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ABEM EM practice questions

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Question 1Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 55-year-old man collapses in the emergency department waiting room. He is unresponsive, pulseless, and apneic. After activating the code team and starting chest compressions, which intervention most directly improves survival in witnessed ventricular fibrillation cardiac arrest?

  1. Passive leg raising
  2. Administration of intravenous epinephrine
  3. Endotracheal intubation
  4. Immediate defibrillation Correct answer.

Explanation

For witnessed shockable cardiac arrest, early defibrillation is the single intervention with the greatest impact on survival, as the probability of successful defibrillation declines rapidly with each minute of delay. Compressions and airway management support circulation but do not restore an organized rhythm.

Question 2Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 28-year-old woman presents with sudden-onset right-sided pleuritic chest pain and dyspnea after a long flight. She is tachycardic and hypoxic. Which finding on bedside ultrasound most supports the diagnosis of a large pulmonary embolism?

  1. Mitral valve vegetations
  2. Hyperdynamic left ventricular contraction with a small left ventricle
  3. A dilated, hypokinetic right ventricle Correct answer.
  4. Pericardial effusion with tamponade physiology

Explanation

Acute right ventricular strain from pulmonary embolism classically produces a dilated, hypokinetic right ventricle on echocardiography, often with septal flattening. This reflects the acute pressure overload on the right heart.

Question 3Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 62-year-old man with a history of hypertension presents with tearing anterior chest pain radiating to the back. Blood pressure is 190/100 mm Hg in the right arm and 150/90 mm Hg in the left arm. Which initial medication is most appropriate for blood pressure control in suspected acute aortic dissection?

  1. Intravenous hydralazine
  2. Intravenous labetalol Correct answer.
  3. Sublingual nifedipine
  4. Oral hydrochlorothiazide

Explanation

Beta-blockade with a titratable intravenous agent such as labetalol is first-line because it lowers both blood pressure and the shear force (dP/dt) on the aortic wall. Vasodilators alone can cause reflex tachycardia that increases shear stress.

Question 4Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 70-year-old woman with atrial fibrillation presents with 90 minutes of left-sided weakness and facial droop. Noncontrast head CT shows no hemorrhage. Blood pressure is 185/105 mm Hg. Which finding is an absolute contraindication to intravenous thrombolysis?

  1. Platelet count of 180,000/µL
  2. Blood pressure of 185/105 mm Hg Correct answer.
  3. History of well-controlled hypertension
  4. Age of 70 years

Explanation

A blood pressure persistently above 185/110 mm Hg is an absolute contraindication to intravenous thrombolysis for acute ischemic stroke because of the markedly increased risk of symptomatic intracranial hemorrhage. Pressure must be lowered and sustained below this threshold before treatment.

Question 5Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 24-year-old man sustains a stab wound to the left fifth intercostal space. He is hypotensive with distended neck veins and muffled heart sounds. Which bedside finding most rapidly confirms the diagnosis of cardiac tamponade?

  1. Widened mediastinum on chest radiograph
  2. Electrical alternans on electrocardiogram
  3. Pulsus paradoxus on manual blood pressure
  4. Pericardial fluid with right ventricular diastolic collapse on ultrasound Correct answer.

Explanation

Focused cardiac ultrasound demonstrating pericardial fluid with right ventricular diastolic collapse is the most rapid and sensitive bedside confirmation of tamponade physiology. It can be obtained within seconds at the bedside and guides immediate pericardiocentesis.

Question 6Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 19-year-old man is brought in after a diving accident with midline neck tenderness and flaccid quadriparesis. Which maneuver is most appropriate during airway management to minimize further spinal injury?

  1. Routine cricoid pressure during intubation
  2. Manual in-line stabilization with jaw thrust Correct answer.
  3. Hyperextension of the neck to align the airway
  4. Rapid sequence intubation with head-down positioning

Explanation

Manual in-line stabilization maintains the cervical spine in a neutral position while allowing jaw thrust and direct laryngoscopy, minimizing movement of an unstable spine. Neck extension and excessive traction risk worsening cord injury.

Question 7Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 4-year-old child presents with drooling, tripod positioning, and a muffled voice after two days of fever. Which management step is most appropriate?

  1. Obtain a lateral neck radiograph before any airway preparation
  2. Keep the child calm and arrange urgent controlled airway evaluation in the operating room Correct answer.
  3. Inspect the posterior pharynx with a tongue blade to visualize the epiglottis
  4. Administer oral antibiotics and discharge with close follow-up

Explanation

Suspected epiglottitis is an airway emergency; the priority is to avoid agitating the child and to secure the airway in a controlled setting with anesthesia and surgery present. Forcing a view of the pharynx can precipitate complete airway obstruction.

Question 8Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 30-year-old woman presents with a diffuse headache, fever, and neck stiffness. Which cerebrospinal fluid profile is most consistent with bacterial meningitis?

  1. Eosinophilic pleocytosis with normal protein
  2. Elevated neutrophils with low glucose and high protein Correct answer.
  3. Lymphocytic pleocytosis with normal glucose
  4. Normal cell count with elevated red blood cells

Explanation

Bacterial meningitis typically produces a neutrophilic pleocytosis, low cerebrospinal fluid glucose relative to serum, and elevated protein. These findings reflect active bacterial infection and inflammation within the subarachnoid space.

Question 9Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 45-year-old man presents with sudden severe epigastric pain radiating to the back and a history of heavy alcohol use. He is tachycardic and hypotensive. Which initial fluid strategy is most appropriate?

  1. Restrictive fluid administration to avoid third-spacing
  2. Colloid infusion as first-line therapy
  3. Aggressive isotonic crystalloid resuscitation with reassessment of response Correct answer.
  4. Hypertonic saline at maintenance rate

Explanation

Early aggressive isotonic crystalloid resuscitation is the cornerstone of initial management of acute pancreatitis, restoring intravascular volume lost to third-spacing and reducing pancreatic hypoperfusion. Fluid status must be reassessed frequently to avoid overload.

Question 10Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 68-year-old woman presents with severe right upper quadrant pain, fever, and jaundice. Ultrasound shows gallstones and a dilated common bile duct. Which diagnosis best fits this presentation?

  1. Perforated peptic ulcer
  2. Acute hepatitis
  3. Acute cholecystitis
  4. Ascending cholangitis Correct answer.

Explanation

The combination of fever, jaundice, and right upper quadrant pain (Charcot triad) with biliary ductal dilation indicates ascending cholangitis, an infection of an obstructed biliary tree requiring antibiotics and biliary drainage.

Question 11Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 2-year-old child presents with a barking cough, inspiratory stridor, and hoarse voice following a few days of coryza. The child is alert and not drooling. Which treatment is most appropriate for moderate symptoms?

  1. Empiric intravenous antibiotics
  2. Intramuscular epinephrine for all cases
  3. Immediate intubation
  4. A single dose of oral dexamethasone Correct answer.

Explanation

Croup is a clinical diagnosis of viral laryngotracheitis, and a single dose of a corticosteroid such as dexamethasone reduces airway edema and symptom duration. Nebulized epinephrine is reserved for moderate to severe stridor at rest.

Question 12Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 50-year-old man is found unresponsive with pinpoint pupils, a respiratory rate of 6/min, and oxygen saturation of 78%. Which intervention is most appropriate after initiating bag-mask ventilation?

  1. Administer naloxone Correct answer.
  2. Administer physostigmine
  3. Administer flumazenil
  4. Administer atropine

Explanation

The triad of depressed mental status, pinpoint pupils, and respiratory depression suggests opioid toxicity; naloxone reverses opioid-induced respiratory depression. Ventilation should be supported while the antidote is given.

Question 13Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 22-year-old woman is brought in after ingesting an unknown amount of acetaminophen several hours ago. She is currently asymptomatic. Which test guides initiation of N-acetylcysteine therapy?

  1. Arterial blood gas
  2. Serum acetaminophen concentration plotted against time since ingestion Correct answer.
  3. Urine toxicology screen
  4. Serum lipase

Explanation

The decision to treat acetaminophen overdose with N-acetylcysteine is guided by the serum acetaminophen level interpreted on the Rumack-Matthew nomogram relative to time of ingestion. Patients can be asymptomatic early despite risk of hepatotoxicity.

Question 14Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 34-year-old man presents with agitation, dilated pupils, dry flushed skin, urinary retention, and tachycardia after ingesting an unknown medication. Which toxidrome does this represent?

  1. Opioid toxidrome
  2. Anticholinergic toxidrome Correct answer.
  3. Sympathomimetic toxidrome
  4. Cholinergic toxidrome

Explanation

The anticholinergic toxidrome classically produces agitation, mydriasis, dry flushed skin, urinary retention, and tachycardia (often summarized as hot, dry, mad, and blind). Physostigmine may be considered in severe cases.

Question 15Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 60-year-old woman with a history of alcohol use disorder presents with confusion and ataxia. She has horizontal nystagmus and ophthalmoplegia. Which diagnosis best explains these findings?

  1. Delirium tremens
  2. Wernicke encephalopathy Correct answer.
  3. Korsakoff syndrome
  4. Hepatic encephalopathy

Explanation

The classic triad of encephalopathy, oculomotor dysfunction (nystagmus, ophthalmoplegia), and gait ataxia in a patient with alcohol use disorder indicates Wernicke encephalopathy from thiamine deficiency. Prompt intravenous thiamine prevents progression to irreversible Korsakoff syndrome.

Question 16Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 25-year-old woman presents with palpitations and anxiety. Her heart rate is 140/min and irregularly irregular. Which electrocardiographic feature is most characteristic of atrial fibrillation?

  1. Diffuse ST-segment elevation
  2. Absent P waves with an irregularly irregular ventricular rhythm Correct answer.
  3. A regular rhythm with a delta wave
  4. Sawtooth flutter waves at 300/min

Explanation

Atrial fibrillation is characterized by the absence of distinct P waves and an irregularly irregular ventricular response, reflecting disorganized atrial activity. Treatment focuses on rate control and anticoagulation based on stroke risk.

Question 17Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 72-year-old man with chronic obstructive pulmonary disease presents with worsening dyspnea and purulent sputum. He is alert with a respiratory rate of 24/min and oxygen saturation of 86% on room air. Which oxygen target is most appropriate?

  1. Withhold supplemental oxygen unless saturation falls below 70%
  2. Target a saturation of 94% to 98%
  3. Titrate oxygen to a saturation of 88% to 92% Correct answer.
  4. Titrate oxygen to 100% saturation

Explanation

In patients with chronic obstructive pulmonary disease who may retain carbon dioxide, oxygen is titrated to a saturation of 88% to 92% to avoid worsening hypercapnia while correcting hypoxemia. Oxygen is never withheld from a hypoxemic patient.

Question 18Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 30-year-old woman presents with sudden-onset sharp chest pain and dyspnea. She is tall and thin. Breath sounds are absent on the right, and percussion is hyperresonant. Which finding on chest radiograph would confirm the diagnosis?

  1. A visible pleural line with no lung markings peripheral to it Correct answer.
  2. Air-fluid level in the lower chest
  3. A deep sulcus sign with a large effusion
  4. Bilateral hilar lymphadenopathy

Explanation

A pneumothorax appears on an upright chest radiograph as a visible visceral pleural line with absent lung markings beyond it. Tension physiology warrants immediate decompression before imaging.

Question 19Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 45-year-old man presents with a swollen, painful left calf after a long car trip. Which test is the diagnostic standard for confirming a proximal deep vein thrombosis?

  1. Contrast venography as first-line
  2. Magnetic resonance imaging of the thigh
  3. D-dimer assay
  4. Duplex compression ultrasound of the leg veins Correct answer.

Explanation

Duplex compression ultrasound is the diagnostic standard for suspected deep vein thrombosis because it is noninvasive, sensitive for proximal clots, and can be repeated if initially negative. D-dimer is useful mainly to rule out disease in low-risk patients.

Question 20Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 58-year-old man with a history of hypertension presents with a sudden, severe headache described as the worst of his life. Noncontrast head CT is normal. Which next step is most appropriate if subarachnoid hemorrhage remains suspected?

  1. Lumbar puncture for xanthochromia Correct answer.
  2. Discharge with analgesic therapy
  3. Immediate magnetic resonance imaging of the brain
  4. Carotid duplex ultrasound

Explanation

When a noncontrast CT is negative but subarachnoid hemorrhage is still suspected, lumbar puncture looking for xanthochromia or red blood cells is the next step, ideally after 12 hours from symptom onset. Modern practice may also use CT angiography depending on timing and institutional protocol.

Question 21Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 70-year-old woman presents with altered mental status, fever, and hypotension. She has a urinary catheter and known pyelonephritis. Which management priority is most appropriate?

  1. Restriction of fluids to prevent edema
  2. Oral antibiotics with outpatient follow-up
  3. Early broad-spectrum antibiotics and fluid resuscitation Correct answer.
  4. Immediate nephrectomy

Explanation

Septic shock from pyelonephritis requires early broad-spectrum antibiotics and aggressive fluid resuscitation to restore perfusion, with source control if obstruction is present. Delays in antibiotics increase mortality.

Question 22Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 40-year-old man presents with a painful, swollen, erythematous leg after a minor injury. He has a low-grade fever. Which finding most supports a diagnosis of cellulitis over deep vein thrombosis?

  1. A history of recent immobilization
  2. Calf tenderness on dorsiflexion
  3. A positive D-dimer
  4. A sharply demarcated area of warmth and tenderness with fever Correct answer.

Explanation

Cellulitis is a clinical diagnosis based on localized warmth, erythema, tenderness, and often fever, usually with a relatively well-demarcated border. Deep vein thrombosis more often presents with swelling and calf tenderness without prominent erythema or fever.

Question 23Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 65-year-old man presents with acute urinary retention, hematuria, and lower abdominal pain. Which initial intervention is most appropriate?

  1. Immediate suprapubic aspiration
  2. Oral alpha-blocker therapy alone
  3. Urethral catheterization for bladder decompression Correct answer.
  4. Intravenous diuretics

Explanation

Acute urinary retention is managed with urethral catheterization to decompress the bladder and relieve pain, followed by evaluation for the underlying cause. Suprapubic catheterization is reserved for failed urethral attempts or urethral injury.

Question 24Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 28-year-old woman presents with severe colicky flank pain radiating to the groin and hematuria. Which finding on urinalysis most supports nephrolithiasis?

  1. Microscopic hematuria Correct answer.
  2. White blood cell casts
  3. Broad waxy casts
  4. Eosinophils

Explanation

Nephrolithiasis commonly produces microscopic hematuria as the stone traumatizes the ureteral mucosa. The diagnosis is confirmed with noncontrast CT of the abdomen and pelvis.

Question 25Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 55-year-old man presents with a deep laceration to the palm from a kitchen knife. He has no tendon or nerve deficits and the wound is clean. Which factor most influences the decision to close the wound primarily?

  1. Presence of a minor scar nearby
  2. Family history of keloids
  3. Patient's handedness
  4. Time since injury and wound contamination Correct answer.

Explanation

The decision to perform primary closure depends on the time elapsed since injury and the degree of contamination, since older or heavily contaminated wounds carry higher infection risk and may require delayed closure or healing by secondary intention. Hand wounds are often managed with careful irrigation and reassessment.

Question 26Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 24-year-old man sustains a blunt splenic injury in a motor vehicle collision. He is hypotensive and tachycardic despite 2 L of crystalloid. Which is the most appropriate next step in management?

  1. Observation with serial abdominal exams
  2. CT of the abdomen with IV contrast
  3. Diagnostic peritoneal lavage to confirm hemoperitoneum
  4. Emergent laparotomy for hemorrhage control Correct answer.

Explanation

Hemodynamically unstable patients with suspected intra-abdominal hemorrhage after blunt trauma require emergent operative exploration rather than further imaging. Crystalloid resuscitation alone does not control ongoing bleeding.

Question 27Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 68-year-old man with a history of hypertension presents with tearing anterior chest pain radiating to the back, a 20 mm Hg blood pressure difference between arms, and a widened mediastinum on chest radiograph. Which is the most appropriate initial diagnostic study?

  1. Troponin and serial ECGs
  2. CT angiography of the chest Correct answer.
  3. Upper endoscopy
  4. Bedside echocardiography

Explanation

The presentation suggests acute aortic dissection, for which CT angiography is the diagnostic study of choice in stable patients. Rapid confirmation guides urgent surgical or medical management.

Question 28Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 3-year-old child is brought in after a generalized tonic-clonic seizure lasting approximately 4 minutes that has now stopped. He is postictal but breathing spontaneously with normal glucose. Which is the most appropriate disposition?

  1. Discharge home without further workup
  2. Observation and evaluation for the cause of the first seizure Correct answer.
  3. Immediate lumbar puncture before any imaging
  4. Empiric intravenous antibiotics

Explanation

A first unprovoked seizure in a child that has terminated requires evaluation for reversible causes and observation. Routine lumbar puncture and empiric antibiotics are not indicated without signs of meningitis.

Question 29Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 55-year-old woman presents with a 3-day history of painful vesicular lesions in a dermatomal distribution on the left thorax. Which is the most appropriate treatment to reduce duration and complications?

  1. Topical antibiotic ointment
  2. Oral acyclovir started immediately Correct answer.
  3. Topical corticosteroid cream
  4. Oral fluconazole

Explanation

Herpes zoster is treated with antiviral therapy, ideally within 72 hours of rash onset, to shorten the course and reduce complications. Acyclovir, valacyclovir, or famciclovir are appropriate.

Question 30Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 45-year-old man presents with sudden painless loss of vision in his right eye described as a curtain descending over the visual field. Fundoscopy shows a pale retina with a cherry-red macula. Which is the most appropriate immediate management?

  1. Oral acetazolamide
  2. Topical beta-blocker drops to the affected eye
  3. Reassurance and outpatient follow-up in one week
  4. Emergent ophthalmology consultation for possible reperfusion therapy Correct answer.

Explanation

Central retinal artery occlusion is an ocular emergency requiring immediate ophthalmology consultation because retinal ischemia causes irreversible vision loss within hours. Therapies aim to restore perfusion urgently.

Question 31Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 30-year-old woman presents with a 2-day history of dysuria, urinary frequency, and suprapubic discomfort without fever or flank pain. She is otherwise healthy and not pregnant. Which is the most appropriate management?

  1. Renal ultrasound before treatment
  2. Observation without antibiotics
  3. Intravenous ceftriaxone and admission
  4. Oral nitrofurantoin for uncomplicated cystitis Correct answer.

Explanation

Uncomplicated cystitis in a healthy nonpregnant woman is treated with a short course of oral antibiotics such as nitrofurantoin. Systemic or parenteral therapy is reserved for pyelonephritis or complicated infection.

Question 32Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 62-year-old man with atrial fibrillation on warfarin presents with a headache and is found to have an intracerebral hemorrhage on CT. His INR is 4.5. Which is the most appropriate immediate reversal strategy?

  1. Protamine sulfate
  2. Four-factor prothrombin complex concentrate plus intravenous vitamin K Correct answer.
  3. Fresh frozen plasma alone
  4. Platelet transfusion

Explanation

For warfarin-associated intracranial hemorrhage, urgent reversal with four-factor prothrombin complex concentrate plus intravenous vitamin K is recommended for rapid correction. Time to reversal affects outcomes.

Question 33Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 28-year-old woman at 34 weeks gestation presents with a blood pressure of 168/112 mm Hg, severe headache, and visual scotomas. Which is the most appropriate first-line antihypertensive for acute control?

  1. Intravenous furosemide
  2. Oral enalapril
  3. Intravenous labetalol Correct answer.
  4. Sublingual nifedipine

Explanation

Severe hypertension in preeclampsia is treated acutely with intravenous labetalol, hydralazine, or oral nifedipine. Labetalol is a standard first-line agent with a favorable safety profile in pregnancy.

Question 34Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 40-year-old man is brought in after a bee sting with diffuse urticaria, wheezing, and a blood pressure of 78/40 mm Hg. Which is the most appropriate first medication?

  1. Nebulized albuterol
  2. Intravenous methylprednisolone
  3. Intravenous diphenhydramine
  4. Intramuscular epinephrine Correct answer.

Explanation

Anaphylaxis is treated first with intramuscular epinephrine, which reverses vasodilation and bronchospasm. Adjunctive antihistamines and corticosteroids do not treat the acute airway and vascular effects.

Question 35Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 75-year-old woman presents with a 1-week history of productive cough, fever, and confusion. She lives in a nursing home. Chest radiograph shows a right lower lobe infiltrate. Which factor most strongly supports inpatient admission?

  1. Presence of confusion Correct answer.
  2. Productive cough
  3. Temperature of 38.2 degrees C
  4. Age over 65 years alone

Explanation

Confusion is a component of the CURB-65 and pneumonia severity tools and indicates a higher risk of adverse outcome. Such patients generally warrant admission and closer monitoring.

Question 36Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 33-year-old man presents with a swollen, painful knee after a minor twisting injury. Arthrocentesis yields cloudy synovial fluid with a white blood cell count of 60,000/mm3 and a Gram stain showing gram-positive cocci in clusters. Which organism is most likely?

  1. Staphylococcus aureus Correct answer.
  2. Pseudomonas aeruginosa
  3. Neisseria gonorrhoeae
  4. Escherichia coli

Explanation

Septic arthritis in adults is most commonly caused by Staphylococcus aureus, which appears as gram-positive cocci in clusters. Empiric therapy should target this organism pending cultures.

Question 37Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 19-year-old woman presents with a 2-day history of sore throat, fever, and tender cervical lymphadenopathy. Rapid strep testing is positive. Which is the most appropriate treatment?

  1. Oral fluconazole
  2. Oral azithromycin
  3. Topical lidocaine gargle
  4. Oral penicillin V Correct answer.

Explanation

Group A streptococcal pharyngitis is treated with penicillin or amoxicillin as first-line therapy to shorten illness and prevent rheumatic fever. Alternatives are used for penicillin allergy.

Question 38Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 50-year-old man presents with sudden-onset severe abdominal pain and is found to have free air under the diaphragm on upright radiograph. He is tachycardic and has rigid abdominal musculature. Which is the most appropriate next step?

  1. Nasogastric decompression and observation
  2. CT of the abdomen before any intervention
  3. Intravenous antibiotics alone
  4. Emergent surgical consultation Correct answer.

Explanation

Pneumoperitoneum with peritonitis indicates a hollow viscus perforation requiring emergent surgical evaluation and operative repair. Delay increases mortality.

Question 39Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 6-month-old infant is brought in for a 1-day history of vomiting and watery diarrhea. He has a sunken fontanelle, dry mucous membranes, and a capillary refill of 4 seconds. Which is the most appropriate initial fluid resuscitation?

  1. Oral rehydration solution only
  2. 5 mL/kg isotonic crystalloid bolus
  3. 20 mL/kg isotonic crystalloid bolus Correct answer.
  4. Maintenance fluids at 1.5 times rate without a bolus

Explanation

Infants with dehydration and signs of shock receive an initial 20 mL/kg isotonic crystalloid bolus, reassessed after each bolus. Oral rehydration is reserved for mild to moderate dehydration without shock.

Question 40Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 24-year-old woman presents with pelvic pain and vaginal bleeding. Her last menstrual period was 7 weeks ago. Which finding most strongly suggests a ruptured ectopic pregnancy requiring emergent surgery?

  1. A positive urine pregnancy test
  2. A small amount of vaginal spotting
  3. Free fluid in the pelvis with hypotension Correct answer.
  4. A history of one prior ectopic pregnancy

Explanation

Hemodynamic instability with free pelvic fluid in a pregnant patient indicates likely ruptured ectopic pregnancy and requires emergent operative intervention. Other findings increase suspicion but do not mandate immediate surgery.

Question 41Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 70-year-old man presents with a 2-hour history of sudden painless loss of vision in one eye. He has a history of hypertension and hyperlipidemia. Which is the most likely diagnosis?

  1. Retinal detachment
  2. Vitreous hemorrhage
  3. Central retinal artery occlusion Correct answer.
  4. Acute angle-closure glaucoma

Explanation

Sudden painless monocular vision loss in an older adult with vascular risk factors suggests central retinal artery occlusion. Fundoscopy typically shows a pale retina with a cherry-red macula.

Question 42Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 58-year-old woman presents with sudden-onset severe vertigo, nausea, and unsteady gait. She has a history of hypertension. Which finding on examination most suggests a central cause rather than benign positional vertigo?

  1. Nystagmus that fatigues with fixation
  2. A positive Dix-Hallpike maneuver
  3. Nausea and vomiting
  4. Direction-changing nystagmus Correct answer.

Explanation

Direction-changing or vertical nystagmus suggests a central vestibular lesion such as a posterior circulation stroke. Peripheral vertigo typically produces unidirectional, fatigable nystagmus suppressed by fixation.

Question 43Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 35-year-old man presents with a deep partial-thickness burn to the anterior chest and both arms after a grease fire. Using the rule of nines, which estimated total body surface area is involved?

  1. 36 percent
  2. 27 percent Correct answer.
  3. 45 percent
  4. 18 percent

Explanation

The anterior trunk is 18 percent and each entire arm is 9 percent, so one arm plus the anterior trunk totals 27 percent. Accurate estimation guides fluid resuscitation.

Question 44Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 42-year-old man is found with a core temperature of 30 degrees C after prolonged cold exposure. He is confused and has an irregular pulse. Which rewarming strategy is most appropriate?

  1. Immersion in hot water at 45 degrees C
  2. Passive external rewarming with blankets alone
  3. Active internal rewarming with warm intravenous fluids and bladder lavage Correct answer.
  4. Vigorous rubbing of the extremities

Explanation

Moderate to severe hypothermia with altered mental status requires active internal rewarming techniques such as warmed IV fluids, bladder or peritoneal lavage, and possibly extracorporeal rewarming. Passive measures are inadequate.

Question 45Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 29-year-old woman presents with a 3-day history of bilateral wrist and knee pain, low-grade fever, and a new annular rash. She recently returned from a camping trip in Connecticut. Which is the most appropriate treatment?

  1. Intravenous ceftriaxone
  2. Oral amoxicillin
  3. Oral doxycycline Correct answer.
  4. Topical hydrocortisone

Explanation

Early disseminated Lyme disease is treated with oral doxycycline, which is effective against Borrelia burgdorferi. Amoxicillin is an alternative in pregnancy or young children.

Question 46Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 48-year-old man presents with a painful, swollen, erythematous scrotum and fever. Ultrasound shows increased blood flow to the epididymis with normal testicular flow. Which is the most appropriate management?

  1. Immediate orchiectomy
  2. Observation without antibiotics
  3. Outpatient oral antibiotics and scrotal support Correct answer.
  4. Emergent surgical exploration

Explanation

Epididymitis with preserved testicular blood flow is managed with antibiotics and supportive care. Surgical exploration is reserved for testicular torsion, which shows absent or decreased flow.

Question 47Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 56-year-old woman presents with a 1-hour history of severe retrosternal chest pressure and diaphoresis. ECG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

  1. Left anterior descending artery
  2. Right coronary artery Correct answer.
  3. Left circumflex artery
  4. Left main coronary artery

Explanation

ST elevation in the inferior leads II, III, and aVF localizes an inferior myocardial infarction, most often due to right coronary artery occlusion. The left anterior descending supplies the anterior wall.

Question 48Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 32-year-old man presents with a 1-day history of periumbilical pain that migrated to the right lower quadrant, anorexia, and low-grade fever. He has rebound tenderness at McBurney point. Which is the most appropriate next step in management?

  1. CT scan before any surgical involvement
  2. Laxatives to relieve the obstruction
  3. Oral antibiotics and outpatient follow-up
  4. Surgical consultation for appendectomy Correct answer.

Explanation

Acute appendicitis with classic signs requires surgical consultation for appendectomy. Imaging may be used selectively but should not delay surgical evaluation.

Question 49Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 60-year-old man with a history of alcohol use disorder presents with hematemesis and hypotension. He has known cirrhosis with ascites. Which is the most appropriate initial pharmacologic therapy in addition to resuscitation?

  1. Oral propranolol
  2. Intravenous furosemide
  3. Intravenous ketorolac
  4. Intravenous octreotide and ceftriaxone Correct answer.

Explanation

Suspected variceal hemorrhage is treated with a vasoactive agent such as octreotide and prophylactic antibiotics, which reduce bleeding and mortality. Endoscopy follows stabilization.

Question 50Emergency Medicine (Qualifying Exam and Certifying Exam content)

A 23-year-old man presents with a swollen, painful scrotum of sudden onset. He has nausea and vomiting. The cremasteric reflex is absent on the affected side. Which is the most appropriate immediate action?

  1. Emergent urologic consultation for surgical exploration Correct answer.
  2. Warm compresses and observation
  3. Scrotal ultrasound before any consultation
  4. Antibiotics and scrotal elevation

Explanation

Testicular torsion is a surgical emergency requiring immediate detorsion to preserve the testis. Delay for imaging can result in testicular loss.