SAEM ACTUAL 2026 EXAM QUESTIONS AND ANSWERS
GRADED A+
✔✔A 45 year old woman presents with right upper quadrant pain and fever. The pain is
worse after eating. On physical exam she has a Murphy's sign. The most likely
diagnosis is:
A. Appendicitis
B. Diverticulitis
C. Cholelithiasis
D. Cholecystitis
E. Mesenteric Ischemia - ✔✔D. Cholecystitis
The answer is D. Right upper quadrant pain, fever and a Murphy's sign suggests
cholecystitis. 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 constipation - ✔✔E. severe chronic constipation
The answer is E. Cecal volvulus occurs as a result of abnormal fixation of the right colon
and increased mobility of the cecum. Depending on the degree of rotation around the
mesenteric axis, cecal volvulus can lead to twisting 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 obstruction 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 causal disease is least likely to
be encountered?
A. sacral pain—ovarian torsion
B. inguinal pain—ureteral colic
C. epigastric pain—myocardial infarction
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatitis - ✔✔A. sacral pain—ovarian torsion
, Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and
cervical motion tenderness, but it is not known to cause sacral pain.
✔✔A 72 year old man with a history of diverticulosis presents with vague abdominal
pain for the past day. His physical exam is notable for normal vital signs, left lower
quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown
stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis
without perforation. Of the following choices, which is the most appropriate
management of this patient?
A. type and cross two units of packed red blood cells
B. immediate surgical intervention
C. discharge on oral pain medications
D. barium enema to evaluate for carcinoma of the colon
E. admission for intravenous antibiotics and fluids - ✔✔E. admission for intravenous
antibiotics and fluids
The answer is E. For mild episodes of diverticulitis in which there is no evidence of
perforation or peritonitis, there is no indication for immediate surgical intervention.
Conservative management with intravenous fluids and antibiotics as well as bowel rest
is typically first attempted. Although colon carcinoma may be a precipitating factor in the
development of diverticulitis, barium enema should be avoided in the acute period due
to high risk of bowel perforation. Although some patients with mild cases of diverticulitis
may be discharged home with conservative treatment, the elderly are at higher risk of
perforation and should be admitted. *Guaiac positive stool* in seen in up to *50%* of
patients with diverticulitis. There is no reason to suspect acute blood loss requiring
transfusion in diverticulitis.
✔✔Regarding esophageal perforation, which of the following is INCORRECT:
A. Esophageal perforation has been reported as a complication of nasogastric tube
placement, endotracheal intubation, and esophagotracheal Combitube intubation.
B. Esophageal perforation may result from forceful 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. - ✔✔D. Over 90% of spontaneous esophageal perforations
occur in the proximal esophagus.
Over 90% of spontaneous esophageal perforations occur in the *distal* esophagus,
whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or
the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt
injury or penetrating trauma, and carcinoma are other causes of esophageal perforation.
GRADED A+
✔✔A 45 year old woman presents with right upper quadrant pain and fever. The pain is
worse after eating. On physical exam she has a Murphy's sign. The most likely
diagnosis is:
A. Appendicitis
B. Diverticulitis
C. Cholelithiasis
D. Cholecystitis
E. Mesenteric Ischemia - ✔✔D. Cholecystitis
The answer is D. Right upper quadrant pain, fever and a Murphy's sign suggests
cholecystitis. 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 constipation - ✔✔E. severe chronic constipation
The answer is E. Cecal volvulus occurs as a result of abnormal fixation of the right colon
and increased mobility of the cecum. Depending on the degree of rotation around the
mesenteric axis, cecal volvulus can lead to twisting 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 obstruction 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 causal disease is least likely to
be encountered?
A. sacral pain—ovarian torsion
B. inguinal pain—ureteral colic
C. epigastric pain—myocardial infarction
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatitis - ✔✔A. sacral pain—ovarian torsion
, Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and
cervical motion tenderness, but it is not known to cause sacral pain.
✔✔A 72 year old man with a history of diverticulosis presents with vague abdominal
pain for the past day. His physical exam is notable for normal vital signs, left lower
quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown
stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis
without perforation. Of the following choices, which is the most appropriate
management of this patient?
A. type and cross two units of packed red blood cells
B. immediate surgical intervention
C. discharge on oral pain medications
D. barium enema to evaluate for carcinoma of the colon
E. admission for intravenous antibiotics and fluids - ✔✔E. admission for intravenous
antibiotics and fluids
The answer is E. For mild episodes of diverticulitis in which there is no evidence of
perforation or peritonitis, there is no indication for immediate surgical intervention.
Conservative management with intravenous fluids and antibiotics as well as bowel rest
is typically first attempted. Although colon carcinoma may be a precipitating factor in the
development of diverticulitis, barium enema should be avoided in the acute period due
to high risk of bowel perforation. Although some patients with mild cases of diverticulitis
may be discharged home with conservative treatment, the elderly are at higher risk of
perforation and should be admitted. *Guaiac positive stool* in seen in up to *50%* of
patients with diverticulitis. There is no reason to suspect acute blood loss requiring
transfusion in diverticulitis.
✔✔Regarding esophageal perforation, which of the following is INCORRECT:
A. Esophageal perforation has been reported as a complication of nasogastric tube
placement, endotracheal intubation, and esophagotracheal Combitube intubation.
B. Esophageal perforation may result from forceful 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. - ✔✔D. Over 90% of spontaneous esophageal perforations
occur in the proximal esophagus.
Over 90% of spontaneous esophageal perforations occur in the *distal* esophagus,
whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or
the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt
injury or penetrating trauma, and carcinoma are other causes of esophageal perforation.
