SAEM CV exam questions and answers
Regarding the diagnosis of acute appendicitis, all the following are true EXCEPT:
A. Vital signs are usually abnormal, even early in the course of acute appendicitis.
B. Rebound is usually elicited only after the appendix has ruptured or infarcted.
C. Rovsing's sign is pain in the right lower quadrant upon palpation of the left
lower quadrant.
D. The obturator sign is pain upon flexion and internal rotation of the hip.
E. The psoas sign is pain upon extension of the hip. - ANSWER>>A. Vital signs are
usually abnormal, even early in the course of acute appendicitis.
The ANSWER is A. The presentation of acute appendicitis varies tremendously.
Early in its course, vital signs including temperature may be normal. Once
perforation has occurred, the rate of low-grade fever (<38 C) increases to about
40%. Other variations in presentation include pain in the right upper quadrant,
typically from a retrocecal or retroiliac appendix.
Rosving's sign is described as:
A. Tenderness in the right upper quadrant that is worse with inspiration.
B. Pelvic pain upon flexion of the thigh while the patient is supine.
C. Pelvic pain upon internal and external rotation of the thigh with the knee
flexed.
D. Pain that increases with the release of pressure of palpation.
E. Pain in the right lower quadrant when left lower quadrant is palpated. -
ANSWER>>E. Pain in the right lower quadrant when left lower quadrant is
palpated.
The ANSWER is E. Rosving's sign is pain in the right lower quadrant when the left
lower quadrant is palpated. Rebound tenderness occurs with the release of
pressure. The iliopsoas sign is pain associated with thigh flexion. The obturator
sign is pain that occurs with thigh rotation. All of these signs are associated with
,appendicitis. Murphy's sign is cessation of inspiration during palpation of the right
upper quadrant and is associated with acute cholecystitis.
In establishing a differential diagnosis of abdominal pain, which of the following is
true?
A. Radiation of pain to the scapula is suggestive of acute hepatitis.
B. Cervical motion tenderness is a useful physical finding for differentiating
women with or without acute appendicitis.
C. In patients with sickle cell anemia who present with abdominal pain and
diarrhea, shigellosis should be a top consideration.
D. The onset of pain prior to the occurrence of nausea and vomiting is more often
suggestive of a surgical etiology.
E. Diverticulitis tends to cause pain in the right upper quadrant. - ANSWER>>D.
The onset of pain prior to the occurrence of nausea and vomiting is more often
suggestive of a surgical etiology.
The ANSWER is D. Pain prior to nausea and vomiting is often suggestive of a
surgical etiology of the pain, such as small bowel obstruction. Cervical motion
tenderness has been noted in up to 25% of women with acute appendicitis.
Patients with sickle cell anemia are prone to Salmonella infections. Radiation of
pain to the scapula is classically present in acute choleycystitis. Diverticulitis pain
is generally located in the left lower quadrant.
Of the following pain patterns, which is the least likely associated with diagnosis
of peptic ulcer disease?
A. non-radiating, burning epigastric pain
B. pain that awakens a patient in the middle of the night
C. unrelenting pain over a period of weeks
D. relief of abdominal pain with antacids
E. pain that is worse preceding a meal - ANSWER>>C. unrelenting pain over a
period of weeks
,The ANSWER is C. Pain from peptic ulcer disease typically occurs in periods of
exacerbation and remission. Unrelenting pain over weeks or months should
suggest an alternative diagnosis. Pain is classically described as non-radiating,
burning epigastric pain. Some patients may also complain of chest or back pain.
Pain is frequently severe enough to awaken patients from sleep in early morning
hours but is often not present upon waking in the morning, as gastric acid
secretion peaks around 2 a.m. and nadirs upon awakening.
A mother brings her 6 week old boy to the emergency room. She states the baby
has been vomiting everything she's tried to feed him for the past 12 hours. She
states that he usually eats readily and completes an entire feeding, but he is
unable to keep anything down. The emesis is non-bloody and non-bilious,
however it is projectile in nature. What is the most likely condition in this patient?
A. viral gastroenteritis
B. constipation
C. appendicitis
D. intussusception
E. pyloric stenosis - ANSWER>>E. pyloric stenosis
The ANSWER is E. Hypertrophic pyloric stenosis typically presents in the second to
sixth week of life and is four times more common in males than females. Infants
with hypertrophic pyloric stenosis typically are vigorous eaters but shortly
afterward regurgitate the entire feeding contents in a projectile fashion. The
emesis is non-bilious. The classic finding on exam is an "olive" palpable in the
abdomen, and diagnosis is typically via ultrasound. Intussusception typically
presents between the ages of 5 and 12 months. Gastroenteritis is characterized
by diarrhea as well as vomiting. Neither constipation nor appendicitis typically
present with protracted vomiting, though the latter condition tends to present
atypically in young children (and elderly adults).
A 46 year old woman presents to the emergency department complaining of
abrupt onset of intermittent severe pain in the left flank and abdomen that woke
her from sleep. She is pacing around the stretcher and appears extremely
, uncomfortable. She has never experienced this type of pain previously and denies
fevers or other symptoms. Renal calculus is suspected. Which of the following is
true regarding the diagnosis of renal calculi in this patient?
A. Urinalysis demonstrating hematuria confirms the diagnosis.
B. KUB detects less than 10% of calculi.
C. Helical CT scan greater than 95% sensitive and specific for renal calculi.
D. Ultrasound is the study of choice for detecting small ureteral calculi.
E. Intravenous pyelogram (IVP) may be used in patients with renal insufficiency. -
ANSWER>>C. Helical CT scan greater than 95% sensitive and specific for renal
calculi.
Helical CT scan has been shown to be both highly sensitive and specific in the
diagnosis of renal calculi. It is the preferred modality for evaluation in many
centers. Although urinalysis typically demonstrates hematuria in patients with
renal calculi, hematuria is not specific enough to confirm the diagnosis, and
imaging is warranted in all first-time presenters. KUB detects approximately 60-
70% of calculi (though studies addressing this issue are somewhat
methodologically flawed). Ultrasound is not reliable for detecting small calculi,
but is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is
contraindicated in patients with renal insufficiency due to the dye load necessary
to perform the study.
A 50 year old man presents with 1 day of gradually worsening, intermittent, left
lower quadrant pain associated with loose stools. He has had no fevers or bloody
bowel movements. Similar symptoms in the past were self-limited. All vital signs
lie within normal limits. Physical examination shows mild tenderness in the left
lower quadrant, normal active bowel sounds and neither masses nor peritoneal
signs. His primary-care physician can see him tomorrow in his clinic. What should
be done next in the E.D.?
A. Discharge home after a single dose of IV antibiotics
B. Discharge home on high-fiber diet, laxatives and stool softeners
C. Gastroenterology consult for endoscopy
Regarding the diagnosis of acute appendicitis, all the following are true EXCEPT:
A. Vital signs are usually abnormal, even early in the course of acute appendicitis.
B. Rebound is usually elicited only after the appendix has ruptured or infarcted.
C. Rovsing's sign is pain in the right lower quadrant upon palpation of the left
lower quadrant.
D. The obturator sign is pain upon flexion and internal rotation of the hip.
E. The psoas sign is pain upon extension of the hip. - ANSWER>>A. Vital signs are
usually abnormal, even early in the course of acute appendicitis.
The ANSWER is A. The presentation of acute appendicitis varies tremendously.
Early in its course, vital signs including temperature may be normal. Once
perforation has occurred, the rate of low-grade fever (<38 C) increases to about
40%. Other variations in presentation include pain in the right upper quadrant,
typically from a retrocecal or retroiliac appendix.
Rosving's sign is described as:
A. Tenderness in the right upper quadrant that is worse with inspiration.
B. Pelvic pain upon flexion of the thigh while the patient is supine.
C. Pelvic pain upon internal and external rotation of the thigh with the knee
flexed.
D. Pain that increases with the release of pressure of palpation.
E. Pain in the right lower quadrant when left lower quadrant is palpated. -
ANSWER>>E. Pain in the right lower quadrant when left lower quadrant is
palpated.
The ANSWER is E. Rosving's sign is pain in the right lower quadrant when the left
lower quadrant is palpated. Rebound tenderness occurs with the release of
pressure. The iliopsoas sign is pain associated with thigh flexion. The obturator
sign is pain that occurs with thigh rotation. All of these signs are associated with
,appendicitis. Murphy's sign is cessation of inspiration during palpation of the right
upper quadrant and is associated with acute cholecystitis.
In establishing a differential diagnosis of abdominal pain, which of the following is
true?
A. Radiation of pain to the scapula is suggestive of acute hepatitis.
B. Cervical motion tenderness is a useful physical finding for differentiating
women with or without acute appendicitis.
C. In patients with sickle cell anemia who present with abdominal pain and
diarrhea, shigellosis should be a top consideration.
D. The onset of pain prior to the occurrence of nausea and vomiting is more often
suggestive of a surgical etiology.
E. Diverticulitis tends to cause pain in the right upper quadrant. - ANSWER>>D.
The onset of pain prior to the occurrence of nausea and vomiting is more often
suggestive of a surgical etiology.
The ANSWER is D. Pain prior to nausea and vomiting is often suggestive of a
surgical etiology of the pain, such as small bowel obstruction. Cervical motion
tenderness has been noted in up to 25% of women with acute appendicitis.
Patients with sickle cell anemia are prone to Salmonella infections. Radiation of
pain to the scapula is classically present in acute choleycystitis. Diverticulitis pain
is generally located in the left lower quadrant.
Of the following pain patterns, which is the least likely associated with diagnosis
of peptic ulcer disease?
A. non-radiating, burning epigastric pain
B. pain that awakens a patient in the middle of the night
C. unrelenting pain over a period of weeks
D. relief of abdominal pain with antacids
E. pain that is worse preceding a meal - ANSWER>>C. unrelenting pain over a
period of weeks
,The ANSWER is C. Pain from peptic ulcer disease typically occurs in periods of
exacerbation and remission. Unrelenting pain over weeks or months should
suggest an alternative diagnosis. Pain is classically described as non-radiating,
burning epigastric pain. Some patients may also complain of chest or back pain.
Pain is frequently severe enough to awaken patients from sleep in early morning
hours but is often not present upon waking in the morning, as gastric acid
secretion peaks around 2 a.m. and nadirs upon awakening.
A mother brings her 6 week old boy to the emergency room. She states the baby
has been vomiting everything she's tried to feed him for the past 12 hours. She
states that he usually eats readily and completes an entire feeding, but he is
unable to keep anything down. The emesis is non-bloody and non-bilious,
however it is projectile in nature. What is the most likely condition in this patient?
A. viral gastroenteritis
B. constipation
C. appendicitis
D. intussusception
E. pyloric stenosis - ANSWER>>E. pyloric stenosis
The ANSWER is E. Hypertrophic pyloric stenosis typically presents in the second to
sixth week of life and is four times more common in males than females. Infants
with hypertrophic pyloric stenosis typically are vigorous eaters but shortly
afterward regurgitate the entire feeding contents in a projectile fashion. The
emesis is non-bilious. The classic finding on exam is an "olive" palpable in the
abdomen, and diagnosis is typically via ultrasound. Intussusception typically
presents between the ages of 5 and 12 months. Gastroenteritis is characterized
by diarrhea as well as vomiting. Neither constipation nor appendicitis typically
present with protracted vomiting, though the latter condition tends to present
atypically in young children (and elderly adults).
A 46 year old woman presents to the emergency department complaining of
abrupt onset of intermittent severe pain in the left flank and abdomen that woke
her from sleep. She is pacing around the stretcher and appears extremely
, uncomfortable. She has never experienced this type of pain previously and denies
fevers or other symptoms. Renal calculus is suspected. Which of the following is
true regarding the diagnosis of renal calculi in this patient?
A. Urinalysis demonstrating hematuria confirms the diagnosis.
B. KUB detects less than 10% of calculi.
C. Helical CT scan greater than 95% sensitive and specific for renal calculi.
D. Ultrasound is the study of choice for detecting small ureteral calculi.
E. Intravenous pyelogram (IVP) may be used in patients with renal insufficiency. -
ANSWER>>C. Helical CT scan greater than 95% sensitive and specific for renal
calculi.
Helical CT scan has been shown to be both highly sensitive and specific in the
diagnosis of renal calculi. It is the preferred modality for evaluation in many
centers. Although urinalysis typically demonstrates hematuria in patients with
renal calculi, hematuria is not specific enough to confirm the diagnosis, and
imaging is warranted in all first-time presenters. KUB detects approximately 60-
70% of calculi (though studies addressing this issue are somewhat
methodologically flawed). Ultrasound is not reliable for detecting small calculi,
but is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is
contraindicated in patients with renal insufficiency due to the dye load necessary
to perform the study.
A 50 year old man presents with 1 day of gradually worsening, intermittent, left
lower quadrant pain associated with loose stools. He has had no fevers or bloody
bowel movements. Similar symptoms in the past were self-limited. All vital signs
lie within normal limits. Physical examination shows mild tenderness in the left
lower quadrant, normal active bowel sounds and neither masses nor peritoneal
signs. His primary-care physician can see him tomorrow in his clinic. What should
be done next in the E.D.?
A. Discharge home after a single dose of IV antibiotics
B. Discharge home on high-fiber diet, laxatives and stool softeners
C. Gastroenterology consult for endoscopy
