SAEM PRACTICE SOLUTION TEST 2026
COMPLETE QUESTIONS AND ANSWERS
GRADED A+
●● A patient presents after slamming her index finger in a window one
day ago (see Figure). Her X-ray is negative. Of the steps listed below,
which is the best option for her management?
[image]
A. antibiotics and discharge
B. drainage and discharge
C. removal of the nail and suture of the underlying laceration
D. splint and discharge
E. none of the above.
Answer: The correct answer is B. This patient has a subungual
hematoma. Large subungual hematomas require drainage using an 18-
gauge needle or a hot microcautery unit. There is debate concerning
management of a subungual hematoma greater than 50% of the nail bed.
One study showed there was a 60% incidence of nail bed laceration in
these patients; therefore, the authors recommended that the nail be
removed and the laceration sutured. However, another study found no
difference in outcome between nail trephination alone versus formal nail
bed repair.
,●● You have a 3 year old female present with her mother with
complaints of 2 days of left ear pain. On exam, you are unable to
visualize the tympanic membrane due to an obstructing mass. You
suspect a foreign body. Which of the following is TRUE regarding the
removing a foreign object from the patient's ear canal?
A. To remove a live insect from the external ear canal, grasp a leg with
hemostats and pull firmly
B. You should avoid the use of lidocaine and other topical anesthetics
due to the risk of localized tissue ischemia
C. Avoid suction as it may lead to a perforation of the tympanic
membrane
D. Referral to an otolaryngologist for foreign body removal under
general anesthesia may be required in an uncooperative infant.
Answer: The answer is D. Irrigating the ear canal with warm water is
acceptable in many instances, and may remove a foreign object with
minimal discomfort. Direct the water jet gently past the object, against
the tympanic membrane, and then back out the ear canal, hopefully
dislodging the foreign object in the process. However, this technique
should not be used in cases of bean or seed insertion because such
objects swell when moistened, which makes subsequent removal more
difficult and increases the risk of pressure necrosis. Irrigation should
also be avoided in cases of tympanic membrane perforation.
●● You suspect that your patient has swallowed a nail. Which of the
following is an indication for endoscopic or surgical removal of this
object?
, A. Radiography visualizes the nail in the gastric fundus
B. The object has progressed from the jejunum through the ileum after
24 hours
C. Abdominal CT scan shows a 1cm nail in the distal sigmoid colon
D. Plain films do not reveal a radiopaque foreign body in the chest or
abdomen.
Answer: The answer is A. Observation can manage most ingested
foreign objects - the patient should pass the object after several days.
Propulsive agents can be given to speed movement along the
gastrointestinal tract. Serial radiography monitors movement.
Endoscopic or surgical intervention is indicated for sharp objects (which
may cause perforation), objects greater than 2 cm in width (which are
likely to lodge at the pylorus or the ileocecal valve), and long rigid
objects (which may have trouble passing through the right angles of the
duodenum). Surgery is indicated if an object fails to move after 24 hours
(indicating impaction), or if the patient develops symptoms of
obstruction or perforation.
Body packers may have ingested substances such as cocaine or heroin,
which can cause great harm should the packaging be disrupted. Proper
management is observation, as most will pass the package(s) without
complications. Urgent package retrieval should not be performed
because of pressures from law enforcement. Endoscopy can in fact be
dangerous to the patient, as it can disrupt the packaging and release toxic
drugs. Endoscopic or surgical intervention is warranted should the
patient develop signs of systemic drug toxicity. The patient can also be
monitored with serial serum drug levels.
COMPLETE QUESTIONS AND ANSWERS
GRADED A+
●● A patient presents after slamming her index finger in a window one
day ago (see Figure). Her X-ray is negative. Of the steps listed below,
which is the best option for her management?
[image]
A. antibiotics and discharge
B. drainage and discharge
C. removal of the nail and suture of the underlying laceration
D. splint and discharge
E. none of the above.
Answer: The correct answer is B. This patient has a subungual
hematoma. Large subungual hematomas require drainage using an 18-
gauge needle or a hot microcautery unit. There is debate concerning
management of a subungual hematoma greater than 50% of the nail bed.
One study showed there was a 60% incidence of nail bed laceration in
these patients; therefore, the authors recommended that the nail be
removed and the laceration sutured. However, another study found no
difference in outcome between nail trephination alone versus formal nail
bed repair.
,●● You have a 3 year old female present with her mother with
complaints of 2 days of left ear pain. On exam, you are unable to
visualize the tympanic membrane due to an obstructing mass. You
suspect a foreign body. Which of the following is TRUE regarding the
removing a foreign object from the patient's ear canal?
A. To remove a live insect from the external ear canal, grasp a leg with
hemostats and pull firmly
B. You should avoid the use of lidocaine and other topical anesthetics
due to the risk of localized tissue ischemia
C. Avoid suction as it may lead to a perforation of the tympanic
membrane
D. Referral to an otolaryngologist for foreign body removal under
general anesthesia may be required in an uncooperative infant.
Answer: The answer is D. Irrigating the ear canal with warm water is
acceptable in many instances, and may remove a foreign object with
minimal discomfort. Direct the water jet gently past the object, against
the tympanic membrane, and then back out the ear canal, hopefully
dislodging the foreign object in the process. However, this technique
should not be used in cases of bean or seed insertion because such
objects swell when moistened, which makes subsequent removal more
difficult and increases the risk of pressure necrosis. Irrigation should
also be avoided in cases of tympanic membrane perforation.
●● You suspect that your patient has swallowed a nail. Which of the
following is an indication for endoscopic or surgical removal of this
object?
, A. Radiography visualizes the nail in the gastric fundus
B. The object has progressed from the jejunum through the ileum after
24 hours
C. Abdominal CT scan shows a 1cm nail in the distal sigmoid colon
D. Plain films do not reveal a radiopaque foreign body in the chest or
abdomen.
Answer: The answer is A. Observation can manage most ingested
foreign objects - the patient should pass the object after several days.
Propulsive agents can be given to speed movement along the
gastrointestinal tract. Serial radiography monitors movement.
Endoscopic or surgical intervention is indicated for sharp objects (which
may cause perforation), objects greater than 2 cm in width (which are
likely to lodge at the pylorus or the ileocecal valve), and long rigid
objects (which may have trouble passing through the right angles of the
duodenum). Surgery is indicated if an object fails to move after 24 hours
(indicating impaction), or if the patient develops symptoms of
obstruction or perforation.
Body packers may have ingested substances such as cocaine or heroin,
which can cause great harm should the packaging be disrupted. Proper
management is observation, as most will pass the package(s) without
complications. Urgent package retrieval should not be performed
because of pressures from law enforcement. Endoscopy can in fact be
dangerous to the patient, as it can disrupt the packaging and release toxic
drugs. Endoscopic or surgical intervention is warranted should the
patient develop signs of systemic drug toxicity. The patient can also be
monitored with serial serum drug levels.
