| Course | NR 509 Advanced Physical Assessment |
|---|---|
| Week | 5 |
| Paper type | Linked focused exam write-up |
| Length | About 1,160 words, 3 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, nurse practitioner core |
| Updated | October 2026 |
Free sample paper for NR 509 Week 5
Two Linked Examinations for One Swollen Abdomen: Ascites and a Large Liver Without the Signs of Cirrhosis in a 63-Year-Old Man, Which Sent the Examination to His Neck Veins and Heart
Student Name
College of Nursing, Chamberlain University
NR 509: Advanced Physical Assessment
Instructor Name
Month Day, Year
Two Linked Examinations for One Swollen Abdomen: Ascites and a Large Liver Without the Signs of Cirrhosis in a 63-Year-Old Man, Which Sent the Examination to His Neck Veins and Heart
The Presenting Question That Opens Both
Mr. E. V., 63, a retired high school band director, reports three months of increasing abdominal girth, ankle swelling and tiredness on stairs. His belt has moved out two notches. He drinks one beer a week and has never drunk heavily. He has no known liver disease and no hepatitis risk factors he is aware of. At age 28 he was treated for Hodgkin lymphoma with chemotherapy and radiation to the chest, and has been in remission since. The presenting question is simple: why is fluid collecting in his abdomen and legs? The examination begins where the complaint is, in the abdomen, and follows the answer where it leads, using the sequence of inspection, auscultation, percussion and palpation for the abdomen and the standard approach to the neck veins and precordium (Bickley et al., 2021).
First System: The Abdomen, Examined to Depth
Inspection, supine: Abdomen protuberant with bulging flanks; umbilicus flat, not everted. No visible dilated veins on the abdominal wall. No scars other than a healed biopsy scar in the left neck.
Auscultation: Bowel sounds present in all quadrants. No bruits over the aorta, renal arteries or liver.
Percussion: Tympany over the central abdomen with dullness in both flanks. Shifting dullness present: with the patient turned onto his left side, the dullness on the right flank moved toward the midline and became tympanic, and the border of dullness shifted about 5 cm. Fluid wave present: with the patient's own hand pressing down along the midline, a tap on one flank was felt on the other.
Liver: Upper border of dullness at the fifth intercostal space in the right midclavicular line; lower edge felt 4 cm under the right rib margin as he breathed in deeply, smooth, firm, mildly tender, not nodular. No pulsation of the liver felt with one hand over the anterior liver and one behind. Spleen: Not palpable in the right lateral decubitus position; Traube's space tympanic.
Signs sought for chronic liver disease: Specifically looked for and absent: jaundice of the sclerae or skin, spider angiomata on the face, chest and upper arms, palmar erythema, gynecomastia, testicular atrophy, asterixis, and dilated periumbilical veins.
The abdominal examination establishes that he has ascites, with shifting dullness and a fluid wave both present, and an enlarged, smooth, tender liver (McGee, 2022).
The Transition, Made Explicit
The abdominal findings raise a question they cannot answer. Ascites with a large liver could come from cirrhosis, but the signs that usually accompany cirrhosis severe enough to cause ascites are all absent, and he has no history of alcohol or hepatitis. A smooth, enlarged, tender liver with ascites and ankle edema is also what a liver congested from behind looks like, when the right side of the heart cannot accept venous return. That possibility is tested at the neck and chest. The second examination is therefore not a routine addition; it is the next step in answering the question the abdomen raised.
Second System: The Cardiovascular Examination on Its Own Terms
Jugular venous pressure: Reclining at roughly 45 degrees, the top of the internal jugular pulsation was seen at the angle of the jaw; sitting upright, it was 8 cm above the sternal angle, giving an estimated venous pressure of about 13 cm of water. The pulsation showed a prominent, rapid collapse after the peak, the y descent.
Kussmaul sign: On deep inspiration, the jugular venous pressure rose rather than fell. Present.
Abdominojugular test: Firm pressure over the mid-abdomen for 10 seconds raised the jugular column by about 4 cm, sustained until pressure was released. Positive.
Precordium: No visible or palpable heave; apical impulse difficult to feel. Heart sounds soft. An early diastolic sound, sharper and earlier than a third heart sound, heard best at the left lower sternal border, consistent with a pericardial knock. No murmurs or rub.
Lungs: Clear to auscultation bilaterally; no crackles; no dullness at the bases. Peripheral: Pitting edema 2+ to the mid-shin, both legs. Radial pulse regular, 94 beats per minute; on quiet inspiration, the pulse volume did not fall noticeably. Blood pressure 112/74 mm Hg.
Negatives Sorted by the System They Qualify
Negatives for the abdomen, against cirrhosis: no jaundice, spider angiomata, palmar erythema, gynecomastia, asterixis or caput medusae, and no palpable spleen, which is often enlarged in portal hypertension. Negatives for the heart, against left-sided failure: clear lungs, no crackles, no displaced apical impulse and no murmur. Negatives for the heart, against tamponade: no marked fall in pulse volume on inspiration. Each set qualifies a different alternative, and keeping them apart shows which diagnosis each one argues against.
An Assessment That Uses Both
Taken together, the two examinations point away from the liver as the source and toward the heart. The ascites and the congested liver found in the first examination are explained by the raised venous pressure found in the second. The particular pattern of the neck veins, a pressure that rises with inspiration and a prominent y descent, with an early diastolic knock, quiet heart sounds and clear lungs, is characteristic of a heart whose filling is restricted by a stiff pericardium (McGee, 2022). His history of chest radiation decades ago is a recognized cause of constrictive pericarditis.
Assessment: Ascites and congestive hepatomegaly with elevated jugular venous pressure, Kussmaul sign and a probable pericardial knock, most consistent with constrictive pericarditis, possibly radiation-related. Alternatives: restrictive cardiomyopathy, also possible after radiation and hard to distinguish at the bedside; isolated right heart failure; and, less likely, cirrhosis. Plan: Echocardiography with attention to respiratory variation in filling; natriuretic peptide; diagnostic paracentesis, in which a high ascitic protein with a high serum-ascites albumin gradient would favor a cardiac cause over cirrhosis; and cardiology referral for pericardial imaging and possibly catheterization.
Why the Order of Examination Mattered
Had the examination started with the heart as a routine step and finished with the abdomen, the same findings would have been recorded, but the reasoning connecting them might not have been. Ascites in a man with no liver history is easy to label as "probable cirrhosis" and send for liver tests. It was the absence of every expected sign of chronic liver disease, noted deliberately during the abdominal examination, that made the neck veins the next place to look. The lesson for documentation is that negatives recorded with a purpose are what move an examination from one system to the next, and the write-up should show that movement.
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
McGee, S. (2022). Evidence-based physical diagnosis (5th ed.). Elsevier.
The Chamberlain NR 509 Week 5 instructions
For Week 5 you examine two related systems for one complaint and connect what each shows. Count on supplying the presenting question, a thorough examination of each system, the reasoning that links them, pertinent negatives, an assessment and APA. Begin with the question that opens both examinations. Examine the first system in depth, including signs you sought and did not find. Make the transition to the second system explicit by saying what question the first left open. Examine the second system on its own terms. Sort negatives by the system they qualify. Write an assessment that uses findings from both, and explain why the order mattered. Record the angle used for the neck veins.
Inside the NR 509 Week 5 example
The opening describes Mr. E. V., a retired band director, with three months of growing girth, ankle swelling and tiredness on stairs. The abdominal section records protuberant flanks, shifting dullness when he turns, a fluid wave, liver dullness from the fifth intercostal space and a smooth, tender edge, and lists the liver disease signs looked for and absent, from jaundice to asterixis. The transition section explains why those absences send the examination to the heart. The cardiovascular section records the jugular pulsation at the jaw at 45 degrees, its rise on inspiration, a sustained rise with abdominal pressure, soft heart sounds and an early diastolic sound. Clear lungs and leg edema follow. The assessment favors constrictive pericarditis, and the closing explains the order.
Reading the NR 509 Week 5 grading rubric
Linked examination rubrics in NR 509 generally reward depth in each system, explicit reasoning between them, accurate technique, organized negatives, an integrated assessment and APA. The paper stands on the link between systems, stating the question the abdomen could not answer. Depth is credited through the liver signs sought and absent. Technique scores for jugular venous pressure measured at a stated angle and the abdominojugular test. Negatives earn points because each is sorted by the system it qualifies. The assessment is credited for using both examinations. McGee's evidence-based diagnosis supports the interpretation. Two references complete APA. Explaining why the order of examination mattered shows reasoning beyond technique.
Common NR 509 Week 5 mistakes, and how to avoid them
Week 5 introduces a loss earlier weeks cannot: a document that examines two systems and connects neither, producing two accurate write-ups side by side. Another loss is recording only the positive findings, so the absent signs of cirrhosis, which carry the reasoning, disappear. Students also skip the transition, examine the second system briefly or write an assessment based on one system. Both systems need depth but not equal length. Connect them through the question the first leaves open, not with padding. If your section examines different systems, the same structure applies. Send your two systems and findings, and an NR 509 linked write-up can make the transition explicit.
Get a NR 509 Week 5 example written to your instructions
Send the Week 5 instructions, the systems your section is covering and your template, and a custom example arrives inside 24 to 48 hours with both examinations written to the depth the rubric expects. The first one is free, and your own findings stay yours to gather.
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NR 509 Week 5 questions, answered
Should both systems get equal space?
Not necessarily equal, but neither should be compressed to a paragraph. The balance follows the presenting question: the system driving the complaint usually earns more room. What a grader marks is whether the second examination is reported on its own terms rather than summarized after the fact.
How do I connect two systems without padding?
One sentence is usually enough. Say what in the first examination made the second worth doing. That single transition is what distinguishes an integrated write-up from two documents sharing a title, and adding paragraphs around it does not improve the score. Point at a finding rather than at the complaint, since a transition resting on a specific result is the one a grader can check.
My section examines different systems than this example.
The systems change and the structure does not. Send the instructions and the systems your section is covering, and a custom example is written around those. What transfers from any focused write-up is the sequence, the density and where the negatives sit. Techniques differ by system, so the example carries the ones belonging to yours rather than generic wording lifted from another pairing.
Where can I find a free NR 509 Week 5 sample paper?
This page shows the complete Week 5 write-up of the abdomen and heart examinations, with the liver signs sought, the transition, the neck vein findings, sorted negatives, the assessment and two references.
Why does the NR 509 Week 5 examination move to the heart?
Because ascites and a large liver appeared without jaundice, spider angiomata or other signs of cirrhosis, so the cause was more likely congestion from the heart than liver disease.