Question 1
Regarding the diagnosis of acute appendicitis, all the following are true EXCEPT:
A. Vital signs are usually abnormal, even early in the course of acute appendicitis.
B. Rebound is usually elicited only after the appendix has ruptured or infarcted.
C. Rovsing's sign is pain in the right lower quadrant upon palpation of the left lower
quadrant.
D. The obturator sign is pain upon flexion and internal rotation of the hip.
E. The psoas sign is pain upon extension of the hip.
CORRECT ANSWER
A. Vital signs are usually abnormal, even early in the course of acute appendicitis.
The answer is A. The presentation of acute appendicitis varies tremendously. 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%. Other variations in presentation
include pain in the right upper quadrant, typically from a retrocecal or retroiliac appendix.
Question 2
Rosving's sign is described as:
A. Tenderness in the right upper quadrant that is worse with inspiration.
B. Pelvic pain upon flexion of the thigh while the patient is supine.
C. Pelvic pain upon internal and external rotation of the thigh with the knee flexed.
D. Pain that increases with the release of pressure of palpation.
E. Pain in the right lower quadrant when left lower quadrant is palpated.
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,CORRECT ANSWER
E. Pain in the right lower quadrant when left lower quadrant is palpated.
The answer is E. Rosving's sign is pain in the right lower quadrant when the left lower
quadrant is palpated. Rebound tenderness occurs with the release of pressure. The iliopsoas
sign is pain associated with thigh flexion. The obturator sign is pain that occurs with thigh
rotation. All of these signs are associated with appendicitis. Murphy's sign is cessation of
inspiration during palpation of the right upper quadrant and is associated with acute
cholecystitis.
Question 3
In establishing a differential diagnosis of abdominal pain, which of the following is true?
A. Radiation of pain to the scapula is suggestive of acute hepatitis.
B. Cervical motion tenderness is a useful physical finding for differentiating women with or
without acute appendicitis.
C. In patients with sickle cell anemia who present with abdominal pain and diarrhea,
shigellosis should be a top consideration.
D. The onset of pain prior to the occurrence of nausea and vomiting is more often
suggestive of a surgical etiology.
E. Diverticulitis tends to cause pain in the right upper quadrant.
CORRECT ANSWER
D. The onset of pain prior to the occurrence of nausea and vomiting is more often
suggestive of a surgical etiology.
The answer is D. Pain prior to nausea and vomiting is often suggestive of a surgical etiology
of the pain, such as small bowel obstruction. Cervical motion tenderness has been noted in
up to 25% of women with acute appendicitis. Patients with sickle cell anemia are prone to
Salmonella infections. Radiation of pain to the scapula is classically present in acute
choleycystitis. Diverticulitis pain is generally located in the left lower quadrant.
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,Question 4
Of the following pain patterns, which is the least likely associated with diagnosis of peptic
ulcer disease?
A. non-radiating, burning epigastric pain
B. pain that awakens a patient in the middle of the night
C. unrelenting pain over a period of weeks
D. relief of abdominal pain with antacids
E. pain that is worse preceding a meal
CORRECT ANSWER
C. unrelenting pain over a period of weeks
The answer is C. Pain from peptic ulcer disease typically occurs in periods of exacerbation
and remission. Unrelenting pain over weeks or months should suggest an alternative
diagnosis. Pain is classically described as non-radiating, burning epigastric pain. Some
patients may also complain of chest or back pain. Pain is frequently severe enough to
awaken patients from sleep in early morning hours but is often not present upon waking in
the morning, as gastric acid secretion peaks around 2 a.m. and nadirs upon awakening.
Question 5
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?
A. viral gastroenteritis
B. constipation
C. appendicitis
D. intussusception
E. pyloric stenosis
CORRECT ANSWER
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, E. pyloric stenosis
The answer is E. 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).
Question 6
A 46 year old woman presents to the emergency department complaining of abrupt onset
of intermittent severe pain in the left flank and abdomen that woke her from sleep. She is
pacing around the stretcher and appears extremely uncomfortable. She has never
experienced this type of pain previously and denies fevers or other symptoms. Renal
calculus is suspected. Which of the following is true regarding the diagnosis of renal calculi
in this patient?
A. Urinalysis demonstrating hematuria confirms the diagnosis.
B. KUB detects less than 10% of calculi.
C. Helical CT scan greater than 95% sensitive and specific for renal calculi.
D. Ultrasound is the study of choice for detecting small ureteral calculi.
E. Intravenous pyelogram (IVP) may be used in patients with renal insufficiency.
CORRECT ANSWER
C. Helical CT scan 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
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@THE STUDY VAULT
Regarding the diagnosis of acute appendicitis, all the following are true EXCEPT:
A. Vital signs are usually abnormal, even early in the course of acute appendicitis.
B. Rebound is usually elicited only after the appendix has ruptured or infarcted.
C. Rovsing's sign is pain in the right lower quadrant upon palpation of the left lower
quadrant.
D. The obturator sign is pain upon flexion and internal rotation of the hip.
E. The psoas sign is pain upon extension of the hip.
CORRECT ANSWER
A. Vital signs are usually abnormal, even early in the course of acute appendicitis.
The answer is A. The presentation of acute appendicitis varies tremendously. 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%. Other variations in presentation
include pain in the right upper quadrant, typically from a retrocecal or retroiliac appendix.
Question 2
Rosving's sign is described as:
A. Tenderness in the right upper quadrant that is worse with inspiration.
B. Pelvic pain upon flexion of the thigh while the patient is supine.
C. Pelvic pain upon internal and external rotation of the thigh with the knee flexed.
D. Pain that increases with the release of pressure of palpation.
E. Pain in the right lower quadrant when left lower quadrant is palpated.
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@THE STUDY VAULT
,CORRECT ANSWER
E. Pain in the right lower quadrant when left lower quadrant is palpated.
The answer is E. Rosving's sign is pain in the right lower quadrant when the left lower
quadrant is palpated. Rebound tenderness occurs with the release of pressure. The iliopsoas
sign is pain associated with thigh flexion. The obturator sign is pain that occurs with thigh
rotation. All of these signs are associated with appendicitis. Murphy's sign is cessation of
inspiration during palpation of the right upper quadrant and is associated with acute
cholecystitis.
Question 3
In establishing a differential diagnosis of abdominal pain, which of the following is true?
A. Radiation of pain to the scapula is suggestive of acute hepatitis.
B. Cervical motion tenderness is a useful physical finding for differentiating women with or
without acute appendicitis.
C. In patients with sickle cell anemia who present with abdominal pain and diarrhea,
shigellosis should be a top consideration.
D. The onset of pain prior to the occurrence of nausea and vomiting is more often
suggestive of a surgical etiology.
E. Diverticulitis tends to cause pain in the right upper quadrant.
CORRECT ANSWER
D. The onset of pain prior to the occurrence of nausea and vomiting is more often
suggestive of a surgical etiology.
The answer is D. Pain prior to nausea and vomiting is often suggestive of a surgical etiology
of the pain, such as small bowel obstruction. Cervical motion tenderness has been noted in
up to 25% of women with acute appendicitis. Patients with sickle cell anemia are prone to
Salmonella infections. Radiation of pain to the scapula is classically present in acute
choleycystitis. Diverticulitis pain is generally located in the left lower quadrant.
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@THE STUDY VAULT
,Question 4
Of the following pain patterns, which is the least likely associated with diagnosis of peptic
ulcer disease?
A. non-radiating, burning epigastric pain
B. pain that awakens a patient in the middle of the night
C. unrelenting pain over a period of weeks
D. relief of abdominal pain with antacids
E. pain that is worse preceding a meal
CORRECT ANSWER
C. unrelenting pain over a period of weeks
The answer is C. Pain from peptic ulcer disease typically occurs in periods of exacerbation
and remission. Unrelenting pain over weeks or months should suggest an alternative
diagnosis. Pain is classically described as non-radiating, burning epigastric pain. Some
patients may also complain of chest or back pain. Pain is frequently severe enough to
awaken patients from sleep in early morning hours but is often not present upon waking in
the morning, as gastric acid secretion peaks around 2 a.m. and nadirs upon awakening.
Question 5
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?
A. viral gastroenteritis
B. constipation
C. appendicitis
D. intussusception
E. pyloric stenosis
CORRECT ANSWER
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@THE STUDY VAULT
, E. pyloric stenosis
The answer is E. 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).
Question 6
A 46 year old woman presents to the emergency department complaining of abrupt onset
of intermittent severe pain in the left flank and abdomen that woke her from sleep. She is
pacing around the stretcher and appears extremely uncomfortable. She has never
experienced this type of pain previously and denies fevers or other symptoms. Renal
calculus is suspected. Which of the following is true regarding the diagnosis of renal calculi
in this patient?
A. Urinalysis demonstrating hematuria confirms the diagnosis.
B. KUB detects less than 10% of calculi.
C. Helical CT scan greater than 95% sensitive and specific for renal calculi.
D. Ultrasound is the study of choice for detecting small ureteral calculi.
E. Intravenous pyelogram (IVP) may be used in patients with renal insufficiency.
CORRECT ANSWER
C. Helical CT scan 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
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@THE STUDY VAULT
