SAEM M4 CURRICULUM 2|LATEST UPDATE
2026|2027|A COMPREHENSIVE REVIEW OF
300 PRACTICE QUESTIONS WITH ANSWERS
RATIONALES |PASS GUARANTEED.
Section I: Abdominal & Gastrointestinal Emergencies
1. A 42-year-old man presents with 18 hours of periumbilical pain that
migrated to the right lower quadrant. He has nausea, anorexia, and a low-
grade fever. On examination, he has right lower quadrant tenderness with
guarding. WBC is 14,500/mL. CT shows a dilated, non-compressible appendix
with peri appendiceal fat stranding. What is the most appropriate
management?
A. Immediate laparoscopic appendectomy
B. IV antibiotics alone with interval appendectomy in 6-8 weeks
C. Observation with serial examinations and discharge if improving
D. CT-guided percutaneous drainage
Correct Answer: A
Rationale: For uncomplicated acute appendicitis in an adult, prompt appendectomy
remains the standard of care. Non-operative management with antibiotics alone is
associated with a high recurrence rate and is reserved for select cases or patients
with significant surgical contraindications. Option B describes an outdated
approach. Option C risks perforation. Option D is indicated for appendiceal
abscess, not uncomplicated appendicitis.
2. A 55-year-old woman presents with right upper quadrant pain, fever, and
vomiting for 24 hours. She has a positive Murphy sign. Ultrasound
demonstrates gallbladder wall thickening, pericholecystic fluid, and an
,impacted gallstone in the cystic duct. What is the most appropriate next step
in management?
A. Immediate laparoscopic cholecystectomy within 24 hours
B. IV antibiotics and delayed cholecystectomy after 6 weeks
C. Urgent ERCP with sphincterotomy
D. Percutaneous cholecystostomy tube placement
Correct Answer: A
Rationale: Current guidelines support early laparoscopic cholecystectomy (within
24-72 hours) for acute cholecystitis, as it reduces hospital stay and perioperative
complications compared with delayed surgery. Option B increases the risk of
recurrent biliary events. Option C is indicated for choledocholithiasis or
cholangitis, not cholecystitis. Option D is reserved for patients who are poor
surgical candidates.
3. A 68-year-old man with prior abdominal surgery presents with vomiting,
abdominal distension, and obstipation. CT shows dilated small bowel loops
with a transition point in the mid-ileum. He has no peritoneal signs, WBC is
normal, and lactate is 1.2 mmol/L. What is the most appropriate initial
management?
A. Immediate exploratory laparotomy
B. NPO status, nasogastric tube decompression, IV fluid resuscitation, and serial
examinations
C. Gastrographic challenge and discharge if tolerated
D. Urgent colonoscopy for decompression
Correct Answer: B
Rationale: Adhesive small bowel obstruction without signs of strangulation
(normal lactate, no peritonitis, no leukocytosis) is managed conservatively initially
with bowel rest, decompression, and fluid resuscitation. Option A is indicated for
signs of ischemia or perforation. Option C is not standard initial management.
Option D is used for colonic pseudo-obstruction (Ogilvie syndrome), not small
bowel obstruction.
,4. A 58-year-old man with cirrhosis presents with hematemesis and melena.
Blood pressure is 88/52 mmHg; heart rate is 118 bpm. He is confused. What is
the most appropriate immediate management after airway stabilization?
A. Immediate endoscopy without medical therapy
B. IV octreotide, IV ceftriaxone, and IV proton pump inhibitor
C. Trans jugular intrahepatic portosystemic shunt (TIPS) placement
D. Sengstacke-Blakemore tube placement
Correct Answer: B
Rationale: For suspected variceal hemorrhage, the immediate priorities are
hemodynamic resuscitation, vasoactive therapy (octreotide), antibiotic prophylaxis
(ceftriaxone), and proton pump inhibitor therapy before endoscopy. Option A
delays critical medical stabilization. TIPS is a definitive salvage therapy after
failed endoscopic management. Balloon tamponade is a temporizing measure for
massive hemorrhage when other measures fail.
5. A 24-year-old man presents with sudden-onset severe epigastric pain
radiating to the back, associated with vomiting. He has a history of heavy
alcohol use. On examination, he has epigastric tenderness and voluntary
guarding. Lipase is elevated at 3 times the upper limit of normal. What is the
most appropriate initial management?
A. Immediate CT-guided drainage
B. Aggressive IV fluid resuscitation, pain control, and antiemetics
C. Urgent ERCP
D. Immediate exploratory laparotomy
Correct Answer: B
Rationale: Acute pancreatitis without evidence of necrosis, infected pseudocyst, or
biliary obstruction is managed supportively with aggressive IV hydration,
analgesia, and antiemetics. ERCP is indicated for concomitant cholangitis or
persistent biliary obstruction. Surgical intervention is reserved for complications
, such as infected necrosis or perforation. Early CT-guided drainage is not indicated
in the absence of infected fluid collections.
6. A 72-year-old woman presents with diffuse abdominal pain, distension, and
inability to pass flatus for 2 days. She has a history of atrial fibrillation and is
not anticoagulated. CT shows colonic dilation with a transition point at the
splenic flexure and no evidence of volvulus. What is the most appropriate
management?
A. Immediate colonoscopy
B. IV neostigmine after excluding mechanical obstruction
C. Immediate exploratory laparotomy
D. Oral polyethylene glycol lavage
Correct Answer: B
Rationale: Acute colonic pseudo-obstruction (Ogilvie syndrome) in the absence of
mechanical obstruction and ischemia can be treated with IV neostigmine after
excluding contraindications such as bradycardia and mechanical obstruction.
Colonoscopy is reserved for failure of medical therapy or when ischemia is
suspected. Surgery is indicated for perforation or ischemia. Oral lavage is
contraindicated due to risk of perforation.
7. A 45-year-old man presents with severe periumbilical pain that is out of
proportion to physical examination findings. He has a history of atrial
fibrillation. CT angiography shows a filling defect in the superior mesenteric
artery. What is the most appropriate management?
A. Immediate exploratory laparotomy
B. IV heparin and emergent vascular surgery consultation
C. IV antibiotics and observation
D. Thrombolytic therapy via catheter-directed infusion
Correct Answer: B
2026|2027|A COMPREHENSIVE REVIEW OF
300 PRACTICE QUESTIONS WITH ANSWERS
RATIONALES |PASS GUARANTEED.
Section I: Abdominal & Gastrointestinal Emergencies
1. A 42-year-old man presents with 18 hours of periumbilical pain that
migrated to the right lower quadrant. He has nausea, anorexia, and a low-
grade fever. On examination, he has right lower quadrant tenderness with
guarding. WBC is 14,500/mL. CT shows a dilated, non-compressible appendix
with peri appendiceal fat stranding. What is the most appropriate
management?
A. Immediate laparoscopic appendectomy
B. IV antibiotics alone with interval appendectomy in 6-8 weeks
C. Observation with serial examinations and discharge if improving
D. CT-guided percutaneous drainage
Correct Answer: A
Rationale: For uncomplicated acute appendicitis in an adult, prompt appendectomy
remains the standard of care. Non-operative management with antibiotics alone is
associated with a high recurrence rate and is reserved for select cases or patients
with significant surgical contraindications. Option B describes an outdated
approach. Option C risks perforation. Option D is indicated for appendiceal
abscess, not uncomplicated appendicitis.
2. A 55-year-old woman presents with right upper quadrant pain, fever, and
vomiting for 24 hours. She has a positive Murphy sign. Ultrasound
demonstrates gallbladder wall thickening, pericholecystic fluid, and an
,impacted gallstone in the cystic duct. What is the most appropriate next step
in management?
A. Immediate laparoscopic cholecystectomy within 24 hours
B. IV antibiotics and delayed cholecystectomy after 6 weeks
C. Urgent ERCP with sphincterotomy
D. Percutaneous cholecystostomy tube placement
Correct Answer: A
Rationale: Current guidelines support early laparoscopic cholecystectomy (within
24-72 hours) for acute cholecystitis, as it reduces hospital stay and perioperative
complications compared with delayed surgery. Option B increases the risk of
recurrent biliary events. Option C is indicated for choledocholithiasis or
cholangitis, not cholecystitis. Option D is reserved for patients who are poor
surgical candidates.
3. A 68-year-old man with prior abdominal surgery presents with vomiting,
abdominal distension, and obstipation. CT shows dilated small bowel loops
with a transition point in the mid-ileum. He has no peritoneal signs, WBC is
normal, and lactate is 1.2 mmol/L. What is the most appropriate initial
management?
A. Immediate exploratory laparotomy
B. NPO status, nasogastric tube decompression, IV fluid resuscitation, and serial
examinations
C. Gastrographic challenge and discharge if tolerated
D. Urgent colonoscopy for decompression
Correct Answer: B
Rationale: Adhesive small bowel obstruction without signs of strangulation
(normal lactate, no peritonitis, no leukocytosis) is managed conservatively initially
with bowel rest, decompression, and fluid resuscitation. Option A is indicated for
signs of ischemia or perforation. Option C is not standard initial management.
Option D is used for colonic pseudo-obstruction (Ogilvie syndrome), not small
bowel obstruction.
,4. A 58-year-old man with cirrhosis presents with hematemesis and melena.
Blood pressure is 88/52 mmHg; heart rate is 118 bpm. He is confused. What is
the most appropriate immediate management after airway stabilization?
A. Immediate endoscopy without medical therapy
B. IV octreotide, IV ceftriaxone, and IV proton pump inhibitor
C. Trans jugular intrahepatic portosystemic shunt (TIPS) placement
D. Sengstacke-Blakemore tube placement
Correct Answer: B
Rationale: For suspected variceal hemorrhage, the immediate priorities are
hemodynamic resuscitation, vasoactive therapy (octreotide), antibiotic prophylaxis
(ceftriaxone), and proton pump inhibitor therapy before endoscopy. Option A
delays critical medical stabilization. TIPS is a definitive salvage therapy after
failed endoscopic management. Balloon tamponade is a temporizing measure for
massive hemorrhage when other measures fail.
5. A 24-year-old man presents with sudden-onset severe epigastric pain
radiating to the back, associated with vomiting. He has a history of heavy
alcohol use. On examination, he has epigastric tenderness and voluntary
guarding. Lipase is elevated at 3 times the upper limit of normal. What is the
most appropriate initial management?
A. Immediate CT-guided drainage
B. Aggressive IV fluid resuscitation, pain control, and antiemetics
C. Urgent ERCP
D. Immediate exploratory laparotomy
Correct Answer: B
Rationale: Acute pancreatitis without evidence of necrosis, infected pseudocyst, or
biliary obstruction is managed supportively with aggressive IV hydration,
analgesia, and antiemetics. ERCP is indicated for concomitant cholangitis or
persistent biliary obstruction. Surgical intervention is reserved for complications
, such as infected necrosis or perforation. Early CT-guided drainage is not indicated
in the absence of infected fluid collections.
6. A 72-year-old woman presents with diffuse abdominal pain, distension, and
inability to pass flatus for 2 days. She has a history of atrial fibrillation and is
not anticoagulated. CT shows colonic dilation with a transition point at the
splenic flexure and no evidence of volvulus. What is the most appropriate
management?
A. Immediate colonoscopy
B. IV neostigmine after excluding mechanical obstruction
C. Immediate exploratory laparotomy
D. Oral polyethylene glycol lavage
Correct Answer: B
Rationale: Acute colonic pseudo-obstruction (Ogilvie syndrome) in the absence of
mechanical obstruction and ischemia can be treated with IV neostigmine after
excluding contraindications such as bradycardia and mechanical obstruction.
Colonoscopy is reserved for failure of medical therapy or when ischemia is
suspected. Surgery is indicated for perforation or ischemia. Oral lavage is
contraindicated due to risk of perforation.
7. A 45-year-old man presents with severe periumbilical pain that is out of
proportion to physical examination findings. He has a history of atrial
fibrillation. CT angiography shows a filling defect in the superior mesenteric
artery. What is the most appropriate management?
A. Immediate exploratory laparotomy
B. IV heparin and emergent vascular surgery consultation
C. IV antibiotics and observation
D. Thrombolytic therapy via catheter-directed infusion
Correct Answer: B
