SAEM Practice 2020/ 508 Questions with
Verified Answers & Rationales/ 2024-2025.
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
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,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
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
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,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
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.
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 afternoon after lunch.
Physical exam reveals marked RUQ tenderness. Likely findings on this patient would include all
of the following EXCEPT:
A. positive sonographic Murphy's sign
B. pain in the right scapula
C. leukocytosis with left shift
D. marked inguinal lymphadenopathy
E. aminotransferases and bilirubin within normal limits - Answer: D. marked inguinal
lymphadenopathy
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
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, show leukocytosis with or without a left shift, 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 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 - Answer: D. Cholecystitis
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 - Answer: E. severe chronic constipation
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.
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Verified Answers & Rationales/ 2024-2025.
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
Page 1 of 253
,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
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
Page 2 of 253
,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
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.
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 afternoon after lunch.
Physical exam reveals marked RUQ tenderness. Likely findings on this patient would include all
of the following EXCEPT:
A. positive sonographic Murphy's sign
B. pain in the right scapula
C. leukocytosis with left shift
D. marked inguinal lymphadenopathy
E. aminotransferases and bilirubin within normal limits - Answer: D. marked inguinal
lymphadenopathy
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
Page 3 of 253
, show leukocytosis with or without a left shift, 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 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 - Answer: D. Cholecystitis
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 - Answer: E. severe chronic constipation
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.
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