pancreatitis
C) Myocardial ischemia
D) All of the above

Ans: D
Chapter: 11

Feedback: Epigastric pain can have many causes. History and physical will help discern which
causes are most likely, but it is important to realize that any of the above, including myocardial
ischemia, is always a possibility. Pneumonia and gallbladder pain can also cause pain in this
location.

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13. Monique is a 33-year-old administrative assistant who has had intermittent lower
abdominal pain approximately one week a month for the past year. It is not related to her
menses. She notes relief with defecation, and a change in form and frequency of her bowel
movements with these episodes. Which of the following is most likely?
A) Colon cancer
B) Cholecystitis
C) Inflammatory bowel disease
D) Irritable bowel syndrome

Ans: D
Chapter: 11

Feedback: Although colon cancer should be a consideration, these symptoms are intermittent
and no note is made of progression. Cholecystitis usually presents with right upper quadrant
pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there
is relief with defecation and there are no mentioned structural or biochemical abnormalities,
irritable bowel syndrome seems most likely. This is a very common condition which can be
triggered by certain foods and stress.

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14. Jim is a 60-year-old man who presents with vomiting. He denies seeing any blood with
emesis, which has been occurring for 2 days. He does note a dark, granular substance resembling
the coffee left in the filter after brewing. What do you suspect?
A) Bleeding from a diverticulum
B) Bleeding from a peptic ulcer
C) Bleeding from a colon cancer
D) Bleeding from cholecystitis

Ans: B
Chapter: 11

Feedback: When blood is exposed to the environment of the stomach, it often resembles
“coffee grounds.” This is not always recognized by patients as blood, so it is important to inquire
about this. This symptom is not common in cholecystitis, and the other possibilities occur lower
in the intestine. It should be noted that conversely, rapid bleeding from the stomach or other
upper gastrointestinal source can produce bright red blood in the stool. Do not rule out proximal
bleeding on the basis of the absence of “coffee grounds.” Likewise, bright red blood seen with
emesis may originate from the stomach. Black, sticky stools also can accompany upper GI
bleeding.

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15. A daycare worker presents to your office with jaundice. She denies IV drug use, blood
transfusion, and travel and has not been sexually active for the past 10 months. Which type of
hepatitis is most likely?
A) Hepatitis A
B) Hepatitis B
C) Hepatitis C
D) Hepatitis D

Ans: A
Chapter: 11
Feedback: The lack of contact with blood and body fluids makes hepatitis B, C, and D
unlikely. She regularly changes the diapers of her clients and is at risk for hepatitis A. Vaccine
against hepatitis A is recommended for daycare workers.

16. Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the
right side. The pain eventually moved to her lateral abdomen and then into her right lower
quadrant. Which is most likely, given this presentation?
A) Appendicitis
B) Dysmenorrhea GRADESMORE.COM
C) Ureteral stone
D) Ovarian cyst

Ans: C
Chapter: 11

Feedback: The presentation of right flank pain spiraling down to the groin is typical of a
ureteral stone. There would most likely be microscopic hematuria as well. The migration pattern
of this condition makes the others less likely.

17. Mrs. LaFarge is a 60-year-old who presents with urinary incontinence. She is unable to get
to the bathroom quickly enough when she senses the need to urinate. She has normal mobility.
Which of the following is most likely?
A) Stress incontinence
B) Urge incontinence
C) Overflow incontinence
D) Functional incontinence

Ans: B

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Chapter: 11

Feedback: Stress incontinence occurs with increased intra-abdominal pressure such as with
coughing, sneezing, or laughing. This history is most consistent with urge incontinence
secondary to detrusor overactivity. Overflow incontinence occurs with anatomic obstruction such
as prostatic hypertrophy (obviously not in this case, as the patient is a woman), urethral stricture,
or neurogenic bladder. Functional incontinence results from lack of mobility severe enough to
impair getting to the bathroom quickly enough.

18. Which is the proper sequence of examination for the abdomen?

A) Auscultation, inspection, palpation, percussion
B) Inspection, percussion, palpation, auscultation
C) Inspection, auscultation, percussion, palpation
D) Auscultation, percussion, inspection, palpation

Ans: C
Chapter: 11

Feedback: The abdominal examination is conducted in a sequence different from other

systems, for which the usual order is inspection, percussion, palpation, and auscultation. Because
palpation may actually cause some bowel
GRADnoise
ESMwhen
ORE. the
CObowels
M are not moving, auscultation is
performed before percussion and palpation in an abdominal examination.

19. A 62-year-old woman has been followed by you for 3 years and has had recent onset of
hypertension. She is still not at goal despite three antihypertensive medicines, and you strongly
doubt nonadherence. Her father died of a heart attack at age 58. Today her pressure is 168/94 and
pressure on the other arm is similar. What would you do next?
A) Add a fourth medicine
B) Refer to nephrology
C) Get a CT scan
D) Listen closely to her abdomen

Ans: D
Chapter: 11

Feedback: At this point, it is important to consider secondary causes for this woman's
hypertension because of its severity, rapidity of progression, and lack of response to therapy.
While you will most likely add a fourth medicine, it is important to carefully examine the
abdomen for the presence of renal artery bruits. These are usually heard best in the upper
quadrants. It may be necessary to have the patient hold her breath, to have a very quiet room, and

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to listen with the diaphragm for a very soft, high-pitched sound with systole. It may also help to
simultaneously feel the patient's pulse (a bruit with both a systolic and diastolic component is
very specific for a significant blockage, while a lone systolic bruit may not be abnormal).
Obtaining a CT scan is not likely to be useful, and you may save the delay, expense, and
inconvenience of a nephrology referral if you can hear a bruit.

20. Mr. Patel is a 64-year-old man who was told by another care provider that his liver is
enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no
knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below
the costal arch. Which of the following would you do next?
A) Check an ultrasound of the liver
B) Obtain a hepatitis panel
C) Determine liver span by percussion
D) Adopt a “watchful waiting” approach

Ans: C
Chapter: 11

Feedback: A liver edge palpable this far below the costal arch should not be ignored.
Ultrasound and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel
has developed emphysema with flattening
GRADofES the
MOdiaphragms.
RE.COM This pushes a normal-sized liver
below the costal arch so that it appears to be enlarged. A liver span should be determined by
percussing down the chest wall until dullness is heard. A measurement is then made between this
point and the lower border of the liver to determine its span; 6–12 centimeters in the
mid-clavicular line is normal. Percussion is the only way to assess liver size on examination, and
in this case it saved the patient much inconvenience and expense.

21. Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents
with fairly significant left upper quadrant pain. On examination of this area a rough grating noise
is heard. What is this sound?
A) It is a splenic rub.
B) It is a variant of bowel noise.
C) It represents borborygmi.
D) It is a vascular noise.

Ans: A
Chapter: 11

Feedback: A rough, grating noise over this area represents a splenic rub, which can accompany
splenic infarction. Rubs also occur over the liver and pleura and pericardium.

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22. You are palpating the abdomen and feel a small mass. Which of the following would you
do next?
A) Ultrasound
B) Examination with the abdominal muscles tensed
C) Surgery referral
D) Determine size by percussion

Ans: B
Chapter: 11

Feedback: It is easy to determine whether the mass is actually in the abdominal wall versus in
the abdomen by palpating with the abdominal wall tensed. This can be accomplished by having
the patient lift her head off the bed while supine. Usually, abdominal wall masses can be
observed, whereas intra-abdominal masses are more concerning.

23. Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice
dullness in the last intercostal space in
GRthe
ADanterior
ESMORaxillary
E.COM line on his left side with a deep
breath. What does this indicate?
A) His spleen is definitely enlarged and further workup is warranted.
B) His spleen is possibly enlarged and close attention should be paid to further examination.
C) His spleen is possibly enlarged and further workup is warranted.
D) His spleen is definitely normal.

Ans: B
Chapter: 11

Feedback: This scenario is not uncommon in infectious mononucleosis. The presence of

dullness with inspiration should definitely increase your attention to further examination of the
spleen, although dullness can occur in normal patients too.

24. A young patient presents with a left-sided mass in her abdomen. You confirm that it is
present in the left upper quadrant. Which of the following would support that this represents an
enlarged kidney rather than her spleen?
A) A palpable “notch” along its edge
B) The inability to push your fingers between the mass and the costal margin
C) The presence of normal tympany over this area

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D) The ability to push your fingers medial and deep to the mass

Ans: C
Chapter: 11

Feedback: A left upper quadrant mass is more likely to be a kidney if there is no palpable
“notch,” you can push your fingers between the mass and the costal margin, there is normal
tympany over this area, and you cannot push your fingers medial and deep to the mass. These
findings are very difficult to appreciate in an obese patient.

25. Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the
midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the
symphysis pubis. What does this most likely represent?
A) Sigmoid mass
B) Tumor in the abdominal wall
C) Hernia
D) Enlarged bladder

Ans: D
Chapter: 11
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Feedback: It is possible that this represents a sigmoid colon mass, but this is less likely than an
enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently
cause partial urinary obstruction with bladder enlargement. If the mass resolves with
catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic
bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A
hernia would most likely not be dull to percussion. Midline abdominal wall tumors of this size
would be unusual but could be discerned by having the patient tense his abdominal muscles.

26. Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note
that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What
should you do next?
A) Obtain abdominal ultrasound
B) Reassess by examination in 6 months
C) Reassess by examination in 3 months
D) Refer to a vascular surgeon

Ans: A
Chapter: 11

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Feedback: A pulsatile mass in this man should be followed up with ultrasound as soon as
possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4
centimeters. It would be inappropriate to recheck him at a later time without taking action.
Likewise, referral to a vascular surgeon before ultrasound may be premature.

27. Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the
following would argue for the presence of ascites?
A) Bilateral flank tympany
B) Dullness which remains despite change in position
C) Dullness centrally when the patient is supine
D) Tympany which changes location with patient position

Ans: D
Chapter: 11

Feedback: A diagnosis of ascites is supported by findings that are consistent with movement of
fluid and gas with changes in position. Gas-filled loops of bowel tend to float so that dullness
when supine would argue against this. Likewise, because fluid gathers in dependent areas, the
flanks should ordinarily be dull with ascites. Tympany which changes location with patient
position (“shifting dullness”) would support the presence of ascites. A fluid wave and edema
would support this diagnosis as well.GRADESMORE.COM

28. Which of the following is consistent with obturator sign?

A) Pain distant from the site used to check rebound tenderness
B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated
C) Pain with extension of the right thigh while the patient is on her left side or while pressing
her knee against your hand with thigh flexion
D) Pain that stops inhalation in the right upper quadrant

Ans: B
Chapter: 11

Feedback: Obturator sign is seen in appendicitis. It is pain with the stretching of the internal
obturator muscle because of inflammation. Pain distant from the site used to check rebound
tenderness is Rovsing's sign and is a reliable sign of peritonitis. Answer “C” describes psoas
sign, which is also seen in appendicitis. Palpation in the right upper quadrant that causes pain
severe enough to stop inhalation is consistent with inflammation of the gallbladder and is called
Murphy's sign.

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29. An elderly woman with a history of coronary bypass comes in with severe, diffuse,
abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on
the abdomen. What do you suspect?
A) Malingering
B) Neuropathy
C) Ischemia
D) Physical abuse

Ans: C
Chapter: 11

Feedback: Ischemic pain can be severe but is not made worse with palpation. The history of
bypass could be a clue that there is vascular narrowing elsewhere. Malingering is less likely, and
neuropathic pain, as seen in herpes zoster, would worsen with touch. You are to be commended
if you considered elder abuse, because this is frequently missed. Ordinarily, this pain would be
worse with examination because of the preceding trauma.

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