SAEM M4 EXAM 2024 NEWEST ACTUAL EXAM 1000+
m m m m m m m m
QUESTIONS WITH DETAILED VERIFIED ANSWERS
m m m m m
WITH RATIONALES (100% CORRECT ANSWERS) / ALR
m m m m m m
EADY GRADED A+
m m
"Regardingmthemdiagnosismofmacutemappendicitis,mall mthemfollowingmaremtruemEXCEPT:
A. Vital msignsmaremusuallymabnormal,mevenmearlyminmthemcoursemofmacutemappendicitis.
B. Reboundmismusuallymelicitedmonlymaftermthemappendixmhasmrupturedmorminfarcted.
C. Rovsing'smsignmismpainminmthemrightmlowermquadrantmuponmpalpationmofmthemleftmlow
ermquadrant.
D. Themobturatormsignmismpainmuponmflexionmandminternal mrotationmofmthemhip.
E. Thempsoasmsignmismpainmuponmextensionmofmthemhip."m-
mANSWER"A.mVital msignsmaremusuallymabnormal,mevenmearlyminmthemcoursemofmacutem
appendicitis.
ThemanswermismA.mThempresentationmofmacutemappendicitismvariesmtremendously.mEarlymin
mitsmcourse,mvital msignsmincluding mtemperature mmaymbemnormal.mOncemperforation mhasmoc
curred,mthemratemofmlow-
grademfeverm(<38mC)mincreasesmtomaboutm40%.mOthermvariationsminmpresentationmincludem
painminmthemrightmuppermquadrant,mtypicallymfrom mamretrocecal mormretroiliacmappendix."
"Rosving'smsignmismdescribedmas:
A. Tendernessminmthemrightmuppermquadrantmthatmismworsemwithminspiration.
B. Pelvicmpainmuponmflexionmofmthemthighmwhilemthempatientmismsupine.
C. Pelvicmpainmuponminternal mandmexternal mrotationmofmthemthighmwithmthemkneemflexed.
D. Painmthatmincreasesmwithmthemreleasemofmpressuremofmpalpation.
E. Painminmthemrightmlowermquadrantmwhenmleftmlowermquadrantmismpalpated."m-
mANSWER"E.mPainminmthemrightmlowermquadrantmwhenmleftmlowermquadrantmismpalpated.
ThemanswermismE.mRosving'smsignmismpainminmthemrightmlowermquadrantmwhenmthemleftmlower
mquadrantmismpalpated.mRebound mtendernessmoccursmwithmthemreleasemofmpressure.mThemil
iopsoasmsignmismpainmassociatedmwithmthighmflexion.mThemobturatormsignmismpainmthatmoccur
smwithmthighmrotation.mAll mofmthesemsignsmaremassociatedmwithmappendicitis.mMurphy'smsign
mismcessation mofminspiration mduringmpalpation mofmthemrightmuppermquadrantmandmismassociat
edmwithmacutemcholecystitis."
"Inmestablishingmamdifferential mdiagnosismofmabdominalmpain,mwhichmofmthemfollowingmismtrue
?
A. Radiationmofmpainmtomthemscapulamismsuggestivemofmacutemhepatitis.
B. Cervical mmotionmtendernessmismamuseful mphysical mfindingmformdifferentiatingmwomenmwi
thmormwithoutmacutemappendicitis.
C. Inmpatientsmwithmsicklemcell manemiamwhompresentmwithmabdominal mpainmandmdiarrhe
a,mshigellosismshouldmbemamtopmconsideration.
, D. Themonsetmofmpainmpriormtomthemoccurrencemofmnauseamandmvomitingmismmoremoft
enmsuggestivemofmamsurgical metiology.
E. Diverticulitismtendsmtomcausempainminmthemrightmuppermquadrant." m-
mANSWER"D.mThemonsetmofmpainmpriormtomthemoccurrence mofmnauseamandmvomiting mismmor
emoftenmsuggestivemofmamsurgical metiology.
ThemanswermismD.mPainmpriormtomnauseamandmvomitingmismoftenmsuggestivemofmamsurgical m
etiologymofmthempain,msuchmasmsmall mbowel mobstruction.mCervicalmmotionmtendernessmhas
mbeenmnotedminmupmtom25%mofmwomenmwithmacutemappendicitis.mPatientsmwithmsicklemcell m
anemiamarempronemtomSalmonellaminfections.mRadiationmofmpainmtomthemscapulamismclassic
allympresentminmacutemcholeycystitis.mDiverticulitismpainmismgenerallymlocatedminmthemleftmlo
wermquadrant."
"Ofmthemfollowingmpainmpatterns,mwhichmismthemleastmlikelymassociatedmwithmdiagnosismofmpe
pticmulcermdisease?
A. non-radiating,mburningmepigastricmpain
B. painmthatmawakensmampatientminmthemmiddlemofmthemnight
C. unrelentingmpainmovermamperiodmofmweeks
D. reliefmofmabdominal mpainmwithmantacids
E. painmthatmismworsemprecedingmammeal"m-
mANSWER"C.munrelenting mpainmovermamperiod mofmweeks
ThemanswermismC.mPainmfrom mpepticmulcermdiseasemtypicallymoccursminmperiodsmofmexacerb
ationmandmremission.mUnrelentingmpainmovermweeksmormmonthsmshouldmsuggestmanmalterna
tivemdiagnosis.mPainmismclassicallymdescribedmasmnon-
radiating,mburningmepigastricmpain.mSomempatientsmmaymalsomcomplainmofmchestmormbackmp
ain.mPainmismfrequentlymseveremenoughmtomawakenmpatientsmfrom msleepminmearlymmorningm
hoursmbutmismoftenmnotmpresentmuponmwakingminmthemmorning,masmgastricmacidmsecretionmp
eaksmaroundm2ma.m.mandmnadirsmuponmawakening."
"Am78myearmoldmfemalempresentsmtomthemE.D.mwithmamsensationmofmleft-
lowermquadrantmabdominal mpain,maccompaniedmbymsomemirregularmbowel mmovementsman
dmlossmofmappetite.mHermabdominal mCTm(twomimages)mismshownminmthemFigure.mWhatmismthe
mmostmlikelymdiagnosis?
A. ovarianmcyst
B. volvulus
C. appendicitis
D. diverticulitis
E. gastroenteritis" m-
mANSWERThe manswermismD.mAmpatientmwithmthismgeneralmpicturemismmostmlikelymtomha
vemdiverticulitis,mwhichmismrevealedmonmthemCTmscanmasmdiverticularmdiseasemwithminfl
ammationm(wall mthickeningmandmstranding).
"Ammothermbringsmherm6mweekmoldmboymtomthememergencymroom.mShemstatesmthembabymh
asmbeenmvomitingmeverythingmshe'smtriedmtomfeedmhim mformthempastm12mhours.mShemstate
smthatmhemusuallymeatsmreadilymandmcompletesmanmentiremfeeding,mbutmhemismunablemtomk
eep
,anythingmdown.mThememesismismnon-bloodymandmnon-
bilious,mhowevermitmismprojectileminmnature.mWhatmismthemmostmlikelymconditionminmthismpatie
nt?
A. viral mgastroenteritis
B. constipation
C. appendicitis
D. intussusception
E. pyloricmstenosis"m-mANSWER"E.mpyloricmstenosis
ThemanswermismE.mHypertrophicmpyloricmstenosismtypicallympresentsminmthemsecondmtomsixt
hmweekmofmlifemandmismfourmtimesmmoremcommonminmmalesmthanmfemales.mInfantsmwithmhyp
ertrophicmpyloricmstenosismtypicallymaremvigorousmeatersmbutmshortlymafterwardmregurgitate
mthementiremfeeding mcontentsminmamprojectile mfashion.mThememesismismnon-
bilious.mThemclassicmfindingmonmexammismanm"olive"mpalpableminmthemabdomen,mandmdiagno
sismismtypicallymviamultrasound.mIntussusceptionmtypicallympresentsmbetweenmthemagesmofm5
mandm12mmonths.mGastroenteritis mismcharacterized mbymdiarrhea masmwellmasmvomiting.mNeith
ermconstipationmnormappendicitismtypicallympresentmwithmprotractedmvomiting,mthoughmtheml
attermconditionmtendsmtompresentmatypicallyminmyoungmchildrenm(andmelderlymadults)."
"Am46myearmoldmwomanmpresentsmtomthememergencymdepartmentmcomplainingmofmabruptmo
nsetmofmintermittentmseverempainminmthemleftmflankmandmabdomenmthatmwokemhermfrom mslee
p.mShemismpacingmaroundmthemstretchermandmappearsmextremelymuncomfortable.mShemhasm
nevermexperiencedmthismtypemofmpainmpreviouslymandmdeniesmfeversmormothermsymptoms.
Renal mcalculusmismsuspected.mWhichmofmthemfollowingmismtruemregardingmthemdiagnosismofmr
enal mcalculi minmthismpatient?
A. Urinalysismdemonstratingmhematuriamconfirmsmthemdiagnosis.
B. KUBmdetectsmlessmthanm10%mofmcalculi.
C. Helical mCTmscanmgreatermthanm95%msensitivemandmspecificmformrenal mcalculi.
D. Ultrasoundmismthemstudymofmchoicemformdetectingmsmall mureteral mcalculi.
E. Intravenousmpyelogram m(IVP)mmaymbemusedminmpatientsmwithmrenal minsufficiency." m-
mANSWER"C.mHelical mCTmscanmgreatermthanm95%msensitive mandmspecificmformrenal mcalc
uli.
ThemanswermismC.mHelical mCTmscanmhasmbeenmshownmtombembothmhighlymsensitivemandmsp
ecificminmthemdiagnosismofmrenal mcalculi.mItmismthempreferredmmodalitymformevaluationminmma
nymcenters.mAlthoughmurinalysismtypicallymdemonstratesmhematuriaminmpatientsmwithmrenal
mcalculi,mhematuria mismnotmspecificmenoughmtomconfirmmthemdiagnosis,mandmimagingmismwar
rantedminmall mfirst-timempresenters.mKUBmdetectsmapproximatelym60-
70%mofmcalculi m(thoughmstudiesmaddressingmthismissuemaremsomewhatmmethodologicallymf
lawed).
Ultrasoundmismnotmreliablemformdetectingmsmallmcalculi,mbutmism85-
94%msensitivemandm100%mspecificmatmdemonstratingmhydronephrosis.mIVPmismcontraindi
catedminmpatientsmwithmrenal minsufficiencymduemtomthemdyemloadmnecessarymtomperform mt
hemstudy."
"Am50myearmoldmmanmpresentsmwithm1mdaymofmgraduallymworsening,mintermittent,mleftmlowerm
quadrantmpainmassociatedmwithmloosemstools.mHemhasmhadmnomfeversmormbloodymbowel mmo
vements.mSimilarmsymptomsminmthempastmweremself-
limited.mAllmvital msignsmliemwithinmnormal mlimits.mPhysicalmexaminationmshowsmmildmtendern
essminmthemleftmlowermquadrant,
, normal mactivembowel msoundsmandmneithermmassesmnormperitoneal msigns.mHismprimary-
caremphysicianmcanmseemhim mtomorrowminmhismclinic.mWhatmshouldmbemdonemnextminmthemE.
D.?
A. DischargemhomemaftermamsinglemdosemofmIVmantibiotics
B. Dischargemhomemonmhigh-fibermdiet,mlaxativesmandmstool msofteners
C. Gastroenterologymconsultmformendoscopy
D. Admitmformobservationmandmserial mexaminations" m-
mANSWER"B.mDischarge mhomemonmhigh-fibermdiet,mlaxativesmandmstool msofteners
ThemanswermismB.mThismpatientmhasmclassicmdiverticulosism(saclikemprotrusionsmofmcolonicm
mucosamthroughmthemmuscularis)mwithoutmsignsmofmacutemdiverticulitism(inflammationmofmdi
verticula).mUsuallymthesempatientsmcanmbemmanagedmasmoutpatientsmwithmamhigh-
fibermdietmandmtreatmentsmtomdecreasemintestinal mspasm.mIfmthempatientmdevelopsmfevermorm
painmincreasesmhemmaymneedmfurthermevaluationmtomrulemoutmabscessmformation.mDiverticu
litismismtreatedmwithmantibiotics,mbowel mrestmandmanalgesics."
"Youmaremtreatingmam25myearmoldmmalemwithmthemrecentmdiagnosismofmCrohn'smdiseaseminmth
emED.mRegardingmCrohn'smdisease,myoumknowmthat:
A. Lesionsmaremtypicallymcontiguous
B. Small mbowel minvolvementmismrare
C. Bleedingmismcommonmduemtomsuperficial mbowel mwall minflammation
D. Theremismamsmall mincreasedmriskmofmcolonmcancer"m-
mANSWER"D.mThere mismamsmall mincreased mriskmofmcolonmcancer
ThemanswermismD.mAlthoughmCrohn'smdiseasemmayminvolvemthementirembowel mtract,mthemre
ctum mismrarelyminvolved.mInvolvedmareasmaremtypicallymnon-
contiguousm(knownmasm"skipmlesions")mandmtheminflammationminvolvesmallmofmthemlayersmo
fmthembowel mwall--
resultingminmmanymofmthemcomplicationsmofmCrohn'smsuchmasmabscessmandmfistulamformati
on,mintestinal mobstruction,mandmperforation.mThemriskmofmcolonmcancermismonlymslightlymele
vatedmabovembaseline.mInmcontrast,mUlcerativemcolitismbeginsminmthemrectum mandmmaymspr
eadmtomthemuppermpartsmofmthemcolonmbutmneverminvolvesmthemsmallmintestine.mThemulcerat
ionsmaremcontiguousmandminvolvemonlymthemcolonicmmucosa.mThemincidencemofmcolonmcan
cermmaymbemincreasedmupmtom30mtimesmovermbaseline."
"Am53myearmoldmobesemwomanmpresentsmtomthememergencymdepartment,maccompaniedmb
ymthreemofmhermchildren,mcomplainingmofmseveremabdominal mpainmthatmbeganmthismafterno
onmaftermlunch.mPhysical mexam mrevealsmmarkedmRUQmtenderness.mLikelymfindingsmonmthi
smpatientmwouldmincludemall mofmthemfollowingmEXCEPT:
A. positivemsonographicmMurphy'smsign
B. painminmthemrightmscapula
C. leukocytosismwithmleftmshift
D. markedminguinal mlymphadenopathy
E. aminotransferasesmandmbilirubinmwithinmnormal mlimits"m-
mANSWER"D.mmarkedminguinal mlymphadenopathy
ThemanswermismD.mThismwomanmismlikelymsufferingmfrom macutemcholecystitis.mPredisposing
mfactorsminclude mfemalemgender,mobesity,mincreased magemandmincreased mparity.
m m m m m m m m
QUESTIONS WITH DETAILED VERIFIED ANSWERS
m m m m m
WITH RATIONALES (100% CORRECT ANSWERS) / ALR
m m m m m m
EADY GRADED A+
m m
"Regardingmthemdiagnosismofmacutemappendicitis,mall mthemfollowingmaremtruemEXCEPT:
A. Vital msignsmaremusuallymabnormal,mevenmearlyminmthemcoursemofmacutemappendicitis.
B. Reboundmismusuallymelicitedmonlymaftermthemappendixmhasmrupturedmorminfarcted.
C. Rovsing'smsignmismpainminmthemrightmlowermquadrantmuponmpalpationmofmthemleftmlow
ermquadrant.
D. Themobturatormsignmismpainmuponmflexionmandminternal mrotationmofmthemhip.
E. Thempsoasmsignmismpainmuponmextensionmofmthemhip."m-
mANSWER"A.mVital msignsmaremusuallymabnormal,mevenmearlyminmthemcoursemofmacutem
appendicitis.
ThemanswermismA.mThempresentationmofmacutemappendicitismvariesmtremendously.mEarlymin
mitsmcourse,mvital msignsmincluding mtemperature mmaymbemnormal.mOncemperforation mhasmoc
curred,mthemratemofmlow-
grademfeverm(<38mC)mincreasesmtomaboutm40%.mOthermvariationsminmpresentationmincludem
painminmthemrightmuppermquadrant,mtypicallymfrom mamretrocecal mormretroiliacmappendix."
"Rosving'smsignmismdescribedmas:
A. Tendernessminmthemrightmuppermquadrantmthatmismworsemwithminspiration.
B. Pelvicmpainmuponmflexionmofmthemthighmwhilemthempatientmismsupine.
C. Pelvicmpainmuponminternal mandmexternal mrotationmofmthemthighmwithmthemkneemflexed.
D. Painmthatmincreasesmwithmthemreleasemofmpressuremofmpalpation.
E. Painminmthemrightmlowermquadrantmwhenmleftmlowermquadrantmismpalpated."m-
mANSWER"E.mPainminmthemrightmlowermquadrantmwhenmleftmlowermquadrantmismpalpated.
ThemanswermismE.mRosving'smsignmismpainminmthemrightmlowermquadrantmwhenmthemleftmlower
mquadrantmismpalpated.mRebound mtendernessmoccursmwithmthemreleasemofmpressure.mThemil
iopsoasmsignmismpainmassociatedmwithmthighmflexion.mThemobturatormsignmismpainmthatmoccur
smwithmthighmrotation.mAll mofmthesemsignsmaremassociatedmwithmappendicitis.mMurphy'smsign
mismcessation mofminspiration mduringmpalpation mofmthemrightmuppermquadrantmandmismassociat
edmwithmacutemcholecystitis."
"Inmestablishingmamdifferential mdiagnosismofmabdominalmpain,mwhichmofmthemfollowingmismtrue
?
A. Radiationmofmpainmtomthemscapulamismsuggestivemofmacutemhepatitis.
B. Cervical mmotionmtendernessmismamuseful mphysical mfindingmformdifferentiatingmwomenmwi
thmormwithoutmacutemappendicitis.
C. Inmpatientsmwithmsicklemcell manemiamwhompresentmwithmabdominal mpainmandmdiarrhe
a,mshigellosismshouldmbemamtopmconsideration.
, D. Themonsetmofmpainmpriormtomthemoccurrencemofmnauseamandmvomitingmismmoremoft
enmsuggestivemofmamsurgical metiology.
E. Diverticulitismtendsmtomcausempainminmthemrightmuppermquadrant." m-
mANSWER"D.mThemonsetmofmpainmpriormtomthemoccurrence mofmnauseamandmvomiting mismmor
emoftenmsuggestivemofmamsurgical metiology.
ThemanswermismD.mPainmpriormtomnauseamandmvomitingmismoftenmsuggestivemofmamsurgical m
etiologymofmthempain,msuchmasmsmall mbowel mobstruction.mCervicalmmotionmtendernessmhas
mbeenmnotedminmupmtom25%mofmwomenmwithmacutemappendicitis.mPatientsmwithmsicklemcell m
anemiamarempronemtomSalmonellaminfections.mRadiationmofmpainmtomthemscapulamismclassic
allympresentminmacutemcholeycystitis.mDiverticulitismpainmismgenerallymlocatedminmthemleftmlo
wermquadrant."
"Ofmthemfollowingmpainmpatterns,mwhichmismthemleastmlikelymassociatedmwithmdiagnosismofmpe
pticmulcermdisease?
A. non-radiating,mburningmepigastricmpain
B. painmthatmawakensmampatientminmthemmiddlemofmthemnight
C. unrelentingmpainmovermamperiodmofmweeks
D. reliefmofmabdominal mpainmwithmantacids
E. painmthatmismworsemprecedingmammeal"m-
mANSWER"C.munrelenting mpainmovermamperiod mofmweeks
ThemanswermismC.mPainmfrom mpepticmulcermdiseasemtypicallymoccursminmperiodsmofmexacerb
ationmandmremission.mUnrelentingmpainmovermweeksmormmonthsmshouldmsuggestmanmalterna
tivemdiagnosis.mPainmismclassicallymdescribedmasmnon-
radiating,mburningmepigastricmpain.mSomempatientsmmaymalsomcomplainmofmchestmormbackmp
ain.mPainmismfrequentlymseveremenoughmtomawakenmpatientsmfrom msleepminmearlymmorningm
hoursmbutmismoftenmnotmpresentmuponmwakingminmthemmorning,masmgastricmacidmsecretionmp
eaksmaroundm2ma.m.mandmnadirsmuponmawakening."
"Am78myearmoldmfemalempresentsmtomthemE.D.mwithmamsensationmofmleft-
lowermquadrantmabdominal mpain,maccompaniedmbymsomemirregularmbowel mmovementsman
dmlossmofmappetite.mHermabdominal mCTm(twomimages)mismshownminmthemFigure.mWhatmismthe
mmostmlikelymdiagnosis?
A. ovarianmcyst
B. volvulus
C. appendicitis
D. diverticulitis
E. gastroenteritis" m-
mANSWERThe manswermismD.mAmpatientmwithmthismgeneralmpicturemismmostmlikelymtomha
vemdiverticulitis,mwhichmismrevealedmonmthemCTmscanmasmdiverticularmdiseasemwithminfl
ammationm(wall mthickeningmandmstranding).
"Ammothermbringsmherm6mweekmoldmboymtomthememergencymroom.mShemstatesmthembabymh
asmbeenmvomitingmeverythingmshe'smtriedmtomfeedmhim mformthempastm12mhours.mShemstate
smthatmhemusuallymeatsmreadilymandmcompletesmanmentiremfeeding,mbutmhemismunablemtomk
eep
,anythingmdown.mThememesismismnon-bloodymandmnon-
bilious,mhowevermitmismprojectileminmnature.mWhatmismthemmostmlikelymconditionminmthismpatie
nt?
A. viral mgastroenteritis
B. constipation
C. appendicitis
D. intussusception
E. pyloricmstenosis"m-mANSWER"E.mpyloricmstenosis
ThemanswermismE.mHypertrophicmpyloricmstenosismtypicallympresentsminmthemsecondmtomsixt
hmweekmofmlifemandmismfourmtimesmmoremcommonminmmalesmthanmfemales.mInfantsmwithmhyp
ertrophicmpyloricmstenosismtypicallymaremvigorousmeatersmbutmshortlymafterwardmregurgitate
mthementiremfeeding mcontentsminmamprojectile mfashion.mThememesismismnon-
bilious.mThemclassicmfindingmonmexammismanm"olive"mpalpableminmthemabdomen,mandmdiagno
sismismtypicallymviamultrasound.mIntussusceptionmtypicallympresentsmbetweenmthemagesmofm5
mandm12mmonths.mGastroenteritis mismcharacterized mbymdiarrhea masmwellmasmvomiting.mNeith
ermconstipationmnormappendicitismtypicallympresentmwithmprotractedmvomiting,mthoughmtheml
attermconditionmtendsmtompresentmatypicallyminmyoungmchildrenm(andmelderlymadults)."
"Am46myearmoldmwomanmpresentsmtomthememergencymdepartmentmcomplainingmofmabruptmo
nsetmofmintermittentmseverempainminmthemleftmflankmandmabdomenmthatmwokemhermfrom mslee
p.mShemismpacingmaroundmthemstretchermandmappearsmextremelymuncomfortable.mShemhasm
nevermexperiencedmthismtypemofmpainmpreviouslymandmdeniesmfeversmormothermsymptoms.
Renal mcalculusmismsuspected.mWhichmofmthemfollowingmismtruemregardingmthemdiagnosismofmr
enal mcalculi minmthismpatient?
A. Urinalysismdemonstratingmhematuriamconfirmsmthemdiagnosis.
B. KUBmdetectsmlessmthanm10%mofmcalculi.
C. Helical mCTmscanmgreatermthanm95%msensitivemandmspecificmformrenal mcalculi.
D. Ultrasoundmismthemstudymofmchoicemformdetectingmsmall mureteral mcalculi.
E. Intravenousmpyelogram m(IVP)mmaymbemusedminmpatientsmwithmrenal minsufficiency." m-
mANSWER"C.mHelical mCTmscanmgreatermthanm95%msensitive mandmspecificmformrenal mcalc
uli.
ThemanswermismC.mHelical mCTmscanmhasmbeenmshownmtombembothmhighlymsensitivemandmsp
ecificminmthemdiagnosismofmrenal mcalculi.mItmismthempreferredmmodalitymformevaluationminmma
nymcenters.mAlthoughmurinalysismtypicallymdemonstratesmhematuriaminmpatientsmwithmrenal
mcalculi,mhematuria mismnotmspecificmenoughmtomconfirmmthemdiagnosis,mandmimagingmismwar
rantedminmall mfirst-timempresenters.mKUBmdetectsmapproximatelym60-
70%mofmcalculi m(thoughmstudiesmaddressingmthismissuemaremsomewhatmmethodologicallymf
lawed).
Ultrasoundmismnotmreliablemformdetectingmsmallmcalculi,mbutmism85-
94%msensitivemandm100%mspecificmatmdemonstratingmhydronephrosis.mIVPmismcontraindi
catedminmpatientsmwithmrenal minsufficiencymduemtomthemdyemloadmnecessarymtomperform mt
hemstudy."
"Am50myearmoldmmanmpresentsmwithm1mdaymofmgraduallymworsening,mintermittent,mleftmlowerm
quadrantmpainmassociatedmwithmloosemstools.mHemhasmhadmnomfeversmormbloodymbowel mmo
vements.mSimilarmsymptomsminmthempastmweremself-
limited.mAllmvital msignsmliemwithinmnormal mlimits.mPhysicalmexaminationmshowsmmildmtendern
essminmthemleftmlowermquadrant,
, normal mactivembowel msoundsmandmneithermmassesmnormperitoneal msigns.mHismprimary-
caremphysicianmcanmseemhim mtomorrowminmhismclinic.mWhatmshouldmbemdonemnextminmthemE.
D.?
A. DischargemhomemaftermamsinglemdosemofmIVmantibiotics
B. Dischargemhomemonmhigh-fibermdiet,mlaxativesmandmstool msofteners
C. Gastroenterologymconsultmformendoscopy
D. Admitmformobservationmandmserial mexaminations" m-
mANSWER"B.mDischarge mhomemonmhigh-fibermdiet,mlaxativesmandmstool msofteners
ThemanswermismB.mThismpatientmhasmclassicmdiverticulosism(saclikemprotrusionsmofmcolonicm
mucosamthroughmthemmuscularis)mwithoutmsignsmofmacutemdiverticulitism(inflammationmofmdi
verticula).mUsuallymthesempatientsmcanmbemmanagedmasmoutpatientsmwithmamhigh-
fibermdietmandmtreatmentsmtomdecreasemintestinal mspasm.mIfmthempatientmdevelopsmfevermorm
painmincreasesmhemmaymneedmfurthermevaluationmtomrulemoutmabscessmformation.mDiverticu
litismismtreatedmwithmantibiotics,mbowel mrestmandmanalgesics."
"Youmaremtreatingmam25myearmoldmmalemwithmthemrecentmdiagnosismofmCrohn'smdiseaseminmth
emED.mRegardingmCrohn'smdisease,myoumknowmthat:
A. Lesionsmaremtypicallymcontiguous
B. Small mbowel minvolvementmismrare
C. Bleedingmismcommonmduemtomsuperficial mbowel mwall minflammation
D. Theremismamsmall mincreasedmriskmofmcolonmcancer"m-
mANSWER"D.mThere mismamsmall mincreased mriskmofmcolonmcancer
ThemanswermismD.mAlthoughmCrohn'smdiseasemmayminvolvemthementirembowel mtract,mthemre
ctum mismrarelyminvolved.mInvolvedmareasmaremtypicallymnon-
contiguousm(knownmasm"skipmlesions")mandmtheminflammationminvolvesmallmofmthemlayersmo
fmthembowel mwall--
resultingminmmanymofmthemcomplicationsmofmCrohn'smsuchmasmabscessmandmfistulamformati
on,mintestinal mobstruction,mandmperforation.mThemriskmofmcolonmcancermismonlymslightlymele
vatedmabovembaseline.mInmcontrast,mUlcerativemcolitismbeginsminmthemrectum mandmmaymspr
eadmtomthemuppermpartsmofmthemcolonmbutmneverminvolvesmthemsmallmintestine.mThemulcerat
ionsmaremcontiguousmandminvolvemonlymthemcolonicmmucosa.mThemincidencemofmcolonmcan
cermmaymbemincreasedmupmtom30mtimesmovermbaseline."
"Am53myearmoldmobesemwomanmpresentsmtomthememergencymdepartment,maccompaniedmb
ymthreemofmhermchildren,mcomplainingmofmseveremabdominal mpainmthatmbeganmthismafterno
onmaftermlunch.mPhysical mexam mrevealsmmarkedmRUQmtenderness.mLikelymfindingsmonmthi
smpatientmwouldmincludemall mofmthemfollowingmEXCEPT:
A. positivemsonographicmMurphy'smsign
B. painminmthemrightmscapula
C. leukocytosismwithmleftmshift
D. markedminguinal mlymphadenopathy
E. aminotransferasesmandmbilirubinmwithinmnormal mlimits"m-
mANSWER"D.mmarkedminguinal mlymphadenopathy
ThemanswermismD.mThismwomanmismlikelymsufferingmfrom macutemcholecystitis.mPredisposing
mfactorsminclude mfemalemgender,mobesity,mincreased magemandmincreased mparity.
