SAEM Practice Test
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 Test
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 The answer is C. Helical CT scan has been shown to be both highly sensitive
from sleep. She is pacing around the stretcher and and specific in the diagnosis of renal calculi. It is the preferred modality for
appears extremely uncomfortable. She has never evaluation in many centers. Although urinalysis typically demonstrates hematuria
experienced this type of pain previously and denies in patients with renal calculi, hematuria is not specific enough to confirm the
fevers or other symptoms. Renal calculus is suspected. diagnosis, and imaging is warranted in all first-time presenters. KUB detects
Which of the following is true regarding the diagnosis of approximately 60-70% of calculi (though studies addressing this issue are
renal calculi in this patient? somewhat methodologically flawed). Ultrasound is not reliable for detecting small
A. Urinalysis demonstrating hematuria confirms the calculi, but is 85-94% sensitive and 100% specific at demonstrating
diagnosis. hydronephrosis. IVP is contraindicated in patients with renal insufficiency due to
B. KUB detects less than 10% of calculi. the dye load necessary 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 The answer is B. This patient has classic diverticulosis (saclike protrusions of
bloody bowel movements. Similar symptoms in the past colonic mucosa through the muscularis) without signs of acute diverticulitis
were self-limited. All vital signs lie within normal limits. (inflammation of diverticula). Usually these patients can be managed as
Physical examination shows mild tenderness in the left outpatients with a high-fiber diet and treatments to decrease intestinal spasm. If
lower quadrant, normal active bowel sounds and neither the patient develops fever or pain increases he may need further evaluation to
masses nor peritoneal signs. His primary-care physician rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest and
can see him tomorrow in his clinic. What should be done analgesics.
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: The answer is D. Although Crohn's disease may involve the entire bowel tract,
the rectum is rarely involved. Involved areas are typically non-contiguous (known
A. Lesions are typically contiguous as "skip lesions") and the inflammation involves all of the layers of the bowel
B. Small bowel involvement is rare wall--resulting in many of the complications of Crohn's such as abscess and
C. Bleeding is common due to superficial bowel wall fistula formation, intestinal obstruction, and perforation. The risk of colon cancer
inflammation is only slightly elevated above baseline. In contrast, Ulcerative colitis begins in
D. There is a small increased risk of colon cancer 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 D. marked inguinal lymphadenopathy
department, accompanied by three of her children,
complaining of severe abdominal pain that began this The answer is D. This woman is likely suffering from acute cholecystitis.
afternoon after lunch. Physical exam reveals marked Predisposing factors include female gender, obesity, increased age and
RUQ tenderness. Likely findings on this patient would increased parity. Inflammation of the gallbladder causes RUQ pain and
include all of the following EXCEPT: sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound
A. positive sonographic Murphy's sign probe is positioned over the gallbladder). Pain may radiate to the right scapula.
B. pain in the right scapula Lab studies usually show leukocytosis with or without a left shift, and
C. leukocytosis with left shift aminotransferases and bilirubin are usually within 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 The answer is D. Right upper quadrant pain, fever and a Murphy's sign suggests
diagnosis is: cholecystitis. 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 Test
All of the following factors predispose to cecal volvulus E. severe chronic constipation
EXCEPT:
The answer is E. Cecal volvulus occurs as a result of abnormal fixation of the
A. pregnancy right colon and increased mobility of the cecum. Depending on the degree of
B. age 25-35 rotation around the mesenteric axis, cecal volvulus can lead to twisting of the
C. prior abdominal surgery mesentery and its blood vessels. Cecal volvulus occurs most commonly in
D. marathon running people 25-35 years old and should be suspected in cases of bowel obstruction
E. severe chronic constipation 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.
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 The answer is E. For mild episodes of diverticulitis in which there is no evidence
quadrant abdominal tenderness without rebound or of perforation or peritonitis, there is no indication for immediate surgical
guarding, and guaiac positive brown stool. Work-up intervention. Conservative management with intravenous fluids and antibiotics as
including KUB and abdominal/pelvic CT scan reveals well as bowel rest is typically first attempted. Although colon carcinoma may be a
diverticulitis without perforation. Of the following choices, precipitating factor in the development of diverticulitis, barium enema should be
which is the most appropriate management of this avoided in the acute period due to high risk of bowel perforation. Although some
patient? patients with mild cases of diverticulitis may be discharged home with
conservative treatment, the elderly are at higher risk of perforation and should be
A. type and cross two units of packed red blood cells admitted. Guaiac positive stool in seen in up to 50% of patients with
B. immediate surgical intervention diverticulitis. There is no reason to suspect acute blood loss requiring transfusion
C. discharge on oral pain medications in diverticulitis.
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 answer is A. The complications of esophageal foreign bodies are rare but
the esophagus could result in: serious. They include esophageal erosion and perforation, mediastinitis,
esophagus-to-trachea or esophagus-to-vasculature fistula formation, stricture
A. Esophageal perforation and mediastinitis formation, diverticuli formation, and tracheal compression (from both the
B. Epiglottal edema and airway obstruction esophageal foreign body and resultant edema or infection). Air trapping is a sign
C. The rapid development of xerostomia of a foreign body of the airway. Rarely, airway foreign bodies act as one-way
D. Barrett's esophagitis valves that could cause hyperinflation of a lung segment, with resultant bleb
rupture and pneumothorax formation.
, SAEM Practice Test
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 The answer is B. Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-
morning lying stiffly in his bed, soiled with urine and threatening reaction to antipsychotic medications, with haloperidol being the
feces. He appears confused and will not respond to most common cause. It is characterized by elevated temperatures, "lead pipe"
questions. He was diagnosed with schizophrenia last muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic
year and has been on several medications. Last month dysfunction (e.g., diaphoresis, labile blood pressure, incontinence,
after his most recent hospital admission for dysrhythmias). While this patient's temperature is only 102.7, students should
schizophrenia, he was discharged with a prescription for note that any patients with temperatures greater than 105 most likely have non-
haloperidol. On physical exam, he is visibly diaphoretic infectious etiologies for temperature elevation. NMS is thought to be due to too
and has vital signs as follows: T 102.7, BP 140/98, P much D2 blockade in the substantia nigra and hypothalamus. Treatment consists
112, R 12. His neuromuscular exam shows extremely of stopping the causative agent and providing supportive care. Medications such
rigid extremities, and his laboratory values are notable as dantrolene, bromocriptine, amantadine, and lorazepam are also often
for a white blood cell count of 15000/mm3 and used. Tardive dyskinesia (choice A) is a chronic movement disorder that results
abnormally elevated creatine phosphokinase levels. from prolonged use of antipsychotics and can include involuntary and periodic
What is the most likely explanation for these findings? movements of the tongue or lips, mouth puckering, or flailing movements either
A. neuroleptic-induced acute dystonia of the extremities or of the spine. Neuroleptic-induced acute dystonia (choice C)
B. neuroleptic malignant syndrome is an acute spasm of a muscle or muscle group associated with the use of
C. schizophrenia, catatonic type antipsychotic agents. It presents with patients complaining of neck twisting
D. tardive dyskinesia (torticollis), fixed upper gaze, facial muscle spasms, or dysarthria from tongue
protrusions. In a similar family with dystonia, neuroleptic-induced akathisia
(choice D) is an extrapyramidal syndrome that is manifest by agitation and
restlessness. Schizophrenia, catatonic type (choice B), 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 The answer is A. Acute dystonia, the most common adverse effect seen with
haloperidal for his psychotic symptoms. In the ED he is neuroleptic agents, occurs in up to 5% of patients. Dystonic reactions, which can
noted to have involuntary contractions of the muscles of occur at any point during long-term therapy and up to 48 hours after
the face, a protruding tongue, deviation of the head to administration of neuroleptics in the emergency department, involve the sudden
one side, and sustained upward deviation of the eyes. onset of involuntary contraction of the muscles in the face, neck, or back. The
Vital signs are stable, and initial labs show no electrolyte patient may have protrusion of the tongue (buccolingual crisis), deviation of the
or hematological abnormalities. Of the following choices, head to one side (acute torticollis), sustained upward deviation of the eyes
the preferred medication for this condition is: (oculogyric crisis), extreme arching of the back (opisthotonos), or rarely
laryngospasm. These symptoms tend to fluctuate, decreasing with voluntary
A. diphenhydramine activity and increasing under emotional stress, which occasionally misleads
B. lorazepam emergency physicians to believe they may be hysterical in nature. Dystonic
C. phenobarbital reactions should be treated with IM or IV benztropine (Cogentin®), 1 to 2 mg,
D. metoprolol or diphenhydramine (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? The answer is C. Nephrogenic diabetes insipidus may be associated with lithium.
A. first degree heart block Potential side effects of haloperidol include acute dystonia, prolonged QT
B. nephrogenic diabetes insipidus interval, 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 The answer is D. Sympathomimetics (cocaine, amphetamines) cause dilated
prove that she is indestructible. The friends report that pupils. Opiates (heroin) cause pinpoint pupils. Internuclear ophthalmoplegia is
she has been using drugs but they do not know which associated with multiple sclerosis. CN VI palsy is not associated with any specific
ones. Which of the following pairs of ocular finding and drugs.
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 The answer is A. Haloperidol is the most studied high potency antipsychotic
and threatening, and his psychoses become more agent used in agitated patients. Typical dosing is 5-10 mg IM every 10-30
severe. In choosing an antipsychotic medication, which minutes. Unlike thioridazine, haloperidol does not cause respiratory
of the following would be the most appropriate choice? depression, has negligible anticholinergic side effects, and rarely causes
hypotension. Although benzodiazepines can be used in the agitated patient,
A. haloperidol respiratory depression can 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 Test
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 The answer is C. Helical CT scan has been shown to be both highly sensitive
from sleep. She is pacing around the stretcher and and specific in the diagnosis of renal calculi. It is the preferred modality for
appears extremely uncomfortable. She has never evaluation in many centers. Although urinalysis typically demonstrates hematuria
experienced this type of pain previously and denies in patients with renal calculi, hematuria is not specific enough to confirm the
fevers or other symptoms. Renal calculus is suspected. diagnosis, and imaging is warranted in all first-time presenters. KUB detects
Which of the following is true regarding the diagnosis of approximately 60-70% of calculi (though studies addressing this issue are
renal calculi in this patient? somewhat methodologically flawed). Ultrasound is not reliable for detecting small
A. Urinalysis demonstrating hematuria confirms the calculi, but is 85-94% sensitive and 100% specific at demonstrating
diagnosis. hydronephrosis. IVP is contraindicated in patients with renal insufficiency due to
B. KUB detects less than 10% of calculi. the dye load necessary 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 The answer is B. This patient has classic diverticulosis (saclike protrusions of
bloody bowel movements. Similar symptoms in the past colonic mucosa through the muscularis) without signs of acute diverticulitis
were self-limited. All vital signs lie within normal limits. (inflammation of diverticula). Usually these patients can be managed as
Physical examination shows mild tenderness in the left outpatients with a high-fiber diet and treatments to decrease intestinal spasm. If
lower quadrant, normal active bowel sounds and neither the patient develops fever or pain increases he may need further evaluation to
masses nor peritoneal signs. His primary-care physician rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest and
can see him tomorrow in his clinic. What should be done analgesics.
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: The answer is D. Although Crohn's disease may involve the entire bowel tract,
the rectum is rarely involved. Involved areas are typically non-contiguous (known
A. Lesions are typically contiguous as "skip lesions") and the inflammation involves all of the layers of the bowel
B. Small bowel involvement is rare wall--resulting in many of the complications of Crohn's such as abscess and
C. Bleeding is common due to superficial bowel wall fistula formation, intestinal obstruction, and perforation. The risk of colon cancer
inflammation is only slightly elevated above baseline. In contrast, Ulcerative colitis begins in
D. There is a small increased risk of colon cancer 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 D. marked inguinal lymphadenopathy
department, accompanied by three of her children,
complaining of severe abdominal pain that began this The answer is D. This woman is likely suffering from acute cholecystitis.
afternoon after lunch. Physical exam reveals marked Predisposing factors include female gender, obesity, increased age and
RUQ tenderness. Likely findings on this patient would increased parity. Inflammation of the gallbladder causes RUQ pain and
include all of the following EXCEPT: sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound
A. positive sonographic Murphy's sign probe is positioned over the gallbladder). Pain may radiate to the right scapula.
B. pain in the right scapula Lab studies usually show leukocytosis with or without a left shift, and
C. leukocytosis with left shift aminotransferases and bilirubin are usually within 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 The answer is D. Right upper quadrant pain, fever and a Murphy's sign suggests
diagnosis is: cholecystitis. 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 Test
All of the following factors predispose to cecal volvulus E. severe chronic constipation
EXCEPT:
The answer is E. Cecal volvulus occurs as a result of abnormal fixation of the
A. pregnancy right colon and increased mobility of the cecum. Depending on the degree of
B. age 25-35 rotation around the mesenteric axis, cecal volvulus can lead to twisting of the
C. prior abdominal surgery mesentery and its blood vessels. Cecal volvulus occurs most commonly in
D. marathon running people 25-35 years old and should be suspected in cases of bowel obstruction
E. severe chronic constipation 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.
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 The answer is E. For mild episodes of diverticulitis in which there is no evidence
quadrant abdominal tenderness without rebound or of perforation or peritonitis, there is no indication for immediate surgical
guarding, and guaiac positive brown stool. Work-up intervention. Conservative management with intravenous fluids and antibiotics as
including KUB and abdominal/pelvic CT scan reveals well as bowel rest is typically first attempted. Although colon carcinoma may be a
diverticulitis without perforation. Of the following choices, precipitating factor in the development of diverticulitis, barium enema should be
which is the most appropriate management of this avoided in the acute period due to high risk of bowel perforation. Although some
patient? patients with mild cases of diverticulitis may be discharged home with
conservative treatment, the elderly are at higher risk of perforation and should be
A. type and cross two units of packed red blood cells admitted. Guaiac positive stool in seen in up to 50% of patients with
B. immediate surgical intervention diverticulitis. There is no reason to suspect acute blood loss requiring transfusion
C. discharge on oral pain medications in diverticulitis.
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 answer is A. The complications of esophageal foreign bodies are rare but
the esophagus could result in: serious. They include esophageal erosion and perforation, mediastinitis,
esophagus-to-trachea or esophagus-to-vasculature fistula formation, stricture
A. Esophageal perforation and mediastinitis formation, diverticuli formation, and tracheal compression (from both the
B. Epiglottal edema and airway obstruction esophageal foreign body and resultant edema or infection). Air trapping is a sign
C. The rapid development of xerostomia of a foreign body of the airway. Rarely, airway foreign bodies act as one-way
D. Barrett's esophagitis valves that could cause hyperinflation of a lung segment, with resultant bleb
rupture and pneumothorax formation.
, SAEM Practice Test
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 The answer is B. Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-
morning lying stiffly in his bed, soiled with urine and threatening reaction to antipsychotic medications, with haloperidol being the
feces. He appears confused and will not respond to most common cause. It is characterized by elevated temperatures, "lead pipe"
questions. He was diagnosed with schizophrenia last muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic
year and has been on several medications. Last month dysfunction (e.g., diaphoresis, labile blood pressure, incontinence,
after his most recent hospital admission for dysrhythmias). While this patient's temperature is only 102.7, students should
schizophrenia, he was discharged with a prescription for note that any patients with temperatures greater than 105 most likely have non-
haloperidol. On physical exam, he is visibly diaphoretic infectious etiologies for temperature elevation. NMS is thought to be due to too
and has vital signs as follows: T 102.7, BP 140/98, P much D2 blockade in the substantia nigra and hypothalamus. Treatment consists
112, R 12. His neuromuscular exam shows extremely of stopping the causative agent and providing supportive care. Medications such
rigid extremities, and his laboratory values are notable as dantrolene, bromocriptine, amantadine, and lorazepam are also often
for a white blood cell count of 15000/mm3 and used. Tardive dyskinesia (choice A) is a chronic movement disorder that results
abnormally elevated creatine phosphokinase levels. from prolonged use of antipsychotics and can include involuntary and periodic
What is the most likely explanation for these findings? movements of the tongue or lips, mouth puckering, or flailing movements either
A. neuroleptic-induced acute dystonia of the extremities or of the spine. Neuroleptic-induced acute dystonia (choice C)
B. neuroleptic malignant syndrome is an acute spasm of a muscle or muscle group associated with the use of
C. schizophrenia, catatonic type antipsychotic agents. It presents with patients complaining of neck twisting
D. tardive dyskinesia (torticollis), fixed upper gaze, facial muscle spasms, or dysarthria from tongue
protrusions. In a similar family with dystonia, neuroleptic-induced akathisia
(choice D) is an extrapyramidal syndrome that is manifest by agitation and
restlessness. Schizophrenia, catatonic type (choice B), 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 The answer is A. Acute dystonia, the most common adverse effect seen with
haloperidal for his psychotic symptoms. In the ED he is neuroleptic agents, occurs in up to 5% of patients. Dystonic reactions, which can
noted to have involuntary contractions of the muscles of occur at any point during long-term therapy and up to 48 hours after
the face, a protruding tongue, deviation of the head to administration of neuroleptics in the emergency department, involve the sudden
one side, and sustained upward deviation of the eyes. onset of involuntary contraction of the muscles in the face, neck, or back. The
Vital signs are stable, and initial labs show no electrolyte patient may have protrusion of the tongue (buccolingual crisis), deviation of the
or hematological abnormalities. Of the following choices, head to one side (acute torticollis), sustained upward deviation of the eyes
the preferred medication for this condition is: (oculogyric crisis), extreme arching of the back (opisthotonos), or rarely
laryngospasm. These symptoms tend to fluctuate, decreasing with voluntary
A. diphenhydramine activity and increasing under emotional stress, which occasionally misleads
B. lorazepam emergency physicians to believe they may be hysterical in nature. Dystonic
C. phenobarbital reactions should be treated with IM or IV benztropine (Cogentin®), 1 to 2 mg,
D. metoprolol or diphenhydramine (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? The answer is C. Nephrogenic diabetes insipidus may be associated with lithium.
A. first degree heart block Potential side effects of haloperidol include acute dystonia, prolonged QT
B. nephrogenic diabetes insipidus interval, 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 The answer is D. Sympathomimetics (cocaine, amphetamines) cause dilated
prove that she is indestructible. The friends report that pupils. Opiates (heroin) cause pinpoint pupils. Internuclear ophthalmoplegia is
she has been using drugs but they do not know which associated with multiple sclerosis. CN VI palsy is not associated with any specific
ones. Which of the following pairs of ocular finding and drugs.
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 The answer is A. Haloperidol is the most studied high potency antipsychotic
and threatening, and his psychoses become more agent used in agitated patients. Typical dosing is 5-10 mg IM every 10-30
severe. In choosing an antipsychotic medication, which minutes. Unlike thioridazine, haloperidol does not cause respiratory
of the following would be the most appropriate choice? depression, has negligible anticholinergic side effects, and rarely causes
hypotension. Although benzodiazepines can be used in the agitated patient,
A. haloperidol respiratory depression can occur, and close monitoring is essential.
B. chlorpromazine
C. thioridazine
D. ketamine
