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SAEM Practice 2020/ 508 Questions with
Verified Answers/ 2024-2025.
Regarding the role of malignancy in the diagnosis of pulmonary embolism (PE):

A. 25% of PE patients without identifiable risk factors are diagnosed with cancer within 2 years.
B. Hematologic malignancies such as leukemia and have the highest incidence of venous
thromboembolism
C. Autopsy studies indicate that greater than 60% of patients who die of ovarian cancer have
PE.
D. The risk of PE is decreased in patients on chemotherapy - Answer: A. 25% of PE patients
without identifiable risk factors are diagnosed with cancer within 2 years.

Patients with esophageal and laryngeal cancer, as well as leukemia and lymphoma have a low
incidence of PE, whereas those with ovarian or colon cancers are at higher risk for developing
PE. Autopsy studies indicate that up to 30% of patients who die of ovarian cancer have PE.

,Chemotherapy increases the risk of developing PE. Development of PE without any identifiable
risk factors warrants a search for an underlying malignancy.
-- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th
edition, pages 1215-1216.

Of the following choices, which diagnosis is most likely in a 53-year-old cancer patient with
chest pain, dyspnea, and the EKG shown in the Figure?

A. pericarditis from metastatic disease
B. third degree heart block
C. anterolateral myocardial ischemia
D. infectious myocarditis
E. pulmonary embolism - Answer: E. pulmonary embolism

The answer is E. The EKG's S1Q3T3 pattern (S in lead I, Q and inverted T in lead III), while not
pathognomonic, is suggestive of PE as a cause of this patient's symptoms.

A 25-year-old female presents with fever, productive cough, and shortness of breath. Physical
exam reveals T101, RR 24 and SpO2 of 94%. Her left tympanic membrane is inflamed and there
are TM bullae. The chest X-ray reveals a large right middle lobe pneumonia. The organism most
commonly associated with this type of presentation is:

A. Legionella pneumoniae
B. Strep pneumoniae
C. H. influenzae
D. Moraxella catarrhalis
E. Mycoplasma pneumoniae - Answer: E. Mycoplasma pneumoniae

,Mycoplasma pneumoniae is a common cause of pneumonia in young adults. It is classically
associated with bullous myringitis.
-- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide,
5th edition, page 454.

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. - Answer: A. Vital signs are usually
abnormal, even early in the course of acute appendicitis.

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. - Answer: E. Pain in
the right lower quadrant when left lower quadrant is palpated.

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. - Answer: D. The onset of pain
prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology.

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 - Answer: C. unrelenting pain over a period of weeks

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