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CRAM SAEM Test | Questions solved 100% Correct
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CRAM SAEM Test | Questionssolved 100% Correct
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.
45yo F p/w RUQ pain & fever. The pain is worse after eating. On PE she has a (+)
Murphy's sign. Most likely dx? - ✔Cholecystitis
,RUQ 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
47yo M presents, confused, to the ED. He has limited ability to give a history. On PE of the skin,
it is noted that there are erythematous changes to both palms. Also, the face and arms are
characterized by a number of superficial, tortuous arterioles which fill from the center outwards.
The examination of the abdomen reveals violaceous lines radiating from the umbilicus, and there
are generally increased venous markings on the abdominal wall (see Figure). What is the most
likely diagnosis? - ✔liver disease
The patient's palmar erythema, spider angiomata, and caput medusa (due to recanalization of the
umbilical vein) are all characteristic of hepatic disease. The figure demonstrates abdominal wall
venous engorgement, as well as ascites (another clue to the patient's liver disease).
A 57-year-old homeless woman with a history of schizophrenia presents to the emergency
department complaining of nausea and severe abdominal pain for 48 hours. The patient is not
cooperative with an upright abdominal image, so a flat plate (as shown in the Figure) is
obtained. Which of the following is the most likely operative finding in this patient? - ✔small
bowel obstruction
Dilated loops of small bowel with air-fluid levels (which are not well-seen on a flat plate)
indicate small bowel obstruction. KUB is not often useful in the diagnosis of appendicitis,
ruptured spleen, gallstone disease, or a rectus sheath hematoma (which is an abdominal wall
condition most likely seen in anticoagulated patients with trauma or coughing). Despite this
woman's history of schizophrenia and possibly diminished ability to relate a clear story of
her pain, her complaint of abdominal pain must be taken seriously with a high suspicion for
underlying pathology.
All of the following factors predispose to cecal volvulus EXCEPT:
A. marathon running
B. pregnancy
C. age 25-35
D. prior abdominal surgery
E. severe chronic constipation - ✔constipation DOES not lead to volvulus
, 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.
Interestingly, marathon runners have been found to have a higher incidence of cecal volvulus,
perhaps from having a thin, flexible mesentery that more easily permits rotation of the cecum
around the mesenteric pedicle.
A 57 year old ill-appearing man presents with fever, chills, abdominal pain, nausea and
vomiting. His abdominal CT is shown in the Figure. Which of the following is LEAST correct
regarding this patient's condition? - ✔/images/upload-
flashcards/601487/924404_m.jpg#$Answer: Emergent percutaneous drainage in the emergency
department is indicated
The patient has a hepatic abscess, typically caused by gram negatives, anaerobic Streptococci or
Entameoba histolytica. Laboratory findings include elevations of WBC, bilirubin, alkaline
phosphatase and serum aminotransferases. CXR may demonstrate a right-sided effusion and
elevation of the right hemidiaphragm. Treatment with triple coverage antibiotics such as
gentamicin, metronidazole and ampicillin should be instituted immediately, however
consultation with a general surgeon, interventional radiologist, or gastroenterologist is
necessary for definitive treatment, which is drainage of the abscess.
Which of the following pairings of referred pain and causal disease is least likely to
be encountered?
A. thoracic back pain—pancreatitis
B. epigastric pain—myocardial infarction
C. inguinal pain—ureteral colic
D. shoulder pain—ruptured spleen
E. sacral pain—ovarian torsion - ✔The answer is E. Ovarian torsion may cause lower
abdominal pain, pelvic pain, adnexal tenderness, and cervical motion tenderness, but it is
not known to cause sacral pain.
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