CRAM SAEM TEST 2 QUESTIONS AND ANSWERS
What is the obturator sign? What diagnosis is it associated with? - answers - a/w
appendicitis
Obturator sign = pain upon flexion and internal rotation of the hip#$/images/upload-
flashcards/601487/854522_m.jpg
What is rovsing's sign? What diagnosis is it associated with? - answers - a/w
appendicitis
Rovsing's sign= pain in the rlq upon palpation of the llq#$/images/upload-
flashcards/601487/854525_m.jpg
In establishing a differential diagnosis of abdominal pain, the onset of pain prior to the
occurrence of n/v is more often suggestive of - answers - 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? - answers - salmonella (not shigellosis)
Radiation of pain to the scapula is suggestive of - answers - acute choleycystitis (not
hepatitis)
Diverticulitis pain is generally located - answers - in the llq
Describe the pain patterns a/w with peptic ulcer disease (pud) - answers - 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? - answers -
/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? - answers - 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).
Early in the course of acute appendicitis, are vital signs usually abnormal? - answers -
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? - answers - 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 - answers - rebound is
usually elicited only after the appendix has ruptured or infarcted.
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? - answers - 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.? - answers -
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: - answers - 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: - answers - 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? - answers - /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
What is the obturator sign? What diagnosis is it associated with? - answers - a/w
appendicitis
Obturator sign = pain upon flexion and internal rotation of the hip#$/images/upload-
flashcards/601487/854522_m.jpg
What is rovsing's sign? What diagnosis is it associated with? - answers - a/w
appendicitis
Rovsing's sign= pain in the rlq upon palpation of the llq#$/images/upload-
flashcards/601487/854525_m.jpg
In establishing a differential diagnosis of abdominal pain, the onset of pain prior to the
occurrence of n/v is more often suggestive of - answers - 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? - answers - salmonella (not shigellosis)
Radiation of pain to the scapula is suggestive of - answers - acute choleycystitis (not
hepatitis)
Diverticulitis pain is generally located - answers - in the llq
Describe the pain patterns a/w with peptic ulcer disease (pud) - answers - 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? - answers -
/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? - answers - 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).
Early in the course of acute appendicitis, are vital signs usually abnormal? - answers -
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? - answers - 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 - answers - rebound is
usually elicited only after the appendix has ruptured or infarcted.
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? - answers - 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.? - answers -
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: - answers - 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: - answers - 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? - answers - /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
