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SAEM EXAM||2025-2026||400 REAL EXAM
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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.
- A. Vital signs are usually abnormal, even early in the course of acute appendicitis. RATIONALE: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. - E. Pain in the right lower quadrant when left lower quadrant is palpated. RATIONALE: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.
- D. The onset of pain prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology. RATIONALE: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 - C. unrelenting pain over a period of weeks RATIONALE: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
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
- B. Discharge home on high-fiber diet, laxatives and stool softeners RATIONALE: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 – D. There is a small increased risk of colon cancer RATIONALE: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 – D. marked inguinal lymphadenopathy RATIONALE: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. 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
- D. Cholecystitis RATIONALE: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
- E. severe chronic constipation
RATIONALE:For mild episodes of diverticulitis in which there is no evidence of perforation or peritonitis, there is no indication for immediate surgical intervention. Conservative management with intravenous fluids and antibiotics as well as bowel rest is typically first attempted. Although colon carcinoma may be a precipitating factor in the development of diverticulitis, barium enema should be avoided in the acute period due to high risk of bowel perforation. Although some patients with mild cases of diverticulitis may be discharged home with conservative treatment, the elderly are at higher risk of perforation and should be admitted. Guaiac positive stool in seen in up to 50% of patients with diverticulitis. There is no reason to suspect acute blood loss requiring transfusion in diverticulitis. Regarding esophageal perforation, which of the following is INCORRECT: A. Esophageal perforation has been reported as a complication of nasogastric tube placement, endotracheal intubation, and esophagotracheal Combitube intubation. B. Esophageal perforation may result from forceful vomiting, coughing, childbirth or heavy lifting. C. Over 80% of esophageal perforations are iatrogenic, usually as complications of upper endoscopy, dilation, or sclerotherapy. D. Over 90% of spontaneous esophageal perforations occur in the proximal esophagus. E. Iatrogenic perforations of the esophagus usually occur in the proximal esophagus or esophagogastric junction. – D. Over 90% of spontaneous esophageal perforations occur in the proximal esophagus. RATIONALE:Over 90% of spontaneous esophageal perforations occur in the distal esophagus, whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt injury or penetrating trauma, and carcinoma are other causes of esophageal perforation. Working in the ED, you have identified a bony object wedged in the mid- esophagus of a 45 year old patient. Failure to promptly remove a foreign body impacted in the esophagus could result in: A. Esophageal perforation and mediastinitis B. Epiglottal edema and airway obstruction C. The rapid development of xerostomia D. Barrett's esophagitis –
A. Esophageal perforation and mediastinitis RATIONALE:The complications of esophageal foreign bodies are rare but serious. They include esophageal erosion and perforation, mediastinitis, esophagus-to-trachea or esophagus- to-vasculature fistula formation, stricture formation, diverticuli formation, and tracheal compression (from both the esophageal foreign body and resultant edema or infection). Air trapping is a sign of a foreign body of the airway. Rarely, airway foreign bodies act as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax formation. A mother brings her 35 year old son to the emergency department because of tremor and mutism for the past three days. His mother found him in his room this morning lying stiffly in his bed, soiled with urine and feces. He appears confused and will not respond to questions. He was diagnosed with schizophrenia last year and has been on several medications. Last month after his most recent hospital admission for schizophrenia, he was discharged with a prescription for haloperidol. On physical exam, he is visibly diaphoretic and has vital signs as follows: T 102.7, BP 140/98, P 112, R 12. His neuromuscular exam shows extremely rigid extremities, and his laboratory values are notable for a white blood cell count of 15000/mm3 and abnormally elevated creatine phosphokinase levels. What is the most likely explanation for these findings? A. neuroleptic-induced acute dystonia B. neuroleptic malignant syndrome C. schizophrenia, catatonic type D. tardive dyskinesia
- B. neuroleptic malignant syndrome RATIONALE:Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life- threatening reaction to antipsychotic medications, with haloperidol being the most common cause. It is characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic dysfunction (e.g., diaphoresis, labile blood pressure, incontinence, dysrhythmias). While this patient's temperature is only 102.7, students should note that any patients with temperatures greater than 105 most likely have non-infectious etiologies for temperature elevation. NMS is thought to be due to too much D blockade in the substantia nigra and hypothalamus. Treatment consists of stopping the causative agent and providing supportive care. Medications such as dantrolene, bromocriptine, amantadine, and lorazepam are also often used. Tardive dyskinesia is a chronic movement disorder that results from prolonged use of antipsychotics and can include involuntary and periodic movements of the
of haloperidol? A. first degree heart block B. nephrogenic diabetes insipidus C. prolonged QT interval D. transient hepatitis - C. prolonged QT interval Nephrogenic diabetes insipidus may be associated with lithium. Potential side effects of haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia A 19 year old woman is brought to the emergency department by her friends because she has been saying that she is a superhero and trying to run into traffic to prove that she is indestructible. The friends report that she has been using drugs but they do not know which ones. Which of the following pairs of ocular finding and recreational drug is commonly observed? A. dilated pupils - heroin B. internuclear ophthalmoplegia - marijuana C. pinpoint pupils - amphetamines D. vertical nystagmus - phencyclidine - D. vertical nystagmus - phencyclidine Sympathomimetics (cocaine, amphetamines) cause dilated pupils. Opiates (heroin) cause pinpoint pupils. Internuclear ophthalmoplegia is associated with multiple sclerosis. CN VI palsy is not associated with any specific drugs. A 42 year old former custodial worker presents stating, "I think that people can hear what I am thinking." In the emergency department, he becomes extremely agitated and threatening, and his psychoses become more severe. In choosing an antipsychotic medication, which of the following would be the most appropriate choice? A. haloperidol B. chlorpromazine C. thioridazine D. ketamine - A. haloperidol Haloperidol is the most studied high potency antipsychotic agent used in agitated patients. Typical dosing is 5-10 mg IM every 10-30 minutes. Unlike thioridazine, haloperidol does not cause respiratory depression, has negligible anticholinergic side effects, and rarely causes hypotension. Although benzodiazepines can be used in the agitated patient, respiratory depression can
occur, and close monitoring is essential. A 20 year old college student is brought to the emergency department by campus police after he was found by his roommate saying people in the TV were trying to kill him. Which of the following criteria is not an indication for admission? A. first-time psychiatric episode B. demonstrates risk for suicide C. inadequate psychosocial support D. lacks capacity to cooperate with treatment - A. first-time psychiatric episode For an acute psychiatric episode, the first goal is medically stabilizing the patient. Subsequently, a patient who presents without previous history of a psychiatric episode does not necessarily need to be admitted. This, of course, depends on the identity and severity of the condition, and whether it can be treated in the emergency department. A 55 year-old male presents with new onset agitation and confusion. Which of the following medical histories would suggest a psychiatric (non-organic) cause? A. History of diabetes mellitus only B. History of alcohol abuse only C. History of hypothyroidism only D. History of chronic obstructive pulmonary disease only - C. History of hypothyroidism only Although hyperthyroidism may result in an agitated state, hypothyroidism is not generally associated with violent behavior. All other answers are potentially treatable medical problems that could account for the presentation of an agitated or violent patient. After assuring the safety of all parties involved, the emergency department physician should rule out organic causes of agitation. In dealing with the potential violent patient, the emergency physician should: A. Approach the patient in a calm, controlled and professional manner B. Assume that the strength of the doctor-patient relationship will ensure safety C. Deal with the patient in a isolated room to protect the patient's privacy D. Use a loud voice and threaten to call security if the patient becomes agitated - A. Approach the patient in a calm, controlled and professional manner Excessive eye contact may be interpreted as a sign of aggression (answer A).
patient is minimally responsive with sonorous respirations and a palpable rapid pulse. The most appropriate initial diagnostic test would be A. Arterial blood gas B. Electrocardiogram C. Fingerstick glucose D. Urine drug screen - C. Fingerstick glucose Hypoglycemia is a common and readily treatable cause for altered mental status. An ABG is unlikely to be diagnostic and more likely to reflect secondary abnormalities caused by respiratory depression. While a urine drug screen may show positives, it cannot quantitate the amount of a substance or the time period in which the exposure occurred so a positive screen may not reflect cause and effect. An EKG, while a part of a toxicology evaluation, is not an appropriate initiate screening test for an unstable patient until airway and readily reversible causes have been addressed. A 27 year old is found unresponsive in his car in the hospital parking lot and brought in by security. During your initial evaluation you find him to be cyanotic with pulse oximetry reading 82% on room air with a respiratory rate of 4 breaths per minute. Radial pulses are present at 120 bpm. Pupils are 1mm bilaterally. Your team is having difficulty finding a vein for an intravenous line due to extensive scarring of his arms. You are suspicious of an overdose, which medication would you want to rapidly administer as a potential antidote in this situation? A. Glucose B. Naloxone C. Thiamine D. Flumazenil - B. Naloxone The patient has stigmata of an opiate overdose with hypopnea, cyanosis, and miotic pupils. In addition, intravenous drug users often use up their veins. While hypoglycemia can definitely cause a depressed mental status and needs to be assessed, it should not result in respiratory depression or miotic pupils. Thiamine is utilized to prevent Wernicke's encephalopathy particularly in malnourished patients who present with hypoglycemia but is not an antidote per se. Flumazenil can be used to temporarily reverse the respiratory depression caused by benzodiazepines but also carries with it the risk of precipitating withdrawal and uncontrollable seizures in chronic benzodiazepine users. As a result, it is not recommended for routine use in patients with altered mental status. A 53 year-old known alcoholic presents with agitation, vomiting and altered mental status. His fingerstick glucose is 148. His serum ethanol level is undetectable and his head CT is normal. An ABG shows a pH of 7.21, pCO2 of
34, pO2 of 98 on room air. His basic chemistry panel includes a sodium of 136, potassium 4.1, chloride 108, bicarbonate 14, BUN 12, creatinine 1.1. What substance are you concerned that he may have ingested: A. Ethylene glycol B. Salicylates
and should be referred appropriately. A 45 year old man is brought to the E.D., with markedly altered mental status as reported by someone who stays with him at a homeless shelter. The patient is very confused and obtunded, and unable to provide a cogent history; the person who brought him to the E.D. notes the patient has a "drinking problem." The patient's vital signs are normal, except for a respiratory rate of 22. As he lays in the stretcher, his appearance is as depicted in the Figure. Of the following choices, which physical finding is most likely to be present on physical examination? A. Homan's sign B. anterior chest pain upon leaning forward, which is relieved by lying flat C. dendritic rash on the posterior thorax, with a sentinel lesion noted on the left shoulder D. upon elevation of the arms to 90-degrees (in 0-degrees abduction), and pronation of the hands with fingers spread, wrists and interphalangeal joints are characterized by jerky alternations of extension and flexion E. increase in systolic blood pressure by more than 10 mmHg with inspiration - D. upon elevation of the arms to 90-degrees (in 0-degrees abduction), and pronation of the hands with fingers spread, wrists and interphalangeal joints are characterized by jerky alternations of extension and flexion This patient has marked ascites (which may incidentally account for his mild tachypnea due to impairment of respiratory excursion). The most likely explanation given the limited information available is liver disease, and asterixis ("liver flap") as described in choice D is a likely marker of advanced hepatic failure. A 60 year old male presents with new onset confusion. Which of the following suggests a functional, as opposed to an organic etiology? A. abnormal vital signs B. acute onset C. auditory hallucinations D. disorientation - C. auditory hallucinations The other findings are all characteristic of organic confusional states. Hallucinations can occur with both organic and functional causes of confusion. Hallucinations associated with organic confusion may be visual, tactile, or auditory. Hallucinations in patients with functional disease tend to be auditory.
Delirium is defined as: A. a stressed psychological state resulting from extreme emotional stimulus B. abnormal behavior associated with decreased alertness and decreased psychomotor activity C. abnormal behavior accompanied by hallucinations, occurring in an oriented patient D. a global inability to relate to the environment and process sensory input - D. a global inability to relate to the environment and process sensory input Alterations in mental status resulting from extreme emotional stimulus would usually be functional abnormalities. Patients with delirium manifest increases in alertness and psychomotor activity. Delirium is more than simple alteration of mental status. Delirium is an organic confusional state. Patients with delirium may have hallucinations, but patients who are oriented are more likely to have functional causes for altered mental status. Which of the following statements regarding psychotic behavior is true? A. Brief psychotic episodes, often precipitated by events such as death of a loved one, can be characterized by extremely bizarre behavior and speech B. Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary C. Delusional disorder usually results in impairment in daily functioning D. Schizophreniform disorder is present when a patient meets the diagnostic criteria for schizophrenia but the process has been present for less than one year
- B. Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary Psychosis can be limited to nonbizarre delusions; patients with this disorder (delusional disorder) rarely have impairment in daily functioning. Fixed, false beliefs that are not held by others with a patient's cultural background are characteristic of delusional thinking. A 75 year old female is brought the to emergency department by a family member with a history of progressive forgetfulness and confusion. She has a history of dementia. The most common cause of dementia in the elderly patient is: A. Alzheimer's disease B. Parkinson's disease C. Pick's disease D. Vascular dementia - A. Most dementia is Alzheimer's type. The second most common cause of dementia is vascular dementia, which accounts for 10 to 20% of all dementias. Primary degenerative dementias include Alzheimer's disease, vascular dementia, subcortical dementias involving the basal ganglia and thalamus
B. Vital sign abnormalities C. Presence of attention deficit D. Signs of trauma - C. Presence of attention deficit Presence of an attention deficit is common to all confusional states. All the other options may be used to differentiate organic versus non-organic causes of confusion. Characteristics of organic causes include acute onset, abnormal vital signs, fluctuating level of consciousness, possibly signs of trauma, and/or focal neurologic signs. Inorganic (functional) causes commonly illustrate chronic onset, stable vital signs, absence of trauma or focal neurologic symptoms, and/or delusions and illusions. With regard to specific causes of hypertension, which of the following is true? A. Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose mental status changes are reversible B. Hypertensive encephalopathy causes adverse outcomes over days or weeks, rather than hours C. Patients with stroke syndromes must have blood pressure normalized as quickly as possible to reduce the risks of worsening neurological deficit D. Laboratory analysis is rarely useful in cases of confirmed pediatric hypertension E. Laboratory analysis is rarely useful in cases of confirmed hypertension in pregnant patients - A. Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose mental status changes are reversible Hypertensive encephalopathy is a true medical emergency, and can cause coma and death over hours; however, encephalopathy due to hypertension is more likely reversible than encephalopathy from other causes. Avoidance of overzealous blood pressure lowering is particularly critical for patients with strokes. Laboratory analysis can be important in cases of hypertension in pediatric patients (for whom renal/renovascular or pheochromocytoma may be identified) and in pregnant patients (for whom laboratory testing can help establish diagnoses such as the HELLP syndrome). A 29 year old woman is found seizing by her husband and is rushed to the emergency department. On presentation, she is noted to have a BP of 162/112, is still seizing, and looks puffy all over. Her husband tells you that they are expecting their first child in a few months. Which of the following is the next best step in this patient's care? A. Control the seizures with magnesium sulfate. B. Draw blood to check CBC, LFT's, BUN, and creatinine.
C. Notify the labor floor that the patient is in the emergency department. D. Perform a CT scan of head if seizures persist. E. Start hydralazine to decrease the patient's blood pressure. - A. Control the seizures with magnesium sulfate. Antihypertensive therapy is only indicated in eclampsia if the diastolic blood pressure remains > 110 mm Hg after seizures are controlled because rapid lowering of blood pressure can result in uterine hypoperfusion. All the other choices (A-D) are appropriate in the management of the patient with eclampsia. Which of the following is not a feature of febrile seizures? A. generalized tonic-clonic seizure B. duration less than 15 minutes C. associated with a rapid rise in body temperature D. occurs in children ages 3 months to 5 years E. associated with postictal state of 30 minutes - E. associated with postictal state of 30 minutes Febrile seizure is not associated with a postictal period. The child usually rapidly regains alertness. Intracranial mass or infection should be a concern if the duration of seizure is greater than 15 minutes or if altered mental status persists after the cessation of seizure activity. A 47 year old man with a history of alcohol abuse presents to the ED after having a seizure. His past includes both seizures and blackouts. His last alcoholic drink was the previous evening. This morning he experienced palpitations, diaphoresis, and dizziness before losing consciousness and having a seizure lasting under a minute. Which of the following is true statement with to alcohol and its association with seizures? A. In people with an underlying seizure disorder, excessive alcohol intake is a risk- factor for seizure due to increased likelihood of head injury, predisposition to metabolic disorders, and lowered seizure threshold. B. Alcohol intake itself can precipitate seizures due to the neurotoxic effects of alcohol and its metabolites. C. Cessation of alcohol can precipitate seizures as part of the alcohol withdrawal syndrome. D. All of the above statements are true. E. All of the above statements are false. - D. All of the above statements are true. A 68 year old diabetic male, previously living independently, is brought in by his
