CRAM SAEM TEST 2 QUESTIONS AND
ANSWERS
n what is the obturator sign? what diagnosis is it associated with? - a/w appendicitis
obturator sign = pain upon flexion and internal rotation of the hip#$/images/upload-
flashcards/601487/854522_m.jpg
what is Rovsing's sign? what diagnosis is it associated with? - a/w appendicitis
Rovsing's sign= pain in the RLQ upon palpation of the LLQ#$/images/upload-
flashcards/601487/854525_m.jpg
Early in the course of acute appendicitis, are vital signs usually abnormal? - no - 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%.
what is the psoas sign? what diagnosis is it associated with? - a/w appendicitis
psoas sign = pain upon extension of the hip.#$/images/upload-flashcards/601487/854528_m.jpg
explain what rebound in the setting of acute appendicitis means - Rebound is usually elicited only after
the appendix has ruptured or infarcted.
In establishing a differential diagnosis of abdominal pain, the onset of PAIN prior to the occurrence of
N/V is more often suggestive of - surgical etiology of the pain, such as small bowel obstruction
what bug should you think of in patients with sickle cell anemia who present with abdominal pain and
diarrhea? - salmonella (not shigellosis)
Radiation of pain to the scapula is suggestive of - acute choleycystitis (NOT hepatitis)
Diverticulitis pain is generally located - in the LLQ
Describe the pain patterns a/w with peptic ulcer disease (PUD) - pain that is worse preceding a meal
non-radiating, burning epigastric pain
pain that awakens a patient in the middle of the night
relief of abdominal pain with antacids
,note: unrelenting pain over a period of weeks should suggest an alternative diagnosis
A 78 year old female presents to the E.D. with a sensation of LLQ abdominal pain, accompanied by some
irregular bowel movements and loss of appetite. Her abdominal CT (two images) is shown in the Figure.
What is the most likely diagnosis? - /images/upload-flashcards/601487/854531_m.jpg#$A patient with
this general picture is most likely to have diverticulitis, which is revealed on the CT scan as diverticular
disease with inflammation (wall thickening and stranding).#$/images/upload-
flashcards/601487/854534_m.jpg
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? - pyloric
stenosis
The answer is C. 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).
46yo F c/o abrupt onset of intermittent severe pain in L flank & abdomen that woke her from sleep. She
is pacing & appears extremely uncomfortable. She has never experienced this type of pain previously
and denies fevers or other symptoms. Renal calculus is suspected. Some questions -
What is the best diagnostic test (KUB, IVP, Helical CT, U/S)?
How helpful is a Urinalysis? - Helical CT scan is 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.
50 yo M p/w 1 day of gradually worsening, intermittent, LLQ pain a/w loose stools. No fevers or bloody
bowel movements. Similar sxs in the past were self-limited. Vital signs wnl. PE shows mild tenderness in
, LLQ, +BS and no masses or peritoneal signs. His PCP can see him tomorrow in his clinic. What should be
done next in the E.D.? - Discharge home on high-fiber diet, laxatives and stool softeners
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 25yoM with the recent diagnosis of Crohn's disease in the ED. Regarding Crohn's
disease, you know that: - There is a small increased risk of colon cancer
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 perforation. The risk of colon cancer is only slightly elevated above
baseline. In contrast, Ulcerative colitis begins in the rectum and may spread to the upper parts of the
colon but never involves the small intestine. The ulcerations are contiguous and involve only the colonic
mucosa. The incidence of colon cancer may be increased up to 30 times over baseline.
53yo obese woman presents to ED, accompanied by three of her children, c/o severe abdominal pain
that began this afternoon after lunch. PE reveals marked RUQ tenderness. Likely findings on this patient
would include: - This woman is likely suffering from acute cholecystitis. Predisposing factors include
female gender, obesity, increased age and increased parity. Inflammation of the gallbladder causes RUQ
pain and sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound probe is
positioned over the gallbladder). Pain may radiate to the right scapula. Lab studies usually show
leukocytosis with or without a left shift, and aminotransferases and bilirubin are usually within normal
limits.
25yo F p/w epigastric pain radiating straight through to the back. Labs are notable only for markedly
elevated amylase and lipase. An abdominal X-ray is taken (see Figure). What's the dx? - /images/upload-
flashcards/601487/924401_m.jpg#$The most likely explanation for her symptoms is gallstone-related
pancreatitis
The X-ray reveals stones in the gallbladder. These particular stones are not likely the cause of
pancreatitis, but the demonstration of gallstone disease raises the likelihood that the patient's
pancreatitis is indeed due to gallstones. In the U.S., the most common etiologies of pancreatitis include
gallstones (45%) and alcoholism (35%). Alcoholic pancreatitis may occur in young patients as well as in
older abusers of alcohol. Many other drugs, infectious agents, and conditions are associated with the
development of pancreatitis. A few examples include hypertriglyceridemia, trauma, pregnancy,
pancreatic carcinoma, atherosclerotic emboli, and scorpion bites.
ANSWERS
n what is the obturator sign? what diagnosis is it associated with? - a/w appendicitis
obturator sign = pain upon flexion and internal rotation of the hip#$/images/upload-
flashcards/601487/854522_m.jpg
what is Rovsing's sign? what diagnosis is it associated with? - a/w appendicitis
Rovsing's sign= pain in the RLQ upon palpation of the LLQ#$/images/upload-
flashcards/601487/854525_m.jpg
Early in the course of acute appendicitis, are vital signs usually abnormal? - no - 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%.
what is the psoas sign? what diagnosis is it associated with? - a/w appendicitis
psoas sign = pain upon extension of the hip.#$/images/upload-flashcards/601487/854528_m.jpg
explain what rebound in the setting of acute appendicitis means - Rebound is usually elicited only after
the appendix has ruptured or infarcted.
In establishing a differential diagnosis of abdominal pain, the onset of PAIN prior to the occurrence of
N/V is more often suggestive of - surgical etiology of the pain, such as small bowel obstruction
what bug should you think of in patients with sickle cell anemia who present with abdominal pain and
diarrhea? - salmonella (not shigellosis)
Radiation of pain to the scapula is suggestive of - acute choleycystitis (NOT hepatitis)
Diverticulitis pain is generally located - in the LLQ
Describe the pain patterns a/w with peptic ulcer disease (PUD) - pain that is worse preceding a meal
non-radiating, burning epigastric pain
pain that awakens a patient in the middle of the night
relief of abdominal pain with antacids
,note: unrelenting pain over a period of weeks should suggest an alternative diagnosis
A 78 year old female presents to the E.D. with a sensation of LLQ abdominal pain, accompanied by some
irregular bowel movements and loss of appetite. Her abdominal CT (two images) is shown in the Figure.
What is the most likely diagnosis? - /images/upload-flashcards/601487/854531_m.jpg#$A patient with
this general picture is most likely to have diverticulitis, which is revealed on the CT scan as diverticular
disease with inflammation (wall thickening and stranding).#$/images/upload-
flashcards/601487/854534_m.jpg
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? - pyloric
stenosis
The answer is C. 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).
46yo F c/o abrupt onset of intermittent severe pain in L flank & abdomen that woke her from sleep. She
is pacing & appears extremely uncomfortable. She has never experienced this type of pain previously
and denies fevers or other symptoms. Renal calculus is suspected. Some questions -
What is the best diagnostic test (KUB, IVP, Helical CT, U/S)?
How helpful is a Urinalysis? - Helical CT scan is 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.
50 yo M p/w 1 day of gradually worsening, intermittent, LLQ pain a/w loose stools. No fevers or bloody
bowel movements. Similar sxs in the past were self-limited. Vital signs wnl. PE shows mild tenderness in
, LLQ, +BS and no masses or peritoneal signs. His PCP can see him tomorrow in his clinic. What should be
done next in the E.D.? - Discharge home on high-fiber diet, laxatives and stool softeners
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 25yoM with the recent diagnosis of Crohn's disease in the ED. Regarding Crohn's
disease, you know that: - There is a small increased risk of colon cancer
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 perforation. The risk of colon cancer is only slightly elevated above
baseline. In contrast, Ulcerative colitis begins in the rectum and may spread to the upper parts of the
colon but never involves the small intestine. The ulcerations are contiguous and involve only the colonic
mucosa. The incidence of colon cancer may be increased up to 30 times over baseline.
53yo obese woman presents to ED, accompanied by three of her children, c/o severe abdominal pain
that began this afternoon after lunch. PE reveals marked RUQ tenderness. Likely findings on this patient
would include: - This woman is likely suffering from acute cholecystitis. Predisposing factors include
female gender, obesity, increased age and increased parity. Inflammation of the gallbladder causes RUQ
pain and sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound probe is
positioned over the gallbladder). Pain may radiate to the right scapula. Lab studies usually show
leukocytosis with or without a left shift, and aminotransferases and bilirubin are usually within normal
limits.
25yo F p/w epigastric pain radiating straight through to the back. Labs are notable only for markedly
elevated amylase and lipase. An abdominal X-ray is taken (see Figure). What's the dx? - /images/upload-
flashcards/601487/924401_m.jpg#$The most likely explanation for her symptoms is gallstone-related
pancreatitis
The X-ray reveals stones in the gallbladder. These particular stones are not likely the cause of
pancreatitis, but the demonstration of gallstone disease raises the likelihood that the patient's
pancreatitis is indeed due to gallstones. In the U.S., the most common etiologies of pancreatitis include
gallstones (45%) and alcoholism (35%). Alcoholic pancreatitis may occur in young patients as well as in
older abusers of alcohol. Many other drugs, infectious agents, and conditions are associated with the
development of pancreatitis. A few examples include hypertriglyceridemia, trauma, pregnancy,
pancreatic carcinoma, atherosclerotic emboli, and scorpion bites.
