Over the past year, hundreds of Emergency Medicine physicians have used TrueLearn’s Emergency Medicine platform for their ABEM ITE, Qual and ConCert exam preparation. At TrueLearn, we’ve gathered feedback from many of our users and have made some major upgrades to our Emergency Medicine SmartBanks for 2016.
ABEM In-Training Exam Q-Bank Updates
At TrueLearn, we’ve made our biggest improvements to our 2016 ABEM In-Training Exam SmartBank. As you can see below, we’ve added 500 brand new ABEM specific questions to the SmartBank.
In addition to these new questions, we’ve also made over 400 updates to our existing Emergency Medicine questions based on psychometric data, resident-submitted feedback and survey results.
ABEM ITE Sample Question
Q: A 48-year-old overweight female presents for evaluation of nausea, nonbilious vomiting, and right upper quadrant pain after eating fast food two hours prior to arrival. She has a history of similar presentations in the past, but this is the worst pain she has had. On examination, the patient is well appearing, obese, without scleral icterus, and palpation of her abdomen catches her breath when you palpate deeply in the right upper quadrant. Her vitals are temperature 37.8º C (100.2º F), heart rate 98/min, blood pressure 130/90.
What physical exam findings has the highest sensitivity for acute cholecystitis?
C) Murphy’s Sign
D) Right upper quadrant pain
Explanation & Analysis
Murphy’s Sign is defined as the sudden cessation of deep inspiration with deep palpation of the right upper quadrant. It has the highest sensitivity for diagnosis of acute cholecystitis with 87% compared to RUQ pain alone at 67 percent and RUQ tenderness of 54 percent. The cessation of deep inspiration is key.
Ultrasonographic findings for acute cholecystitis include gallbladder wall thickening > 3mm (but most patients have a wall >5mm with acute cholecystitis), presence of pericholecystic fluid, and biliary duct dilatation of >7mm. Ultrasound has a sensitivity of 94% and a specificity of 78 percent for detecting acute cholecystitis. Small stones (<1mm) may be impossible to detect with ultrasound, especially if they are in the gallbladder neck, cystic duct or common bile duct.
Acute cholecystitis should be managed with operative removal of the gallbladder, antibiotics (3rd generation cephalosporin + metronidazole or flouroquinolone + metronidazole are first line), pain control, maintenance intravenous fluids. If not treated, acute cholecystitis can lead to ascending cholangitis, or even worse gangrenous/emphysematous cholecystitis.
Answer A: Fever is the least sensitive characteristic of acute cholecystitis with only 35 percent, but does have 80 percent specificity. However, the differential for fever and abdominal pain can be vast and other associated signs/symptoms in conjunction with fever can increase the sensitivity/specificity when compared with fever alone.
Answer B: Leukocytosis of >10,000/mL was studied and found to be only 63 percent sensitive and 57 percent specific for acute cholecystitis. Leukocytosis can be present in numerous other states/disease processes.
Answer D: Patient’s report of right upper quadrant pain has a sensitivity of only 67 percent compared to the presence of a Murphy’s Sign with 87 percent sensitivity.
Bottom Line: Murphy’s Sign is the most sensitive clinical finding in the diagnosis of acute cholecystitis.
For more information, see: Tintinalli’s Emergency Medicine, 7th Edition. Chapter 82: Pancreatitis and Cholecystitis
ABEM Qualifying Exam & ConCert Exam Q-Bank Updates
Along with making significant updates to our ABEM ITE SmartBank, we’ve also added 500 questions to each of our 2015 ABEM Qualifying Exam and ABEM ConCert SmartBanks. This brings the number of questions in each SmartBank up to 1,500 questions.
Subscribe to TrueLearn to Gain Access to the SmartBank
Ready to gain access to TrueLearn’s full SmartBank of questions to help you better prepare for your Emergency Medicine exam? Learn more about TrueLearn’s subscription options and get started today.