Emergency Medicine SAEM exam test bank_2021/2022.
Regarding the diagnosis of acute appendicits, all the following are true EXCEPT:
A. Vital signs are usually abnormal, even early in the course of acute appendicits.
B. Rebound is usually elicited only aſter the appendix has ruptured or infarcted.
C. Rovsing's sign is pain in the right lower quadrant upon palpaton of the leſt lower quadrant.
D. The obturator sign is pain upon flexion and internal rotaton of the hip.
E. The psoas sign is pain upon extension of the hip. Correct Answer: A. Vital signs are usually abnormal,
even early in the course of acute appendicits.
The answer is A. The presentaton of acute appendicits varies tremendously. Early in its course, vital
signs including temperature may be normal. Once perforaton has occurred, the rate of low-grade fever
(<38 C) increases to about 40%. Other variatons in presentaton 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 inspiraton.
B. Pelvic pain upon flexion of the thigh while the patent is supine.
C. Pelvic pain upon internal and external rotaton of the thigh with the knee flexed.
D. Pain that increases with the release of pressure of palpaton.
E. Pain in the right lower quadrant when leſt lower quadrant is palpated. Correct Answer: E. Pain in the
right lower quadrant when leſt lower quadrant is palpated.
The answer is E. Rosving's sign is pain in the right lower quadrant when the leſt 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 rotaton. All of these signs are
associated with appendicits. Murphy's sign is cessaton of inspiraton during palpaton of the right upper
quadrant and is associated with acute cholecystts.
In establishing a differental diagnosis of abdominal pain, which of the following is true?
A. Radiaton of pain to the scapula is suggestve of acute hepatts.
B. Cervical moton tenderness is a useful physical finding for differentatng women with or without
acute appendicits.
C. In patents with sickle cell anemia who present with abdominal pain and diarrhea, shigellosis should
be a top consideraton.
D. The onset of pain prior to the occurrence of nausea and vomitng is more oſten suggestve of a
surgical etology.
E. Divertculits tends to cause pain in the right upper quadrant. Correct Answer: D. The onset of pain
prior to the occurrence of nausea and vomitng is more oſten suggestve of a surgical etology.
The answer is D. Pain prior to nausea and vomitng is oſten suggestve of a surgical etology of the pain,
such as small bowel obstructon. Cervical moton tenderness has been noted in up to 25% of women
with acute appendicits. Patents with sickle cell anemia are prone to Salmonella infectons. Radiaton of
pain to the scapula is classically present in acute choleycystts. Divertculits pain is generally located in
the leſt lower quadrant.
Of the following pain paterns, which is the least likely associated with diagnosis of peptc ulcer disease?
,A. non-radiatng, burning epigastric pain
B. pain that awakens a patent in the middle of the night
C. unrelentng pain over a period of weeks
D. relief of abdominal pain with antacids
E. pain that is worse preceding a meal Correct Answer: C. unrelentng pain over a period of weeks
The answer is C. Pain from peptc ulcer disease typically occurs in periods of exacerbaton and remission.
Unrelentng pain over weeks or months should suggest an alternatve diagnosis. Pain is classically
described as non-radiatng, burning epigastric pain. Some patents may also complain of chest or back
pain. Pain is frequently severe enough to awaken patents from sleep in early morning hours but is oſten
not present upon waking in the morning, as gastric acid secreton 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 vomitng
everything she's tried to feed him for the past 12 hours. She states that he usually eats readily and
completes an entre feeding, but he is unable to keep anything down. The emesis is non-bloody and
non-bilious, however it is projectle in nature. What is the most likely conditon in this patent?
A. viral gastroenterits
B. constpaton
C. appendicits
D. intussuscepton
E. pyloric stenosis Correct Answer: E. pyloric stenosis
The answer is E. Hypertrophic pyloric stenosis typically presents in the second to sixth week of life and is
four tmes more common in males than females. Infants with hypertrophic pyloric stenosis typically are
vigorous eaters but shortly aſterward regurgitate the entre feeding contents in a projectle fashion. The
emesis is non-bilious. The classic finding on exam is an "olive" palpable in the abdomen, and diagnosis is
typically via ultrasound. Intussuscepton typically presents between the ages of 5 and 12 months.
Gastroenterits is characterized by diarrhea as well as vomitng. Neither constpaton nor appendicits
typically present with protracted vomitng, though the later conditon 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
intermitent severe pain in the leſt 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 patent?
A. Urinalysis demonstratng hematuria confirms the diagnosis.
B. KUB detects less than 10% of calculi.
C. Helical CT scan greater than 95% sensitve and specific for renal calculi.
D. Ultrasound is the study of choice for detectng small ureteral calculi.
E. Intravenous pyelogram (IVP) may be used in patents with renal insufficiency. Correct Answer: C.
Helical CT scan greater than 95% sensitve and specific for renal calculi.
The answer is C. Helical CT scan has been shown to be both highly sensitve and specific in the diagnosis
of renal calculi. It is the preferred modality for evaluaton in many centers. Although urinalysis typically
demonstrates hematuria in patents with renal calculi, hematuria is not specific enough to confirm the
diagnosis, and imaging is warranted in all first-tme presenters. KUB detects approximately 60-70% of
,calculi (though studies addressing this issue are somewhat methodologically flawed). Ultrasound is not
reliable for detectng small calculi, but is 85-94% sensitve and 100% specific at demonstratng
hydronephrosis. IVP is contraindicated in patents 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, intermitent, leſt 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 examinaton shows mild
tenderness in the leſt lower quadrant, normal actve 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 aſter a single dose of IV antbiotcs
B. Discharge home on high-fiber diet, laxatves and stool soſteners
C. Gastroenterology consult for endoscopy
D. Admit for observaton and serial examinatons Correct Answer: B. Discharge home on high-fiber diet,
laxatves and stool soſteners
The answer is B. This patent has classic divertculosis (saclike protrusions of colonic mucosa through the
muscularis) without signs of acute divertculits (inflammaton of divertcula). Usually these patents can
be managed as outpatents with a high-fiber diet and treatments to decrease intestnal spasm. If the
patent develops fever or pain increases he may need further evaluaton to rule out abscess formaton.
Divertculits is treated with antbiotcs, bowel rest and analgesics.
You are treatng a 25 year old male with the recent diagnosis of Crohn's disease in the ED. Regarding
Crohn's disease, you know that:
A. Lesions are typically contguous
B. Small bowel involvement is rare
C. Bleeding is common due to superficial bowel wall inflammaton
D. There is a small increased risk of colon cancer Correct Answer: D. There is a small increased risk of
colon cancer
The answer is D. Although Crohn's disease may involve the entre bowel tract, the rectum is rarely
involved. Involved areas are typically non-contguous (known as "skip lesions") and the inflammaton
involves all of the layers of the bowel wall--resultng in many of the complicatons of Crohn's such as
abscess and fistula formaton, intestnal obstructon, and perforaton. The risk of colon cancer is only
slightly elevated above baseline. In contrast, Ulceratve colits begins in the rectum and may spread to
the upper parts of the colon but never involves the small intestne. The ulceratons are contguous and
involve only the colonic mucosa. The incidence of colon cancer may be increased up to 30 tmes over
baseline.
A 53 year old obese woman presents to the emergency department, accompanied by three of her
children, complaining of severe abdominal pain that began this aſternoon aſter lunch. Physical exam
reveals marked RUQ tenderness. Likely findings on this patent would include all of the following
EXCEPT:
A. positve sonographic Murphy's sign
B. pain in the right scapula
C. leukocytosis with leſt shiſt
, D. marked inguinal lymphadenopathy
E. aminotransferases and bilirubin within normal limits Correct Answer: D. marked inguinal
lymphadenopathy
The answer is D. This woman is likely suffering from acute cholecystts. Predisposing factors include
female gender, obesity, increased age and increased parity. Inflammaton of the gallbladder causes RUQ
pain and sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound probe is
positoned over the gallbladder). Pain may radiate to the right scapula. Lab studies usually show
leukocytosis with or without a leſt shiſt, and aminotransferases and bilirubin are usually within normal
limits.
A 45 year old woman presents with right upper quadrant pain and fever. The pain is worse aſter eatng.
On physical exam she has a Murphy's sign. The most likely diagnosis is:
A. Appendicits
B. Divertculits
C. Cholelithiasis
D. Cholecystts
E. Mesenteric Ischemia Correct Answer: D. Cholecystts
The answer is D. Right upper quadrant pain, fever and a Murphy's sign suggests cholecystts.
Cholelithiasis presents with similar pain, but is not associated with fever or a Murphy's sign
All of the following factors predispose to cecal volvulus EXCEPT:
A. pregnancy
B. age 25-35
C. prior abdominal surgery
D. marathon running
E. severe chronic constpaton Correct Answer: E. severe chronic constpaton
The answer is E. Cecal volvulus occurs as a result of abnormal fixaton of the right colon and increased
mobility of the cecum. Depending on the degree of rotaton around the mesenteric axis, cecal volvulus
can lead to twistng of the mesentery and its blood vessels. Cecal volvulus occurs most commonly in
people 25-35 years old and should be suspected in cases of bowel obstructon without known risk
factors. Prior abdominal surgery and pregnancy predispose to obstructon or cecal volvulus; however,
chronic constpaton is not known to predispose to cecal volvulus. Interestngly, marathon runners have
been found to have a higher incidence of cecal volvulus, perhaps from having a thin, flexible mesentery
that more easily permits rotaton of the cecum around the mesenteric pedicle.
Which of the following pairings of referred pain and causal disease is least likely to be encountered?
A. sacral pain—ovarian torsion
B. inguinal pain—ureteral colic
C. epigastric pain—myocardial infarcton
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatts Correct Answer: A. sacral pain—ovarian torsion
Regarding the diagnosis of acute appendicits, all the following are true EXCEPT:
A. Vital signs are usually abnormal, even early in the course of acute appendicits.
B. Rebound is usually elicited only aſter the appendix has ruptured or infarcted.
C. Rovsing's sign is pain in the right lower quadrant upon palpaton of the leſt lower quadrant.
D. The obturator sign is pain upon flexion and internal rotaton of the hip.
E. The psoas sign is pain upon extension of the hip. Correct Answer: A. Vital signs are usually abnormal,
even early in the course of acute appendicits.
The answer is A. The presentaton of acute appendicits varies tremendously. Early in its course, vital
signs including temperature may be normal. Once perforaton has occurred, the rate of low-grade fever
(<38 C) increases to about 40%. Other variatons in presentaton 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 inspiraton.
B. Pelvic pain upon flexion of the thigh while the patent is supine.
C. Pelvic pain upon internal and external rotaton of the thigh with the knee flexed.
D. Pain that increases with the release of pressure of palpaton.
E. Pain in the right lower quadrant when leſt lower quadrant is palpated. Correct Answer: E. Pain in the
right lower quadrant when leſt lower quadrant is palpated.
The answer is E. Rosving's sign is pain in the right lower quadrant when the leſt 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 rotaton. All of these signs are
associated with appendicits. Murphy's sign is cessaton of inspiraton during palpaton of the right upper
quadrant and is associated with acute cholecystts.
In establishing a differental diagnosis of abdominal pain, which of the following is true?
A. Radiaton of pain to the scapula is suggestve of acute hepatts.
B. Cervical moton tenderness is a useful physical finding for differentatng women with or without
acute appendicits.
C. In patents with sickle cell anemia who present with abdominal pain and diarrhea, shigellosis should
be a top consideraton.
D. The onset of pain prior to the occurrence of nausea and vomitng is more oſten suggestve of a
surgical etology.
E. Divertculits tends to cause pain in the right upper quadrant. Correct Answer: D. The onset of pain
prior to the occurrence of nausea and vomitng is more oſten suggestve of a surgical etology.
The answer is D. Pain prior to nausea and vomitng is oſten suggestve of a surgical etology of the pain,
such as small bowel obstructon. Cervical moton tenderness has been noted in up to 25% of women
with acute appendicits. Patents with sickle cell anemia are prone to Salmonella infectons. Radiaton of
pain to the scapula is classically present in acute choleycystts. Divertculits pain is generally located in
the leſt lower quadrant.
Of the following pain paterns, which is the least likely associated with diagnosis of peptc ulcer disease?
,A. non-radiatng, burning epigastric pain
B. pain that awakens a patent in the middle of the night
C. unrelentng pain over a period of weeks
D. relief of abdominal pain with antacids
E. pain that is worse preceding a meal Correct Answer: C. unrelentng pain over a period of weeks
The answer is C. Pain from peptc ulcer disease typically occurs in periods of exacerbaton and remission.
Unrelentng pain over weeks or months should suggest an alternatve diagnosis. Pain is classically
described as non-radiatng, burning epigastric pain. Some patents may also complain of chest or back
pain. Pain is frequently severe enough to awaken patents from sleep in early morning hours but is oſten
not present upon waking in the morning, as gastric acid secreton 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 vomitng
everything she's tried to feed him for the past 12 hours. She states that he usually eats readily and
completes an entre feeding, but he is unable to keep anything down. The emesis is non-bloody and
non-bilious, however it is projectle in nature. What is the most likely conditon in this patent?
A. viral gastroenterits
B. constpaton
C. appendicits
D. intussuscepton
E. pyloric stenosis Correct Answer: E. pyloric stenosis
The answer is E. Hypertrophic pyloric stenosis typically presents in the second to sixth week of life and is
four tmes more common in males than females. Infants with hypertrophic pyloric stenosis typically are
vigorous eaters but shortly aſterward regurgitate the entre feeding contents in a projectle fashion. The
emesis is non-bilious. The classic finding on exam is an "olive" palpable in the abdomen, and diagnosis is
typically via ultrasound. Intussuscepton typically presents between the ages of 5 and 12 months.
Gastroenterits is characterized by diarrhea as well as vomitng. Neither constpaton nor appendicits
typically present with protracted vomitng, though the later conditon 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
intermitent severe pain in the leſt 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 patent?
A. Urinalysis demonstratng hematuria confirms the diagnosis.
B. KUB detects less than 10% of calculi.
C. Helical CT scan greater than 95% sensitve and specific for renal calculi.
D. Ultrasound is the study of choice for detectng small ureteral calculi.
E. Intravenous pyelogram (IVP) may be used in patents with renal insufficiency. Correct Answer: C.
Helical CT scan greater than 95% sensitve and specific for renal calculi.
The answer is C. Helical CT scan has been shown to be both highly sensitve and specific in the diagnosis
of renal calculi. It is the preferred modality for evaluaton in many centers. Although urinalysis typically
demonstrates hematuria in patents with renal calculi, hematuria is not specific enough to confirm the
diagnosis, and imaging is warranted in all first-tme presenters. KUB detects approximately 60-70% of
,calculi (though studies addressing this issue are somewhat methodologically flawed). Ultrasound is not
reliable for detectng small calculi, but is 85-94% sensitve and 100% specific at demonstratng
hydronephrosis. IVP is contraindicated in patents 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, intermitent, leſt 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 examinaton shows mild
tenderness in the leſt lower quadrant, normal actve 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 aſter a single dose of IV antbiotcs
B. Discharge home on high-fiber diet, laxatves and stool soſteners
C. Gastroenterology consult for endoscopy
D. Admit for observaton and serial examinatons Correct Answer: B. Discharge home on high-fiber diet,
laxatves and stool soſteners
The answer is B. This patent has classic divertculosis (saclike protrusions of colonic mucosa through the
muscularis) without signs of acute divertculits (inflammaton of divertcula). Usually these patents can
be managed as outpatents with a high-fiber diet and treatments to decrease intestnal spasm. If the
patent develops fever or pain increases he may need further evaluaton to rule out abscess formaton.
Divertculits is treated with antbiotcs, bowel rest and analgesics.
You are treatng a 25 year old male with the recent diagnosis of Crohn's disease in the ED. Regarding
Crohn's disease, you know that:
A. Lesions are typically contguous
B. Small bowel involvement is rare
C. Bleeding is common due to superficial bowel wall inflammaton
D. There is a small increased risk of colon cancer Correct Answer: D. There is a small increased risk of
colon cancer
The answer is D. Although Crohn's disease may involve the entre bowel tract, the rectum is rarely
involved. Involved areas are typically non-contguous (known as "skip lesions") and the inflammaton
involves all of the layers of the bowel wall--resultng in many of the complicatons of Crohn's such as
abscess and fistula formaton, intestnal obstructon, and perforaton. The risk of colon cancer is only
slightly elevated above baseline. In contrast, Ulceratve colits begins in the rectum and may spread to
the upper parts of the colon but never involves the small intestne. The ulceratons are contguous and
involve only the colonic mucosa. The incidence of colon cancer may be increased up to 30 tmes over
baseline.
A 53 year old obese woman presents to the emergency department, accompanied by three of her
children, complaining of severe abdominal pain that began this aſternoon aſter lunch. Physical exam
reveals marked RUQ tenderness. Likely findings on this patent would include all of the following
EXCEPT:
A. positve sonographic Murphy's sign
B. pain in the right scapula
C. leukocytosis with leſt shiſt
, D. marked inguinal lymphadenopathy
E. aminotransferases and bilirubin within normal limits Correct Answer: D. marked inguinal
lymphadenopathy
The answer is D. This woman is likely suffering from acute cholecystts. Predisposing factors include
female gender, obesity, increased age and increased parity. Inflammaton of the gallbladder causes RUQ
pain and sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound probe is
positoned over the gallbladder). Pain may radiate to the right scapula. Lab studies usually show
leukocytosis with or without a leſt shiſt, and aminotransferases and bilirubin are usually within normal
limits.
A 45 year old woman presents with right upper quadrant pain and fever. The pain is worse aſter eatng.
On physical exam she has a Murphy's sign. The most likely diagnosis is:
A. Appendicits
B. Divertculits
C. Cholelithiasis
D. Cholecystts
E. Mesenteric Ischemia Correct Answer: D. Cholecystts
The answer is D. Right upper quadrant pain, fever and a Murphy's sign suggests cholecystts.
Cholelithiasis presents with similar pain, but is not associated with fever or a Murphy's sign
All of the following factors predispose to cecal volvulus EXCEPT:
A. pregnancy
B. age 25-35
C. prior abdominal surgery
D. marathon running
E. severe chronic constpaton Correct Answer: E. severe chronic constpaton
The answer is E. Cecal volvulus occurs as a result of abnormal fixaton of the right colon and increased
mobility of the cecum. Depending on the degree of rotaton around the mesenteric axis, cecal volvulus
can lead to twistng of the mesentery and its blood vessels. Cecal volvulus occurs most commonly in
people 25-35 years old and should be suspected in cases of bowel obstructon without known risk
factors. Prior abdominal surgery and pregnancy predispose to obstructon or cecal volvulus; however,
chronic constpaton is not known to predispose to cecal volvulus. Interestngly, marathon runners have
been found to have a higher incidence of cecal volvulus, perhaps from having a thin, flexible mesentery
that more easily permits rotaton of the cecum around the mesenteric pedicle.
Which of the following pairings of referred pain and causal disease is least likely to be encountered?
A. sacral pain—ovarian torsion
B. inguinal pain—ureteral colic
C. epigastric pain—myocardial infarcton
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatts Correct Answer: A. sacral pain—ovarian torsion
