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Saturday, August 15, 2026
RenalMedium
A 55-year-old man has 6 weeks of abdominal distention and swelling of both ankles. He drinks a pint of vodka daily. He has no orthopnea, paroxysmal nocturnal dyspnea, or foamy urine. BP 102/62, HR 92. There are spider angiomata on the chest and gynecomastia, the abdomen is distended with an everted umbilicus, and there is pitting edema to the mid-calf. Which additional physical examination finding is most likely to be present?
AJugular venous pressure elevated at 10 cm
BBrawny hyperpigmentation around both ankles
CShifting dullness on percussion of the flanks
DFirm swelling across the dorsum of both feet
Reveal the answer & full explanation
Correct answer: C — Shifting dullness on percussion of the flanks
AJugular venous pressure elevated at 10 cm
BBrawny hyperpigmentation around both ankles
CShifting dullness on percussion of the flanks✓
DFirm swelling across the dorsum of both feet
Portal hypertension from cirrhosis raises sinusoidal pressure and splanchnic nitric oxide production, producing arterial underfilling, renal sodium retention, and ascites with dependent peripheral edema. Free peritoneal fluid layers dependently, so the flanks are dull and the air-filled bowel floats to the top; rolling the patient shifts the air-fluid interface and moves the level of dullness. Shifting dullness on percussion of the flanks is therefore the expected finding and detects roughly 1500 mL of ascites, making it more sensitive than a fluid wave. Spider angiomata and gynecomastia in the stem are supportive stigmata of chronic liver disease but do not localize the fluid. Jugular venous pressure elevated at 10 cm - the sign of elevated right atrial pressure in heart failure or constrictive physiology, and it is characteristically normal or low in decompensated cirrhosis because effective arterial volume is reduced. Firm swelling across the dorsum of both feet - the pattern of lymphedema, which spares the peritoneal cavity and does not produce flank dullness or spider angiomata. Brawny hyperpigmentation around both ankles - chronic venous insufficiency, a purely local venous hypertension problem that does not cause abdominal distention. Confirmation is ultrasonography with diagnostic paracentesis and a serum-ascites albumin gradient of 1.1 g/dL or higher, but the discriminating bedside step is percussion for shifting dullness.
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Every day, FirstPassPA publishes one free, board-style question modeled on the PANRE (Physician Assistant National Recertifying Exam) and PANCE. Each one is a clinical vignette with a single best answer and a full explanation — including why the other options are wrong — so a two-minute daily habit steadily builds the pattern recognition the boards reward.
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How to use it
Read the vignette, commit to an answer before you reveal it, and then read the explanation even when you get the question right — the reasoning for the distractors is usually where the real learning is. Rotate through the daily questions to keep every organ system fresh, and when your exam date gets closer, layer in longer, blueprint-weighted question blocks in the app.
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Does the Question of the Day help for the PANCE too?
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