Emergency Medicine SAEM Final Exam 2023-2024
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.
The answer is C. 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
D. Admit for observation and serial examinations - ANSWER B. Discharge home on
high-fiber diet, laxatives and stool softeners
The answer is B. This patient has classic diverticulosis (saclike protrusions of colonic mucosa
through the muscularis) without signs of acute diverticulitis (inflammation of diverticula).
Usually these patients can be managed as outpatients with a high-fiber diet and treatments to
decrease intestinal spasm. If the patient develops fever or pain increases he may need further
evaluation to rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest
and analgesics.
You are treating 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 contiguous
B. Small bowel involvement is rare
C. Bleeding is common due to superficial bowel wall inflammation
D. There is a small increased risk of colon cancer - ANSWER D. There is a small increased
risk of colon cancer
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 as "skip lesions") and the
inflammation involves all of the layers of the bowel wall--resulting in many of the
complications of Crohn's such as abscess and fistula formation, intestinal obstruction, and
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.
The answer is C. 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
D. Admit for observation and serial examinations - ANSWER B. Discharge home on
high-fiber diet, laxatives and stool softeners
The answer is B. This patient has classic diverticulosis (saclike protrusions of colonic mucosa
through the muscularis) without signs of acute diverticulitis (inflammation of diverticula).
Usually these patients can be managed as outpatients with a high-fiber diet and treatments to
decrease intestinal spasm. If the patient develops fever or pain increases he may need further
evaluation to rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest
and analgesics.
You are treating 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 contiguous
B. Small bowel involvement is rare
C. Bleeding is common due to superficial bowel wall inflammation
D. There is a small increased risk of colon cancer - ANSWER D. There is a small increased
risk of colon cancer
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 as "skip lesions") and the
inflammation involves all of the layers of the bowel wall--resulting in many of the
complications of Crohn's such as abscess and fistula formation, intestinal obstruction, and
