SAEM - Practice Exam Questions and Correct Answers (Verified Answers)
Regarding the diagnosis of acute appendicitis, all the A. Vital signs are usually abnormal, even early in the course of acute
following are true EXCEPT: appendicitis.
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.
B. Rebound is usually elicited only after the appendix Early in its course, vital signs including temperature may be normal. Once
has ruptured or infarcted. perforation has occurred, the rate of low-grade fever (<38 C) increases to about
C. Rovsing's sign is pain in the right lower quadrant upon 40%. Other variations in presentation include pain in the right upper quadrant,
palpation of the left lower quadrant. typically from a retrocecal or retroiliac appendix.
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.
Rosving's sign is described as: E. Pain in the right lower quadrant when left lower quadrant is palpated.
A. Tenderness in the right upper quadrant that is worse
with inspiration. The answer is E. Rosving's sign is pain in the right lower quadrant when the left
B. Pelvic pain upon flexion of the thigh while the patient lower quadrant is palpated. Rebound tenderness occurs with the release of
is supine. pressure. The iliopsoas sign is pain associated with thigh flexion. The obturator
C. Pelvic pain upon internal and external rotation of the sign is pain that occurs with thigh rotation. All of these signs are associated with
thigh with the knee flexed. appendicitis. Murphy's sign is cessation of inspiration during palpation of the right
D. Pain that increases with the release of pressure of upper quadrant and is associated with acute cholecystitis.
palpation.
E. Pain in the right lower quadrant when left lower
quadrant is palpated.
In establishing a differential diagnosis of abdominal pain, D. The onset of pain prior to the occurrence of nausea and vomiting is more often
which of the following is true? suggestive of a surgical etiology.
A. Radiation of pain to the scapula is suggestive of acute
hepatitis. The answer is D. Pain prior to nausea and vomiting is often suggestive of a
B. Cervical motion tenderness is a useful physical finding surgical etiology of the pain, such as small bowel obstruction. Cervical motion
for differentiating women with or without acute tenderness has been noted in up to 25% of women with acute appendicitis.
appendicitis. Patients with sickle cell anemia are prone to Salmonella infections. Radiation of
C. In patients with sickle cell anemia who present with pain to the scapula is classically present in acute choleycystitis. Diverticulitis pain
abdominal pain and diarrhea, shigellosis should be a top is generally located in the left lower quadrant.
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.
Of the following pain patterns, which is the least likely C. unrelenting pain over a period of weeks
associated with diagnosis of peptic ulcer disease?
A. non-radiating, burning epigastric pain The answer is C. Pain from peptic ulcer disease typically occurs in periods of
B. pain that awakens a patient in the middle of the night exacerbation and remission. Unrelenting pain over weeks or months should
C. unrelenting pain over a period of weeks suggest an alternative diagnosis. Pain is classically described as non-radiating,
D. relief of abdominal pain with antacids burning epigastric pain. Some patients may also complain of chest or back pain.
E. pain that is worse preceding a meal 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 E. pyloric stenosis
room. She states the baby has been vomiting everything
she's tried to feed him for the past 12 hours. She states The answer is E. Hypertrophic pyloric stenosis typically presents in the second to
that he usually eats readily and completes an entire sixth week of life and is four times more common in males than females. Infants
feeding, but he is unable to keep anything down. The with hypertrophic pyloric stenosis typically are vigorous eaters but shortly
emesis is non-bloody and non-bilious, however it is afterward regurgitate the entire feeding contents in a projectile fashion. The
projectile in nature. What is the most likely condition in emesis is non-bilious. The classic finding on exam is an "olive" palpable in the
this patient? abdomen, and diagnosis is typically via ultrasound. Intussusception typically
A. viral gastroenteritis presents between the ages of 5 and 12 months. Gastroenteritis is characterized
B. constipation by diarrhea as well as vomiting. Neither constipation nor appendicitis typically
C. appendicitis present with protracted vomiting, though the latter condition tends to present
D. intussusception atypically in young children (and elderly adults).
E. pyloric stenosis
, SAEM - Practice Exam Questions and Correct Answers (Verified Answers)
A 46 year old woman presents to the emergency C. Helical CT scan greater than 95% sensitive and specific for renal calculi.
department complaining of abrupt onset of intermittent
severe pain in the left flank and abdomen that woke her Helical CT scan has been shown to be both highly sensitive and specific in the
from sleep. She is pacing around the stretcher and diagnosis of renal calculi. It is the preferred modality for evaluation in many
appears extremely uncomfortable. She has never centers. Although urinalysis typically demonstrates hematuria in patients with
experienced this type of pain previously and denies renal calculi, hematuria is not specific enough to confirm the diagnosis, and
fevers or other symptoms. Renal calculus is suspected. imaging is warranted in all first-time presenters. KUB detects approximately 60-
Which of the following is true regarding the diagnosis of 70% of calculi (though studies addressing this issue are somewhat
renal calculi in this patient? methodologically flawed). Ultrasound is not reliable for detecting small calculi, but
A. Urinalysis demonstrating hematuria confirms the is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is
diagnosis. contraindicated in patients with renal insufficiency due to the dye load necessary
B. KUB detects less than 10% of calculi. to perform the study.
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.
A 50 year old man presents with 1 day of gradually B. Discharge home on high-fiber diet, laxatives and stool softeners
worsening, intermittent, left lower quadrant pain
associated with loose stools. He has had no fevers or This patient has classic diverticulosis (saclike protrusions of colonic mucosa
bloody bowel movements. Similar symptoms in the past through the muscularis) without signs of acute diverticulitis (inflammation of
were self-limited. All vital signs lie within normal limits. diverticula). Usually these patients can be managed as outpatients with a high-
Physical examination shows mild tenderness in the left fiber diet and treatments to decrease intestinal spasm. If the patient develops
lower quadrant, normal active bowel sounds and neither fever or pain increases he may need further evaluation to rule out abscess
masses nor peritoneal signs. His primary-care physician formation. Diverticulitis is treated with antibiotics, bowel rest and analgesics.
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
You are treating a 25 year old male with the recent D. There is a small increased risk of colon cancer
diagnosis of Crohn's disease in the ED. Regarding
Crohn's disease, you know that: 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")
A. Lesions are typically contiguous and the inflammation involves all of the layers of the bowel wall--resulting in
B. Small bowel involvement is rare many of the complications of Crohn's such as abscess and fistula formation,
C. Bleeding is common due to superficial bowel wall intestinal obstruction, and perforation. The risk of colon cancer is only slightly
inflammation elevated above baseline. In contrast, Ulcerative colitis begins in the rectum and
D. There is a small increased risk of colon cancer 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 D. marked inguinal lymphadenopathy
department, accompanied by three of her children,
complaining of severe abdominal pain that began this This woman is likely suffering from acute cholecystitis. Predisposing factors
afternoon after lunch. Physical exam reveals marked include female gender, obesity, increased age and increased parity. Inflammation
RUQ tenderness. Likely findings on this patient would of the gallbladder causes RUQ pain and sonographic Murphy's sign (inspiratory
include all of the following EXCEPT: arrest, due to pain, while the ultrasound probe is positioned over the gallbladder).
A. positive sonographic Murphy's sign Pain may radiate to the right scapula. Lab studies usually show leukocytosis with
B. pain in the right scapula or without a left shift, and aminotransferases and bilirubin are usually within
C. leukocytosis with left shift normal limits.
D. marked inguinal lymphadenopathy
E. aminotransferases and bilirubin within normal limits
A 45 year old woman presents with right upper quadrant D. Cholecystitis
pain and fever. The pain is worse after eating. On
physical exam she has a Murphy's sign. The most likely Right upper quadrant pain, fever and a Murphy's sign suggests cholecystitis.
diagnosis is: Cholelithiasis presents with similar pain, but is not associated with fever or a
Murphy's sign
A. Appendicitis
B. Diverticulitis
C. Cholelithiasis
D. Cholecystitis
E. Mesenteric Ischemia
, SAEM - Practice Exam Questions and Correct Answers (Verified Answers)
All of the following factors predispose to cecal volvulus E. severe chronic constipation
EXCEPT:
Cecal volvulus occurs as a result of abnormal fixation of the right colon and
A. pregnancy increased mobility of the cecum. Depending on the degree of rotation around the
B. age 25-35 mesenteric axis, cecal volvulus can lead to twisting of the mesentery and its
C. prior abdominal surgery blood vessels. Cecal volvulus occurs most commonly in people 25-35 years old
D. marathon running and should be suspected in cases of bowel obstruction without known risk
E. severe chronic constipation 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.
Which of the following pairings of referred pain and A. sacral pain—ovarian torsion
causal disease is least likely to be encountered?
Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal
A. sacral pain—ovarian torsion tenderness, and cervical motion tenderness, but it is not known to cause sacral
B. inguinal pain—ureteral colic pain.
C. epigastric pain—myocardial infarction
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatitis
A 72 year old man with a history of diverticulosis E. admission for intravenous antibiotics and fluids
presents with vague abdominal pain for the past day. His
physical exam is notable for normal vital signs, left lower For mild episodes of diverticulitis in which there is no evidence of perforation or
quadrant abdominal tenderness without rebound or peritonitis, there is no indication for immediate surgical intervention. Conservative
guarding, and guaiac positive brown stool. Work-up management with intravenous fluids and antibiotics as well as bowel rest is
including KUB and abdominal/pelvic CT scan reveals typically first attempted. Although colon carcinoma may be a precipitating factor
diverticulitis without perforation. Of the following choices, in the development of diverticulitis, barium enema should be avoided in the acute
which is the most appropriate management of this period due to high risk of bowel perforation. Although some patients with mild
patient? cases of diverticulitis may be discharged home with conservative treatment, the
elderly are at higher risk of perforation and should be admitted. Guaiac positive
A. type and cross two units of packed red blood cells stool in seen in up to 50% of patients with diverticulitis. There is no reason to
B. immediate surgical intervention suspect acute blood loss requiring transfusion in diverticulitis.
C. discharge on oral pain medications
D. barium enema to evaluate for carcinoma of the colon
E. admission for intravenous antibiotics and fluids
Regarding esophageal perforation, which of the following D. Over 90% of spontaneous esophageal perforations occur in the proximal
is INCORRECT: esophagus.
A. Esophageal perforation has been reported as a Over 90% of spontaneous esophageal perforations occur in
complication of nasogastric tube placement, the distal esophagus, whereas iatrogenic perforations are frequently at the
endotracheal intubation, and esophagotracheal pharyngoesophageal junction or the esophagogastric junction. Foreign body or
Combitube intubation. caustic substance ingestion, severe blunt injury or penetrating trauma, and
B. Esophageal perforation may result from forceful carcinoma are other causes of esophageal perforation.
vomiting, coughing, childbirth or heavy lifting.
C. Over 80% of esophageal perforations are iatrogenic,
usually as complications of upper endoscopy, dilation, or
sclerotherapy.
D. Over 90% of spontaneous esophageal perforations
occur in the proximal esophagus.
E. Iatrogenic perforations of the esophagus usually occur
in the proximal esophagus or esophagogastric junction.
Working in the ED, you have identified a bony object A. Esophageal perforation and mediastinitis
wedged in the mid-esophagus of a 45 year old patient.
Failure to promptly remove a foreign body impacted in The complications of esophageal foreign bodies are rare but serious. They
the esophagus could result in: include esophageal erosion and perforation, mediastinitis, esophagus-to-trachea
or esophagus-to-vasculature fistula formation, stricture formation, diverticuli
A. Esophageal perforation and mediastinitis formation, and tracheal compression (from both the esophageal foreign body and
B. Epiglottal edema and airway obstruction resultant edema or infection). Air trapping is a sign of a foreign body of the
C. The rapid development of xerostomia airway. Rarely, airway foreign bodies act as one-way valves that could cause
D. Barrett's esophagitis hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax
formation.
, SAEM - Practice Exam Questions and Correct Answers (Verified Answers)
A mother brings her 35 year old son to the emergency B. neuroleptic malignant syndrome
department because of tremor and mutism for the past
three days. His mother found him in his room this Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-threatening
morning lying stiffly in his bed, soiled with urine and reaction to antipsychotic medications, with haloperidol being the most common
feces. He appears confused and will not respond to cause. It is characterized by elevated temperatures, "lead pipe" muscle rigidity,
questions. He was diagnosed with schizophrenia last altered mental status, choreoathetosis, tremors, and autonomic dysfunction (e.g.,
year and has been on several medications. Last month diaphoresis, labile blood pressure, incontinence, dysrhythmias). While this
after his most recent hospital admission for patient's temperature is only 102.7, students should note that any patients with
schizophrenia, he was discharged with a prescription for temperatures greater than 105 most likely have non-infectious etiologies for
haloperidol. On physical exam, he is visibly diaphoretic temperature elevation. NMS is thought to be due to too much D2 blockade in the
and has vital signs as follows: T 102.7, BP 140/98, P substantia nigra and hypothalamus. Treatment consists of stopping the causative
112, R 12. His neuromuscular exam shows extremely agent and providing supportive care. Medications such as dantrolene,
rigid extremities, and his laboratory values are notable bromocriptine, amantadine, and lorazepam are also often used. Tardive
for a white blood cell count of 15000/mm3 and dyskinesia is a chronic movement disorder that results from prolonged use of
abnormally elevated creatine phosphokinase levels. antipsychotics and can include involuntary and periodic movements of the
What is the most likely explanation for these findings? tongue or lips, mouth puckering, or flailing movements either of the extremities or
A. neuroleptic-induced acute dystonia of the spine. Neuroleptic-induced acute dystonia is an acute spasm of a muscle
B. neuroleptic malignant syndrome or muscle group associated with the use of antipsychotic agents. It presents with
C. schizophrenia, catatonic type patients complaining of neck twisting (torticollis), fixed upper gaze, facial muscle
D. tardive dyskinesia spasms, or dysarthria from tongue protrusions. In a similar family with dystonia,
neuroleptic-induced akathisia is an extrapyramidal syndrome that is manifest by
agitation and restlessness. Schizophrenia, catatonic type, a diagnosis of
exclusion, usually does not present with this degree of impairment.
A 25 year old man returns to the ED, 24 hours after A. diphenhydramine
being released from the hospital with a new diagnosis of
schizophrenia. He has recently started to take Acute dystonia, the most common adverse effect seen with neuroleptic agents,
haloperidal for his psychotic symptoms. In the ED he is occurs in up to 5% of patients. Dystonic reactions, which can occur at any point
noted to have involuntary contractions of the muscles of during long-term therapy and up to 48 hours after administration of neuroleptics
the face, a protruding tongue, deviation of the head to in the emergency department, involve the sudden onset of involuntary
one side, and sustained upward deviation of the eyes. contraction of the muscles in the face, neck, or back. The patient may have
Vital signs are stable, and initial labs show no electrolyte protrusion of the tongue (buccolingual crisis), deviation of the head to one side
or hematological abnormalities. Of the following choices, (acute torticollis), sustained upward deviation of the eyes (oculogyric crisis),
the preferred medication for this condition is: extreme arching of the back (opisthotonos), or rarely laryngospasm. These
symptoms tend to fluctuate, decreasing with voluntary activity and increasing
A. diphenhydramine under emotional stress, which occasionally misleads emergency physicians to
B. lorazepam believe they may be hysterical in nature. Dystonic reactions should be treated
C. phenobarbital with IM or IV benztropine (Cogentin®), 1 to 2 mg, or diphenhydramine
D. metoprolol (Benadryl®), 25 to 50 mg. Intravenous administration usually results in near-
immediate reversal of symptoms. Patients should receive oral therapy with the
same medication for 48 to 72 hours to prevent recurrent symptoms.
A 70 year old male with acute delirium requires C. prolonged QT interval
administration of haloperidol for agitation. Which of the
following is a recognized side effect of haloperidol? Nephrogenic diabetes insipidus may be associated with lithium. Potential side
A. first degree heart block effects of haloperidol include acute dystonia, prolonged QT interval,
B. nephrogenic diabetes insipidus Parkinsonism, and akathisia
C. prolonged QT interval
D. transient hepatitis
A 19 year old woman is brought to the emergency D. vertical nystagmus - phencyclidine
department by her friends because she has been saying
that she is a superhero and trying to run into traffic to Sympathomimetics (cocaine, amphetamines) cause dilated pupils. Opiates
prove that she is indestructible. The friends report that (heroin) cause pinpoint pupils. Internuclear ophthalmoplegia is associated with
she has been using drugs but they do not know which multiple sclerosis. CN VI palsy is not associated with any specific drugs.
ones. Which of the following pairs of ocular finding and
recreational drug is commonly observed?
A. dilated pupils - heroin
B. internuclear ophthalmoplegia - marijuana
C. pinpoint pupils - amphetamines
D. vertical nystagmus - phencyclidine
A 42 year old former custodial worker presents stating, "I A. haloperidol
think that people can hear what I am thinking." In the
emergency department, he becomes extremely agitated Haloperidol is the most studied high potency antipsychotic agent used in agitated
and threatening, and his psychoses become more patients. Typical dosing is 5-10 mg IM every 10-30 minutes. Unlike thioridazine,
severe. In choosing an antipsychotic medication, which haloperidol does not cause respiratory depression, has negligible
of the following would be the most appropriate choice? anticholinergic side effects, and rarely causes hypotension. Although
benzodiazepines can be used in the agitated patient, respiratory depression can
A. haloperidol occur, and close monitoring is essential.
B. chlorpromazine
C. thioridazine
D. ketamine
Regarding the diagnosis of acute appendicitis, all the A. Vital signs are usually abnormal, even early in the course of acute
following are true EXCEPT: appendicitis.
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.
B. Rebound is usually elicited only after the appendix Early in its course, vital signs including temperature may be normal. Once
has ruptured or infarcted. perforation has occurred, the rate of low-grade fever (<38 C) increases to about
C. Rovsing's sign is pain in the right lower quadrant upon 40%. Other variations in presentation include pain in the right upper quadrant,
palpation of the left lower quadrant. typically from a retrocecal or retroiliac appendix.
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.
Rosving's sign is described as: E. Pain in the right lower quadrant when left lower quadrant is palpated.
A. Tenderness in the right upper quadrant that is worse
with inspiration. The answer is E. Rosving's sign is pain in the right lower quadrant when the left
B. Pelvic pain upon flexion of the thigh while the patient lower quadrant is palpated. Rebound tenderness occurs with the release of
is supine. pressure. The iliopsoas sign is pain associated with thigh flexion. The obturator
C. Pelvic pain upon internal and external rotation of the sign is pain that occurs with thigh rotation. All of these signs are associated with
thigh with the knee flexed. appendicitis. Murphy's sign is cessation of inspiration during palpation of the right
D. Pain that increases with the release of pressure of upper quadrant and is associated with acute cholecystitis.
palpation.
E. Pain in the right lower quadrant when left lower
quadrant is palpated.
In establishing a differential diagnosis of abdominal pain, D. The onset of pain prior to the occurrence of nausea and vomiting is more often
which of the following is true? suggestive of a surgical etiology.
A. Radiation of pain to the scapula is suggestive of acute
hepatitis. The answer is D. Pain prior to nausea and vomiting is often suggestive of a
B. Cervical motion tenderness is a useful physical finding surgical etiology of the pain, such as small bowel obstruction. Cervical motion
for differentiating women with or without acute tenderness has been noted in up to 25% of women with acute appendicitis.
appendicitis. Patients with sickle cell anemia are prone to Salmonella infections. Radiation of
C. In patients with sickle cell anemia who present with pain to the scapula is classically present in acute choleycystitis. Diverticulitis pain
abdominal pain and diarrhea, shigellosis should be a top is generally located in the left lower quadrant.
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.
Of the following pain patterns, which is the least likely C. unrelenting pain over a period of weeks
associated with diagnosis of peptic ulcer disease?
A. non-radiating, burning epigastric pain The answer is C. Pain from peptic ulcer disease typically occurs in periods of
B. pain that awakens a patient in the middle of the night exacerbation and remission. Unrelenting pain over weeks or months should
C. unrelenting pain over a period of weeks suggest an alternative diagnosis. Pain is classically described as non-radiating,
D. relief of abdominal pain with antacids burning epigastric pain. Some patients may also complain of chest or back pain.
E. pain that is worse preceding a meal 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 E. pyloric stenosis
room. She states the baby has been vomiting everything
she's tried to feed him for the past 12 hours. She states The answer is E. Hypertrophic pyloric stenosis typically presents in the second to
that he usually eats readily and completes an entire sixth week of life and is four times more common in males than females. Infants
feeding, but he is unable to keep anything down. The with hypertrophic pyloric stenosis typically are vigorous eaters but shortly
emesis is non-bloody and non-bilious, however it is afterward regurgitate the entire feeding contents in a projectile fashion. The
projectile in nature. What is the most likely condition in emesis is non-bilious. The classic finding on exam is an "olive" palpable in the
this patient? abdomen, and diagnosis is typically via ultrasound. Intussusception typically
A. viral gastroenteritis presents between the ages of 5 and 12 months. Gastroenteritis is characterized
B. constipation by diarrhea as well as vomiting. Neither constipation nor appendicitis typically
C. appendicitis present with protracted vomiting, though the latter condition tends to present
D. intussusception atypically in young children (and elderly adults).
E. pyloric stenosis
, SAEM - Practice Exam Questions and Correct Answers (Verified Answers)
A 46 year old woman presents to the emergency C. Helical CT scan greater than 95% sensitive and specific for renal calculi.
department complaining of abrupt onset of intermittent
severe pain in the left flank and abdomen that woke her Helical CT scan has been shown to be both highly sensitive and specific in the
from sleep. She is pacing around the stretcher and diagnosis of renal calculi. It is the preferred modality for evaluation in many
appears extremely uncomfortable. She has never centers. Although urinalysis typically demonstrates hematuria in patients with
experienced this type of pain previously and denies renal calculi, hematuria is not specific enough to confirm the diagnosis, and
fevers or other symptoms. Renal calculus is suspected. imaging is warranted in all first-time presenters. KUB detects approximately 60-
Which of the following is true regarding the diagnosis of 70% of calculi (though studies addressing this issue are somewhat
renal calculi in this patient? methodologically flawed). Ultrasound is not reliable for detecting small calculi, but
A. Urinalysis demonstrating hematuria confirms the is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is
diagnosis. contraindicated in patients with renal insufficiency due to the dye load necessary
B. KUB detects less than 10% of calculi. to perform the study.
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.
A 50 year old man presents with 1 day of gradually B. Discharge home on high-fiber diet, laxatives and stool softeners
worsening, intermittent, left lower quadrant pain
associated with loose stools. He has had no fevers or This patient has classic diverticulosis (saclike protrusions of colonic mucosa
bloody bowel movements. Similar symptoms in the past through the muscularis) without signs of acute diverticulitis (inflammation of
were self-limited. All vital signs lie within normal limits. diverticula). Usually these patients can be managed as outpatients with a high-
Physical examination shows mild tenderness in the left fiber diet and treatments to decrease intestinal spasm. If the patient develops
lower quadrant, normal active bowel sounds and neither fever or pain increases he may need further evaluation to rule out abscess
masses nor peritoneal signs. His primary-care physician formation. Diverticulitis is treated with antibiotics, bowel rest and analgesics.
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
You are treating a 25 year old male with the recent D. There is a small increased risk of colon cancer
diagnosis of Crohn's disease in the ED. Regarding
Crohn's disease, you know that: 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")
A. Lesions are typically contiguous and the inflammation involves all of the layers of the bowel wall--resulting in
B. Small bowel involvement is rare many of the complications of Crohn's such as abscess and fistula formation,
C. Bleeding is common due to superficial bowel wall intestinal obstruction, and perforation. The risk of colon cancer is only slightly
inflammation elevated above baseline. In contrast, Ulcerative colitis begins in the rectum and
D. There is a small increased risk of colon cancer 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 D. marked inguinal lymphadenopathy
department, accompanied by three of her children,
complaining of severe abdominal pain that began this This woman is likely suffering from acute cholecystitis. Predisposing factors
afternoon after lunch. Physical exam reveals marked include female gender, obesity, increased age and increased parity. Inflammation
RUQ tenderness. Likely findings on this patient would of the gallbladder causes RUQ pain and sonographic Murphy's sign (inspiratory
include all of the following EXCEPT: arrest, due to pain, while the ultrasound probe is positioned over the gallbladder).
A. positive sonographic Murphy's sign Pain may radiate to the right scapula. Lab studies usually show leukocytosis with
B. pain in the right scapula or without a left shift, and aminotransferases and bilirubin are usually within
C. leukocytosis with left shift normal limits.
D. marked inguinal lymphadenopathy
E. aminotransferases and bilirubin within normal limits
A 45 year old woman presents with right upper quadrant D. Cholecystitis
pain and fever. The pain is worse after eating. On
physical exam she has a Murphy's sign. The most likely Right upper quadrant pain, fever and a Murphy's sign suggests cholecystitis.
diagnosis is: Cholelithiasis presents with similar pain, but is not associated with fever or a
Murphy's sign
A. Appendicitis
B. Diverticulitis
C. Cholelithiasis
D. Cholecystitis
E. Mesenteric Ischemia
, SAEM - Practice Exam Questions and Correct Answers (Verified Answers)
All of the following factors predispose to cecal volvulus E. severe chronic constipation
EXCEPT:
Cecal volvulus occurs as a result of abnormal fixation of the right colon and
A. pregnancy increased mobility of the cecum. Depending on the degree of rotation around the
B. age 25-35 mesenteric axis, cecal volvulus can lead to twisting of the mesentery and its
C. prior abdominal surgery blood vessels. Cecal volvulus occurs most commonly in people 25-35 years old
D. marathon running and should be suspected in cases of bowel obstruction without known risk
E. severe chronic constipation 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.
Which of the following pairings of referred pain and A. sacral pain—ovarian torsion
causal disease is least likely to be encountered?
Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal
A. sacral pain—ovarian torsion tenderness, and cervical motion tenderness, but it is not known to cause sacral
B. inguinal pain—ureteral colic pain.
C. epigastric pain—myocardial infarction
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatitis
A 72 year old man with a history of diverticulosis E. admission for intravenous antibiotics and fluids
presents with vague abdominal pain for the past day. His
physical exam is notable for normal vital signs, left lower For mild episodes of diverticulitis in which there is no evidence of perforation or
quadrant abdominal tenderness without rebound or peritonitis, there is no indication for immediate surgical intervention. Conservative
guarding, and guaiac positive brown stool. Work-up management with intravenous fluids and antibiotics as well as bowel rest is
including KUB and abdominal/pelvic CT scan reveals typically first attempted. Although colon carcinoma may be a precipitating factor
diverticulitis without perforation. Of the following choices, in the development of diverticulitis, barium enema should be avoided in the acute
which is the most appropriate management of this period due to high risk of bowel perforation. Although some patients with mild
patient? cases of diverticulitis may be discharged home with conservative treatment, the
elderly are at higher risk of perforation and should be admitted. Guaiac positive
A. type and cross two units of packed red blood cells stool in seen in up to 50% of patients with diverticulitis. There is no reason to
B. immediate surgical intervention suspect acute blood loss requiring transfusion in diverticulitis.
C. discharge on oral pain medications
D. barium enema to evaluate for carcinoma of the colon
E. admission for intravenous antibiotics and fluids
Regarding esophageal perforation, which of the following D. Over 90% of spontaneous esophageal perforations occur in the proximal
is INCORRECT: esophagus.
A. Esophageal perforation has been reported as a Over 90% of spontaneous esophageal perforations occur in
complication of nasogastric tube placement, the distal esophagus, whereas iatrogenic perforations are frequently at the
endotracheal intubation, and esophagotracheal pharyngoesophageal junction or the esophagogastric junction. Foreign body or
Combitube intubation. caustic substance ingestion, severe blunt injury or penetrating trauma, and
B. Esophageal perforation may result from forceful carcinoma are other causes of esophageal perforation.
vomiting, coughing, childbirth or heavy lifting.
C. Over 80% of esophageal perforations are iatrogenic,
usually as complications of upper endoscopy, dilation, or
sclerotherapy.
D. Over 90% of spontaneous esophageal perforations
occur in the proximal esophagus.
E. Iatrogenic perforations of the esophagus usually occur
in the proximal esophagus or esophagogastric junction.
Working in the ED, you have identified a bony object A. Esophageal perforation and mediastinitis
wedged in the mid-esophagus of a 45 year old patient.
Failure to promptly remove a foreign body impacted in The complications of esophageal foreign bodies are rare but serious. They
the esophagus could result in: include esophageal erosion and perforation, mediastinitis, esophagus-to-trachea
or esophagus-to-vasculature fistula formation, stricture formation, diverticuli
A. Esophageal perforation and mediastinitis formation, and tracheal compression (from both the esophageal foreign body and
B. Epiglottal edema and airway obstruction resultant edema or infection). Air trapping is a sign of a foreign body of the
C. The rapid development of xerostomia airway. Rarely, airway foreign bodies act as one-way valves that could cause
D. Barrett's esophagitis hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax
formation.
, SAEM - Practice Exam Questions and Correct Answers (Verified Answers)
A mother brings her 35 year old son to the emergency B. neuroleptic malignant syndrome
department because of tremor and mutism for the past
three days. His mother found him in his room this Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-threatening
morning lying stiffly in his bed, soiled with urine and reaction to antipsychotic medications, with haloperidol being the most common
feces. He appears confused and will not respond to cause. It is characterized by elevated temperatures, "lead pipe" muscle rigidity,
questions. He was diagnosed with schizophrenia last altered mental status, choreoathetosis, tremors, and autonomic dysfunction (e.g.,
year and has been on several medications. Last month diaphoresis, labile blood pressure, incontinence, dysrhythmias). While this
after his most recent hospital admission for patient's temperature is only 102.7, students should note that any patients with
schizophrenia, he was discharged with a prescription for temperatures greater than 105 most likely have non-infectious etiologies for
haloperidol. On physical exam, he is visibly diaphoretic temperature elevation. NMS is thought to be due to too much D2 blockade in the
and has vital signs as follows: T 102.7, BP 140/98, P substantia nigra and hypothalamus. Treatment consists of stopping the causative
112, R 12. His neuromuscular exam shows extremely agent and providing supportive care. Medications such as dantrolene,
rigid extremities, and his laboratory values are notable bromocriptine, amantadine, and lorazepam are also often used. Tardive
for a white blood cell count of 15000/mm3 and dyskinesia is a chronic movement disorder that results from prolonged use of
abnormally elevated creatine phosphokinase levels. antipsychotics and can include involuntary and periodic movements of the
What is the most likely explanation for these findings? tongue or lips, mouth puckering, or flailing movements either of the extremities or
A. neuroleptic-induced acute dystonia of the spine. Neuroleptic-induced acute dystonia is an acute spasm of a muscle
B. neuroleptic malignant syndrome or muscle group associated with the use of antipsychotic agents. It presents with
C. schizophrenia, catatonic type patients complaining of neck twisting (torticollis), fixed upper gaze, facial muscle
D. tardive dyskinesia spasms, or dysarthria from tongue protrusions. In a similar family with dystonia,
neuroleptic-induced akathisia is an extrapyramidal syndrome that is manifest by
agitation and restlessness. Schizophrenia, catatonic type, a diagnosis of
exclusion, usually does not present with this degree of impairment.
A 25 year old man returns to the ED, 24 hours after A. diphenhydramine
being released from the hospital with a new diagnosis of
schizophrenia. He has recently started to take Acute dystonia, the most common adverse effect seen with neuroleptic agents,
haloperidal for his psychotic symptoms. In the ED he is occurs in up to 5% of patients. Dystonic reactions, which can occur at any point
noted to have involuntary contractions of the muscles of during long-term therapy and up to 48 hours after administration of neuroleptics
the face, a protruding tongue, deviation of the head to in the emergency department, involve the sudden onset of involuntary
one side, and sustained upward deviation of the eyes. contraction of the muscles in the face, neck, or back. The patient may have
Vital signs are stable, and initial labs show no electrolyte protrusion of the tongue (buccolingual crisis), deviation of the head to one side
or hematological abnormalities. Of the following choices, (acute torticollis), sustained upward deviation of the eyes (oculogyric crisis),
the preferred medication for this condition is: extreme arching of the back (opisthotonos), or rarely laryngospasm. These
symptoms tend to fluctuate, decreasing with voluntary activity and increasing
A. diphenhydramine under emotional stress, which occasionally misleads emergency physicians to
B. lorazepam believe they may be hysterical in nature. Dystonic reactions should be treated
C. phenobarbital with IM or IV benztropine (Cogentin®), 1 to 2 mg, or diphenhydramine
D. metoprolol (Benadryl®), 25 to 50 mg. Intravenous administration usually results in near-
immediate reversal of symptoms. Patients should receive oral therapy with the
same medication for 48 to 72 hours to prevent recurrent symptoms.
A 70 year old male with acute delirium requires C. prolonged QT interval
administration of haloperidol for agitation. Which of the
following is a recognized side effect of haloperidol? Nephrogenic diabetes insipidus may be associated with lithium. Potential side
A. first degree heart block effects of haloperidol include acute dystonia, prolonged QT interval,
B. nephrogenic diabetes insipidus Parkinsonism, and akathisia
C. prolonged QT interval
D. transient hepatitis
A 19 year old woman is brought to the emergency D. vertical nystagmus - phencyclidine
department by her friends because she has been saying
that she is a superhero and trying to run into traffic to Sympathomimetics (cocaine, amphetamines) cause dilated pupils. Opiates
prove that she is indestructible. The friends report that (heroin) cause pinpoint pupils. Internuclear ophthalmoplegia is associated with
she has been using drugs but they do not know which multiple sclerosis. CN VI palsy is not associated with any specific drugs.
ones. Which of the following pairs of ocular finding and
recreational drug is commonly observed?
A. dilated pupils - heroin
B. internuclear ophthalmoplegia - marijuana
C. pinpoint pupils - amphetamines
D. vertical nystagmus - phencyclidine
A 42 year old former custodial worker presents stating, "I A. haloperidol
think that people can hear what I am thinking." In the
emergency department, he becomes extremely agitated Haloperidol is the most studied high potency antipsychotic agent used in agitated
and threatening, and his psychoses become more patients. Typical dosing is 5-10 mg IM every 10-30 minutes. Unlike thioridazine,
severe. In choosing an antipsychotic medication, which haloperidol does not cause respiratory depression, has negligible
of the following would be the most appropriate choice? anticholinergic side effects, and rarely causes hypotension. Although
benzodiazepines can be used in the agitated patient, respiratory depression can
A. haloperidol occur, and close monitoring is essential.
B. chlorpromazine
C. thioridazine
D. ketamine
