SAEM Practice 2026 Exam study guide
COMPLETE EXAM Questions and
Answers (Verified Answers) (Latest
Update 2026) UPDATE!!
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. - 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.
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. - 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.
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. - 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.
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 - 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.
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 - ANSWER-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).
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. -
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 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.
A 50 year old man presents with 1 day of gradually worsening, intermittent, left lower
quadrant pain associated with loose stools. He has had no fevers or bloody bowel
movements. Similar symptoms in the past were self-limited. All vital signs lie within
normal limits. Physical examination shows mild tenderness in the left lower quadrant,
normal active bowel sounds and neither masses nor peritoneal signs. His primary-care
physician can see him tomorrow in his clinic. What should be done next in the E.D.?
A. Discharge home after a single dose of IV antibiotics
B. Discharge home on high-fiber diet, laxatives and stool softeners
C. Gastroenterology consult for endoscopy
D. Admit for observation and serial examinations - ANSWER-B. 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 25 year old male with the recent diagnosis of Crohn's disease in the
ED. Regarding Crohn's disease, you know that:
A. Lesions are typically contiguous
B. Small bowel involvement is rare
C. Bleeding is common due to superficial bowel wall inflammation
D. There is a small increased risk of colon cancer - ANSWER-D. 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.
A 53 year old obese woman presents to the emergency department, accompanied by
three of her children, complaining of severe abdominal pain that began this afternoon
after lunch. Physical exam reveals marked RUQ tenderness. Likely findings on this
patient would include all of the following EXCEPT:
A. positive sonographic Murphy's sign
B. pain in the right scapula
C. leukocytosis with left shift
D. marked inguinal lymphadenopathy
E. aminotransferases and bilirubin within normal limits - ANSWER-D. marked inguinal
lymphadenopathy
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.
A 45 year old woman presents with right upper quadrant pain and fever. The pain is
worse after eating. On physical exam she has a Murphy's sign. The most likely
diagnosis is:
A. Appendicitis
B. Diverticulitis
C. Cholelithiasis
D. Cholecystitis
COMPLETE EXAM Questions and
Answers (Verified Answers) (Latest
Update 2026) UPDATE!!
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. - 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.
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. - 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.
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. - 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.
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 - 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.
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 - ANSWER-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).
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. -
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 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.
A 50 year old man presents with 1 day of gradually worsening, intermittent, left lower
quadrant pain associated with loose stools. He has had no fevers or bloody bowel
movements. Similar symptoms in the past were self-limited. All vital signs lie within
normal limits. Physical examination shows mild tenderness in the left lower quadrant,
normal active bowel sounds and neither masses nor peritoneal signs. His primary-care
physician can see him tomorrow in his clinic. What should be done next in the E.D.?
A. Discharge home after a single dose of IV antibiotics
B. Discharge home on high-fiber diet, laxatives and stool softeners
C. Gastroenterology consult for endoscopy
D. Admit for observation and serial examinations - ANSWER-B. 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 25 year old male with the recent diagnosis of Crohn's disease in the
ED. Regarding Crohn's disease, you know that:
A. Lesions are typically contiguous
B. Small bowel involvement is rare
C. Bleeding is common due to superficial bowel wall inflammation
D. There is a small increased risk of colon cancer - ANSWER-D. 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.
A 53 year old obese woman presents to the emergency department, accompanied by
three of her children, complaining of severe abdominal pain that began this afternoon
after lunch. Physical exam reveals marked RUQ tenderness. Likely findings on this
patient would include all of the following EXCEPT:
A. positive sonographic Murphy's sign
B. pain in the right scapula
C. leukocytosis with left shift
D. marked inguinal lymphadenopathy
E. aminotransferases and bilirubin within normal limits - ANSWER-D. marked inguinal
lymphadenopathy
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.
A 45 year old woman presents with right upper quadrant pain and fever. The pain is
worse after eating. On physical exam she has a Murphy's sign. The most likely
diagnosis is:
A. Appendicitis
B. Diverticulitis
C. Cholelithiasis
D. Cholecystitis
