CRAM SAEM Test 2 Questions And Answers With Complete Solutions Latest Updated 2024/2025 | Scored A+

CRAM SAEM Test 2 Questions And Answers With Complete Solutions Latest Updated 2024/2025 | Scored A+. what is the obturator sign? what diagnosis is it associated with? - Correct Answer- a/w appendicitis obturator sign = pain upon flexion and internal rotation of the hip#$/images/uploadflashcards/601487/854522_ what is Rovsing's sign? what diagnosis is it associated with? - Correct Answer- a/w appendicitis Rovsing's sign= pain in the RLQ upon palpation of the LLQ#$/images/uploadflashcards/601487/854525_ Early in the course of acute appendicitis, are vital signs usually abnormal? - Correct Answer- no - early in its course, vital signs including temperature may be normal. Once perforation has occurred, the rate of low-grade fever (<38 C) increases to about 40%. what is the psoas sign? what diagnosis is it associated with? - Correct Answer- a/w appendicitis psoas sign = pain upon extension of the hip.#$/images/uploadflashcards/601487/854528_ explain what rebound in the setting of acute appendicitis means - Correct AnswerRebound is usually elicited only after the appendix has ruptured or infarcted. In establishing a differential diagnosis of abdominal pain, the onset of PAIN prior to the occurrence of N/V is more often suggestive of - Correct Answer- surgical etiology of the pain, such as small bowel obstruction what bug should you think of in patients with sickle cell anemia who present with abdominal pain and diarrhea? - Correct Answer- salmonella (not shigellosis) Radiation of pain to the scapula is suggestive of - Correct Answer- acute choleycystitis (NOT hepatitis) Diverticulitis pain is generally located - Correct Answer- in the LLQ CRAM SAEM Test 2 Questions And Answers With Complete Solutions Latest Updated 2024/2025 | Scored A+ Describe the pain patterns a/w with peptic ulcer disease (PUD) - Correct Answer- pain that is worse preceding a meal non-radiating, burning epigastric pain pain that awakens a patient in the middle of the night relief of abdominal pain with antacids note: unrelenting pain over a period of weeks should suggest an alternative diagnosis A 78 year old female presents to the E.D. with a sensation of LLQ abdominal pain, accompanied by some irregular bowel movements and loss of appetite. Her abdominal CT (two images) is shown in the Figure. What is the most likely diagnosis? - Correct Answer- /images/upload-flashcards/601487/854531_#$A patient with this general picture is most likely to have diverticulitis, which is revealed on the CT scan as diverticular disease with inflammation (wall thickening and stranding).#$/images/uploadflashcards/601487/854534_ A mother brings her 6 week old boy to the emergency room. She states the baby has been vomiting everything she's tried to feed him for the past 12 hours. She states that he usually eats readily and completes an entire feeding, but he is unable to keep anything down. The emesis is non-bloody and non-bilious, however it is projectile in nature. What is the most likely condition in this patient? - Correct Answer- pyloric stenosis The answer is C. Hypertrophic pyloric stenosis typically presents in the second to sixth week of life and is four times more common in males than females. Infants with hypertrophic pyloric stenosis typically are vigorous eaters but shortly afterward regurgitate the entire feeding contents in a projectile fashion. The emesis is non-bilious. The classic finding on exam is an "olive" palpable in the abdomen, and diagnosis is typically via ultrasound. Intussusception typically presents between the ages of 5 and 12 months. Gastroenteritis is characterized by diarrhea as well as vomiting. Neither constipation nor appendicitis typically present with protracted vomiting, though the latter condition tends to present atypically in young children (and elderly adults). 46yo F c/o abrupt onset of intermittent severe pain in L flank & abdomen that woke her from sleep. She is pacing & appears extremely uncomfortable. She has never experienced this type of pain previously and denies fevers or other symptoms. Renal calculus is suspected. Some questions - What is the best diagnostic test (KUB, IVP, Helical CT, U/S)? How helpful is a Urinalysis? - Correct Answer- Helical CT scan is greater than 95% sensitive and specific for renal calculi Helical CT scan has been shown to be both highly sensitive and specific in the diagnosis of renal calculi. It is the preferred modality for evaluation in many centers. Although urinalysis typically demonstrates hematuria in patients with renal calculi, hematuria is not specific enough to confirm the diagnosis, and imaging is warranted in all first-time presenters. KUB detects approximately 60-70% of calculi (though studies addressing this issue are somewhat methodologically flawed). Ultrasound is not reliable for detecting small calculi, but is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is contraindicated in patients with renal insufficiency due to the dye load necessary to perform the study. 50 yo M p/w 1 day of gradually worsening, intermittent, LLQ pain a/w loose stools. No fevers or bloody bowel movements. Similar sxs in the past were self-limited. Vital signs wnl. PE shows mild tenderness in LLQ, +BS and no masses or peritoneal signs. His PCP can see him tomorrow in his clinic. What should be done next in the E.D.? - Correct Answer- Discharge home on high-fiber diet, laxatives and stool softeners This patient has classic diverticulosis (saclike protrusions of colonic mucosa through the muscularis) without signs of acute diverticulitis (inflammation of diverticula). Usually these patients can be managed as outpatients with a high-fiber diet and treatments to decrease intestinal spasm. If the patient develops fever or pain increases he may need further evaluation to rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest and analgesics. You are treating a 25yoM with the recent diagnosis of Crohn's disease in the ED. Regarding Crohn's disease, you know that: - Correct Answer- There is a small increased risk of colon cancer Although Crohn's disease may involve the entire bowel tract, the rectum is rarely involved. Involved areas are typically non-contiguous (known as "skip lesions") and the inflammation involves all of the layers of the bowel wall--resulting in many of the complications of Crohn's such as abscess and fistula formation, intestinal obstruction, and perforation. The risk of colon cancer is only slightly elevated above baseline. In contrast, Ulcerative colitis begins in the rectum and may spread to the upper parts of the colon but never involves the small intestine. The ulcerations are contiguous and involve only the colonic mucosa. The incidence of colon cancer may be increased up to 30 times over baseline. 53yo obese woman presents to ED, accompanied by three of her children, c/o severe abdominal pain that began this afternoon after lunch. PE reveals marked RUQ tenderness. Likely findings on this patient would include: - Correct Answer- This woman is likely suffering from acute cholecystitis. Predisposing factors include female gender, obesity, increased age and increased parity. Inflammation of the gallbladder causes RUQ pain and sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound probe is positioned over the gallbladder). Pain may radiate to the right scapula. Lab studies usually show leukocytosis with or without a left shift, and aminotransferases and bilirubin are usually within normal limits. 25yo F p/w epigastric pain radiating straight through to the back. Labs are notable only for markedly elevated amylase and lipase. An abdominal X-ray is taken (see Figure). What's the dx? - Correct Answer- /images/uploadflashcards/601487/924401_#$The most likely explanation for her symptoms is gallstone-related pancreatitis The X-ray reveals stones in the gallbladder. These particular stones are not likely the cause of pancreatitis, but the demonstration of gallstone disease raises the likelihood that the patient's pancreatitis is indeed due to gallstones. In the U.S., the most common etiologies of pancreatitis include gallstones (45%) and alcoholism (35%). Alcoholic pancreatitis may occur in young patients as well as in older abusers of alcohol. Many other drugs, infectious agents, and conditions are associated with the development of pancreatitis. A few examples include hypertriglyceridemia, trauma, pregnancy, pancreatic carcinoma, atherosclerotic emboli, and scorpion bites. 45yo F p/w RUQ pain & fever. The pain is worse after eating. On PE she has a (+) Murphy's sign. Most likely dx? - Correct Answer- Cholecystitis RUQ pain, fever and a Murphy's sign suggests cholecystitis. Cholelithiasis presents with similar pain, but is not associated with fever or a Murphy's sign 47yo M presents, confused, to the ED. He has limited ability to give a history. On PE of the skin, it is noted that there are erythematous changes to both palms. Also, the face and arms are characterized by a number of superficial, tortuous arterioles which fill from the center outwards. The examination of the abdomen reveals violaceous lines radiating from the umbilicus, and there are generally increased venous markings on the abdominal wall (see Figure). What is the most likely diagnosis? - Correct Answer- liver disease The patient's palmar erythema, spider angiomata, and caput medusa (due to recanalization of the umbilical vein) are all characteristic of hepatic disease. The figure demonstrates abdominal wall venous engorgement, as well as ascites (another clue to the patient's liver disease). A 57-year-old homeless woman with a history of schizophrenia presents to the emergency department complaining of nausea and severe abdominal pain for 48 hours. The patient is not cooperative with an upright abdominal image, so a flat plate (as shown in the Figure) is obtained. Which of the following is the most likely operative finding in this patient? - Correct Answer- small bowel obstruction Dilated loops of small bowel with air-fluid levels (which are not well-seen on a flat plate) indicate small bowel obstruction. KUB is not often useful in the diagnosis of appendicitis, ruptured spleen, gallstone disease, or a rectus sheath hematoma (which is an abdominal wall condition most likely seen in anticoagulated patients with trauma or coughing). Despite this woman's history of schizophrenia and possibly diminished ability to relate a clear story of her pain, her complaint of abdominal pain must be taken seriously with a high suspicion for underlying pathology. All of the following factors predispose to cecal volvulus EXCEPT: A. marathon running B. pregnancy C. age 25-35 D. prior abdominal surgery E. severe chronic constipation - Correct Answer- constipation DOES not lead to volvulus Cecal volvulus occurs as a result of abnormal fixation of the right colon and increased mobility of the cecum. Depending on the degree of rotation around the mesenteric axis, cecal volvulus can lead to twisting of the mesentery and its blood vessels. Cecal volvulus occurs most commonly in people 25-35 years old and should be suspected in cases of bowel obstruction without known risk factors. Prior abdominal surgery and pregnancy predispose to obstruction or cecal volvulus; however, chronic constipation is not known to predispose to cecal volvulus. Interestingly, marathon runners have been found to have a higher incidence of cecal volvulus, perhaps from having a thin, flexible mesentery that more easily permits rotation of the cecum around the mesenteric pedicle. A 57 year old ill-appearing man presents with fever, chills, abdominal pain, nausea and vomiting. His abdominal CT is shown in the Figure. Which of the following is LEAST correct regarding this patient's condition? - Correct Answer- /images/uploadflashcards/601487/924404_#$Answer: Emergent percutaneous drainage in the emergency department is indicated The patient has a hepatic abscess, typically caused by gram negatives, anaerobic Streptococci or Entameoba histolytica. Laboratory findings include elevations of WBC, bilirubin, alkaline phosphatase and serum aminotransferases. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately, however consultation with a general surgeon, interventional radiologist, or gastroenterologist is necessary for definitive treatment, which is drainage of the abscess. Which of the following pairings of referred pain and causal disease is least likely to be encountered? A. thoracic back pain—pancreatitis B. epigastric pain—myocardial infarction C. inguinal pain—ureteral colic D. shoulder pain—ruptured spleen E. sacral pain—ovarian torsion - Correct Answer- The answer is E. Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and cervical motion tenderness, but it is not known to cause sacral pain. A 72 year old man with a history of diverticulosis presents with vague abdominal pain for the past day. His physical exam is notable for normal vital signs, left lower quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis without perforation. Of the following choices, which is the most appropriate management of this patient? - Correct Answer- The answer is E. For mild episodes of diverticulitis in which there is no evidence of perforation or peritonitis, there is no indication for immediate surgical intervention. Conservative management with intravenous fluids and antibiotics as well as bowel rest is typically first attempted. Although colon carcinoma may be a precipitating factor in the development of diverticulitis, barium enema should be avoided in the acute period due to high risk of bowel perforation. Although some patients with mild cases of diverticulitis may be discharged home with conservative treatment, the elderly are at higher risk of perforation and should be admitted. Guaiac positive stool in seen in up to 50% of patients with diverticulitis. There is no reason to suspect acute blood loss requiring transfusion in diverticulitis. Regarding esophageal perforation, which of the following is INCORRECT: A. Over 90% of spontaneous esophageal perforations occur in the proximal esophagus. B. Over 80% of esophageal perforations are iatrogenic, usually as complications of upper endoscopy, dilation, or sclerotherapy. C. Esophageal perforation has been reported as a complication of nasogastric tube placement, endotracheal intubation, and esophagotracheal Combitube intubation. D. Iatrogenic perforations of the esophagus usually occur in the proximal esophagus or esophagogastric junction. E. Esophageal perforation may result from forceful vomiting, coughing, childbirth or heavy lifting. - Correct Answer- The answer is A. Over 90% of spontaneous esophageal perforations occur in the distal esophagus, whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt injury or penetrating trauma, and carcinoma are other causes of esophageal perforation. Working in the ED, you have identified a bony object wedged in the mid-esophagus of a 45 year old patient. Failure to promptly remove a foreign body impacted in the esophagus could result in: - Correct Answer- Esophageal perforation and mediastinitis Working in the ED, you have identified a bony object wedged in the mid-esophagus of a 45 year old patient. Failure to promptly remove a foreign body impacted in the esophagus could result in: A. The rapid development of xerostomia B. Epiglottal edema and airway obstruction C. Esophageal perforation and mediastinitis D. Barrett's esophagitis The answer is C. The complications of esophageal foreign bodies are rare but serious. They include esophageal erosion and perforation, mediastinitis, esophagus-to-trachea or esophagus-to-vasculature fistula formation, stricture formation, diverticuli formation, and tracheal compression (from both the esophageal foreign body and resultant edema or infection). Air trapping is a sign of a foreign body of the airway. Rarely, airway foreign bodies act as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax formation. A mother brings her 35 year old son to the emergency department because of tremor and mutism for the past three days. His mother found him in his room this morning lying stiffly in his bed, soiled with urine and feces. He appears confused and will not respond to questions. He was diagnosed with schizophrenia last year and has been on several medications. Last month after his most recent hospital admission for schizophrenia, he was discharged with a prescription for haloperidol. On physical exam, he is visibly diaphoretic and has vital signs as follows: T 102.7, BP 140/98, P 112, R 12. His neuromuscular exam shows extremely rigid extremities, and his laboratory values are notable for a white blood cell count of 15000/mm3 and abnormally elevated creatine phosphokinase levels. What is the most likely explanation for these findings? - Correct Answer- Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-threatening reaction to antipsychotic medications, with haloperidol being the most common cause. It is characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic dysfunction (e.g., diaphoresis, labile blood pressure, incontinence, dysrhythmias). While this patient's temperature is only 102.7, students should note that any patients with temperatures greater than 105 most likely have non-infectious etiologies for temperature elevation. NMS is thought to be due to too much D2 blockade in the substantia nigra and hypothalamus. Treatment consists of stopping the causative agent and providing supportive care. Medications such as dantrolene, bromocriptine, amantadine, and lorazepam are also often used.