1. Holcomb, Susan Simmons ARNP-BC, PhD

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Joshua Phelps, 37, arrives at the ED complaining of right lower quadrant abdominal pain. You obtain his vital signs and find out that he has no known allergies and takes no medications. His BP is 156/94; pulse, 100 and regular; respirations, 20; and temperature, 99.6[degrees] F (37.6[degrees] C).

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1. What's the next step in investigating his problem?


a. Perform a physical assessment.


b. Alert the healthcare provider to his arrival.


c. Connect him to a cardiac monitor.


d. Gather a detailed history of his current complaint.


Mr. Phelps' pain began last evening and is associated with nausea, but he hasn't vomited. Eating doesn't seem to affect the pain, and he hasn't had any bowel or bladder changes.



2. In assessing Mr. Phelps' pain, what information should you obtain?


a. onset, location, and duration


b. intensity and quality


c. aggravating and relieving factors


d. all of the above


Mr. Phelps describes his pain as constant, deep and achy, and worse with movement. On a pain scale of 0 to 10, with 10 being the worst pain he's ever experienced, he rates the pain at a 7. He doesn't want to lie supine and is guarding his right lower quadrant.



3. When assessing Mr. Phelps' abdomen, which assessment should you dolast?


a. palpation


b. auscultation


c. inspection


d. percussion


Abdominal assessment shows a normal inspection, normoactive bowel sounds, and no masses, enlargement, or tenderness of the liver or spleen. However, Mr. Phelps did display rebound tenderness and positive Rovsing, obturator, and psoas signs. Based on his history and physical assessment, the healthcare provider orders a complete blood cell count and urinalysis. The results indicate a total white blood cell (WBC) count of 15,000/mm3 with 96% neutrophils. The urinalysis is normal.



4. Mr. Phelps' signs and symptoms, history, physical assessment, and lab findings suggest which diagnosis?


a. abdominal aortic dissection


b. acute appendicitis


c. renal calculi


d. acute cholecystitis



5. The healthcare provider decides to order imaging studies. Which of the following ismost likelyto confirm or rule out this diagnosis?


a. a computed tomography (CT) scan with contrast of the abdomen and pelvis


b. abdominal X-rays


c. magnetic resonance imaging (MRI) of the abdomen and pelvis


d. ultrasound of the abdomen and pelvis




1. d. History of the present illness is the most important aspect of the exam and should include all signs and symptoms. If the patient complains of nausea and vomiting and changes in bowel habits, find out if he's traveled recently, if his water supply has changed, if he's swum in lakes or public swimming pools, or if he's been exposed to other areas of concern made public by the health department, such as food recalls or contaminated waterways.


2. d. Find outwhen the pain began; its location, quality, and intensity; whether it's constant or intermittent; what makes it worse or better; and any associated signs and symptoms. Ask the patient if the pain wakes him at night. Try to have him objectively rate his pain by using a valid and reliable pain intensity rating scale.


3. a. When you do an abdominal exam, always perform palpation last because it may stimulate peristalsis and change baseline auscultation data. Palpation may also induce pain that impedes further examination. Always begin palpation on the asymptomatic side, and perform light palpation before deep palpation.


4. b. Right lower quadrant abdominal pain is a typical sign of acute appendicitis in adults. Rebound tenderness, positive psoas and obturator signs, and a WBC count over 10,000/mm3 with an increase in neutrophils (left shift) all increase the likelihood of the diagnosis.


Rebound tenderness suggests peritoneal inflammation, as from appendicitis. Rebound tenderness is present if, when you slowly and firmly press your fingers into the area of tenderness, the patient's pain worsens when you quickly lift them. Pain in the patient's right lower quadrant when you apply pressure to his left lower quadrant (a positive Rovsing sign) also suggests appendicitis.


To look for a psoas sign, have the patient lie supine. Place your hand on his thigh just above his right knee and ask him to raise that thigh against your hand. If this maneuver increases his abdominal pain, the psoas sign is positive.


To look for an obturator sign, flex his right thigh at the hip. With his knee bent, rotate his leg internally at the hip. The obturator sign is positive when this action reproduces right lower quadrant abdominal pain.


Leukocytosis can indicate infection or necrosis; a predominance of neutrophils in the differential usually signals bacterial infection.


5. a. There's no gold standard for imaging studies to detect appendicitis, but a CT scan is generally the study of choice because it's usually more available and less expensive than MRI and more reliable than abdominal X-rays or ultrasound. Findings of the CT scan of Mr. Phelps' abdomen and pelvis are consistent with acute appendicitis without perforation. He's diagnosed with acute appendicitis and scheduled for surgery.



Miller SK, Alpert PT. Assessment and differential diagnosis of abdominal pain. Nurse Pract. 2006; 31(7):38-47.


Richardson E, Paulson CP, Hitchcock K, Gerayli F. History, exam, and labs: Is one enough to diagnose acute adult appendicitis? J Fam Pract. 2007; 56(6):474-476.


Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. [Context Link]