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CAQ-EM practice questions

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Question 1Emergency Medicine

A 58-year-old man with crushing substernal chest pain has an ECG showing 3 mm ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

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

Explanation

ST elevation in the inferior leads II, III, and aVF localizes injury to the inferior wall, which is supplied by the right coronary artery in most individuals. The left anterior descending supplies the anterior wall, and the circumflex typically supplies the lateral wall.

Question 2Emergency Medicine

Which finding best distinguishes an absence seizure from a complex partial (focal impaired awareness) seizure in the emergency department?

  1. Brief duration with immediate return to baseline and no postictal confusion Correct answer.
  2. A preceding aura of unusual smells
  3. A postictal period of confusion lasting 10 to 30 minutes
  4. Presence of urinary incontinence during the event

Explanation

Absence seizures typically last seconds, involve staring and automatisms, and end abruptly with no postictal confusion. Focal impaired awareness seizures usually last longer and are followed by a period of postictal confusion.

Question 3Emergency Medicine

A young adult presents after a bee sting with urticaria, wheezing, and a blood pressure of 78/40 mmHg. Which medication is the first-line treatment?

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

Explanation

Intramuscular epinephrine into the lateral thigh is the first-line therapy for anaphylaxis because it reverses vasodilation, mucosal edema, and bronchospasm rapidly. Antihistamines, bronchodilators, and steroids are adjuncts and do not treat airway or circulatory collapse.

Question 4Emergency Medicine

Which initial ventilation strategy is appropriate for a patient with severe asthma exacerbation in status asthmaticus who requires intubation?

  1. High respiratory rate with short expiratory time to maximize minute ventilation
  2. Large tidal volumes of 10 to 12 mL/kg to overcome airway resistance
  3. Low respiratory rate with prolonged expiratory time and permissive hypercapnia Correct answer.
  4. Immediate high positive end-expiratory pressure of 15 cm H2O

Explanation

Severe asthma causes dynamic hyperinflation and air trapping, so ventilation should use low rates, prolonged expiratory times, and lower tidal volumes while tolerating hypercapnia. This approach reduces the risk of breath stacking and barotrauma.

Question 5Emergency Medicine

A trauma patient arrives with a systolic blood pressure of 80 mmHg, distended neck veins, muffled heart sounds, and clear lungs. Which intervention is most appropriate next?

  1. Emergent pericardiocentesis or pericardial window Correct answer.
  2. Needle decompression of the left chest
  3. Rapid infusion of two liters of crystalloid
  4. Immediate bedside thoracotomy

Explanation

The triad of hypotension, distended neck veins, and muffled heart sounds with clear lung fields suggests cardiac tamponade, which requires drainage of the pericardial effusion. Pericardiocentesis or a pericardial window relieves the obstruction to filling.

Question 6Emergency Medicine

Which electrolyte abnormality most commonly produces peaked T waves, widened QRS complexes, and a sine-wave pattern on ECG?

  1. Hypomagnesemia
  2. Hypercalcemia
  3. Hyperkalemia Correct answer.
  4. Hypokalemia

Explanation

Hyperkalemia progressively produces peaked T waves, PR prolongation, QRS widening, and eventually a sine-wave morphology that precedes cardiac arrest. Prompt calcium administration stabilizes the myocardium.

Question 7Emergency Medicine

A patient with diabetic ketoacidosis has a potassium of 3.0 mEq/L on the initial panel. What is the correct approach to potassium before starting an insulin infusion?

  1. Start insulin immediately and add potassium to the same bag
  2. Withhold all potassium until the glucose normalizes
  3. Give insulin without potassium because total body potassium is high
  4. Replete potassium first, then begin insulin Correct answer.

Explanation

Insulin drives potassium intracellularly and can precipitate life-threatening hypokalemia in DKA when the serum level is already low. Potassium must be repleted before or alongside insulin initiation, with close monitoring.

Question 8Emergency Medicine

A patient with suspected opioid overdose has a respiratory rate of 4/min and pinpoint pupils. After an initial dose of naloxone produces adequate breathing, the patient becomes agitated and combative. What is the best interpretation?

  1. The naloxone dose was inadequate
  2. The patient is developing serotonin syndrome
  3. The dose produced abrupt reversal with withdrawal symptoms Correct answer.
  4. The patient has a coexisting stimulant overdose

Explanation

Naloxone can precipitate acute opioid withdrawal when given in excessive doses, causing agitation, vomiting, and hypertension. The goal is titrated reversal of respiratory depression, not full arousal.

Question 9Emergency Medicine

Which finding is most consistent with carbon monoxide poisoning in a patient rescued from a house fire?

  1. Markedly low pulse oximetry despite normal arterial oxygen tension
  2. Cherry-red skin discoloration in most patients
  3. Pulse oximetry reading of 99% with an elevated carboxyhemoglobin level Correct answer.
  4. Immediate improvement of symptoms with supplemental oxygen by mask

Explanation

Standard pulse oximetry cannot distinguish carboxyhemoglobin from oxyhemoglobin, so readings appear falsely normal while the carboxyhemoglobin is elevated. Diagnosis requires co-oximetry.

Question 10Emergency Medicine

A 24-year-old woman presents with sudden unilateral severe headache peaking within seconds. Which diagnostic step is most appropriate?

  1. Emergent noncontrast head CT followed by lumbar puncture if CT is negative Correct answer.
  2. Outpatient MRI in one week
  3. Reassurance and discharge with analgesics
  4. Trial of triptan therapy and reassessment

Explanation

A thunderclap headache raises concern for subarachnoid hemorrhage, which requires urgent noncontrast head CT, with lumbar puncture for xanthochromia if the CT is negative and suspicion persists. Delay risks rebleeding and worse outcomes.

Question 11Emergency Medicine

Which parameter on the NIH Stroke Scale most strongly predicts the need for urgent large-vessel intervention evaluation in acute ischemic stroke?

  1. Presence of cortical signs such as gaze deviation, aphasia, or neglect Correct answer.
  2. Isolated mild dysarthria
  3. Presence of a chronic gait abnormality
  4. Isolated mild facial droop

Explanation

Cortical signs such as gaze deviation, aphasia, and neglect suggest a large-vessel occlusion and warrant urgent vascular imaging for possible thrombectomy. Isolated minor deficits are less likely to reflect a large-vessel occlusion.

Question 12Emergency Medicine

A patient with a known abdominal aortic aneurysm presents with sudden severe back pain and hypotension. Which finding on bedside ultrasound most supports a ruptured aneurysm?

  1. A pericardial effusion
  2. Dilated bowel loops with air-fluid levels
  3. A normal aortic diameter with a gallbladder wall thickened
  4. Aortic diameter greater than 3 cm with retroperitoneal fluid Correct answer.

Explanation

An enlarged aorta with surrounding retroperitoneal fluid on bedside ultrasound supports rupture in a hypotensive patient with back pain. Immediate surgical or endovascular consultation and resuscitation are required.

Question 13Emergency Medicine

Which initial fluid resuscitation approach is recommended for a burn patient with 40% total body surface area burns and no other injuries?

  1. Colloid infusion at 1 mL/kg per percent TBSA
  2. Lactated Ringer's at 2 mL/kg per percent TBSA over the first 24 hours, with half in the first 8 hours Correct answer.
  3. No fluids until the patient reaches the burn center
  4. Normal saline at 4 mL/kg per percent TBSA over the first 24 hours

Explanation

The Parkland formula uses lactated Ringer's at 2 mL/kg per percent TBSA over 24 hours from the time of injury, giving half in the first 8 hours. Colloids are not first-line in the initial resuscitation.

Question 14Emergency Medicine

A patient with a suspected cervical spine injury is hypotensive with bradycardia and warm extremities after a high-speed collision. Which diagnosis should be considered?

  1. Hypovolemic shock
  2. Neurogenic shock Correct answer.
  3. Cardiogenic shock from myocardial contusion
  4. Septic shock

Explanation

Neurogenic shock from cervical cord injury causes loss of sympathetic tone, producing hypotension with bradycardia and warm skin. Hemorrhagic shock typically presents with tachycardia and cool extremities.

Question 15Emergency Medicine

A patient with severe hyponatremia develops confusion and a generalized seizure. What is the most appropriate initial management?

  1. Intravenous furosemide as monotherapy
  2. Rapid correction to a normal sodium level within two hours
  3. Free water restriction alone
  4. Hypertonic saline bolus to raise sodium by 4 to 6 mEq/L Correct answer.

Explanation

Severe symptomatic hyponatremia with seizures is a neurologic emergency requiring hypertonic saline to raise serum sodium by 4 to 6 mEq/L promptly. Correction should then proceed slowly to avoid osmotic demyelination.

Question 16Emergency Medicine

Which organism is the most common cause of community-acquired bacterial pneumonia in adults?

  1. Streptococcus pneumoniae Correct answer.
  2. Mycoplasma pneumoniae
  3. Legionella pneumophila
  4. Pseudomonas aeruginosa

Explanation

Streptococcus pneumoniae remains the most frequently identified bacterial cause of community-acquired pneumonia in adults. Atypical organisms and Pseudomonas are less common in patients without specific risk factors.

Question 17Emergency Medicine

A patient with a tension pneumothorax after chest trauma has worsening hypotension and absent breath sounds on the right. What is the immediate next step?

  1. Emergent bronchoscopy
  2. Portable chest radiograph before any intervention
  3. Intubation with positive pressure ventilation alone
  4. Needle decompression followed by tube thoracostomy Correct answer.

Explanation

Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression, followed by tube thoracostomy. Waiting for imaging risks cardiovascular collapse.

Question 18Emergency Medicine

Which medication is the preferred first-line treatment for a patient with stable narrow-complex supraventricular tachycardia that does not respond to vagal maneuvers?

  1. Intravenous adenosine Correct answer.
  2. Intravenous atropine
  3. Oral digoxin
  4. Intravenous amiodarone

Explanation

Adenosine is first-line for stable narrow-complex SVT after failed vagal maneuvers because it transiently blocks the AV node and terminates reentrant rhythms. Its very short half-life limits sustained adverse effects.

Question 19Emergency Medicine

A child presents with drooling, tripod positioning, and muffled voice after a few days of fever. Which action is most appropriate?

  1. Administer oral antibiotics and discharge
  2. Perform a tongue blade examination of the throat in the emergency department
  3. Keep the child calm and arrange urgent airway evaluation in the operating room Correct answer.
  4. Obtain a throat swab for strep culture

Explanation

The presentation suggests epiglottitis with risk of sudden airway obstruction, so the child should be kept calm and the airway secured in a controlled setting such as the operating room. Throat examination can precipitate complete obstruction.

Question 20Emergency Medicine

Which finding is most consistent with preeclampsia with severe features in a patient at 34 weeks gestation?

  1. Blood pressure of 165/115 mmHg with new headache and visual changes Correct answer.
  2. Blood pressure of 138/88 mmHg with trace proteinuria
  3. Blood pressure of 142/92 mmHg with no symptoms
  4. Isolated ankle edema

Explanation

Preeclampsia with severe features includes severe-range blood pressures and symptoms such as headache or visual disturbance, which mandate urgent treatment and delivery planning. Mild hypertension without symptoms does not meet severe criteria.

Question 21Emergency Medicine

A patient presents with altered mental status, fever, and neck stiffness. Which intervention should occur before lumbar puncture if there are signs of raised intracranial pressure?

  1. Withholding antibiotics until cerebrospinal fluid is obtained
  2. Blood cultures and empiric antibiotics Correct answer.
  3. Waiting 24 hours for imaging results
  4. Giving corticosteroids alone

Explanation

In suspected bacterial meningitis, blood cultures and empiric antibiotics should be given promptly, even before lumbar puncture when the procedure is delayed. Delaying antibiotics worsens outcomes.

Question 22Emergency Medicine

Which statement about the use of focused assessment with sonography for trauma (FAST) in blunt abdominal trauma is correct?

  1. It is most sensitive for hollow viscus injury
  2. It replaces the need for CT in all stable patients
  3. It can detect free intraperitoneal fluid but cannot identify the specific injured organ Correct answer.
  4. It reliably excludes retroperitoneal injury

Explanation

FAST detects free fluid in dependent spaces and is useful for rapid triage in unstable patients, but it does not localize the organ of injury and is insensitive for retroperitoneal and hollow viscus injuries. Stable patients often require CT for definitive characterization.

Question 23Emergency Medicine

A patient with a known seizure disorder has been seizing for 25 minutes. Which medication sequence is appropriate?

  1. Oral phenytoin alone
  2. Observation without medication
  3. Intravenous mannitol
  4. Intravenous benzodiazepine first, followed by a second-line antiepileptic such as levetiracetam or fosphenytoin Correct answer.

Explanation

Status epilepticus requires prompt benzodiazepine therapy, followed by a second-line antiepileptic if seizures persist. Prolonged seizures increase the risk of neuronal injury and systemic complications.

Question 24Emergency Medicine

A patient with suspected acute decompensated heart failure is dyspneic with bilateral crackles and a blood pressure of 170/100 mmHg. Which initial therapy is most appropriate?

  1. Oral furosemide alone
  2. Intravenous nitroglycerin with noninvasive positive pressure ventilation Correct answer.
  3. Rapid bolus of 2 liters normal saline
  4. Intravenous metoprolol

Explanation

Hypertensive acute decompensated heart failure with pulmonary edema benefits from afterload reduction with nitroglycerin and noninvasive ventilation to improve oxygenation and reduce work of breathing. Fluid loading and beta-blockade can worsen the picture.

Question 25Emergency Medicine

Which finding best supports the diagnosis of a perforated peptic ulcer in a patient with sudden severe epigastric pain?

  1. Hyperactive bowel sounds
  2. Elevated serum amylase alone
  3. Free subdiaphragmatic air on an upright chest radiograph Correct answer.
  4. Pain relieved by food intake

Explanation

Free subdiaphragmatic air indicates pneumoperitoneum and strongly supports a perforated viscus. Sudden severe pain with rigidity is typical, and urgent surgical evaluation is needed.

Question 26Emergency Medicine

A patient presents with a heart rate of 118/min, blood pressure 132/84 mmHg, respiratory rate 22/min, and oxygen saturation 94% on room air. Which finding best meets the systemic inflammatory response syndrome (SIRS) criteria for this patient?

  1. Oxygen saturation of 94% on room air
  2. Blood pressure greater than 120/80 mmHg
  3. Heart rate greater than 90/min Correct answer.
  4. Respiratory rate less than 20/min

Explanation

SIRS requires at least two of: temperature above 38 C or below 36 C, heart rate above 90/min, respiratory rate above 20/min, or white blood cell count abnormalities. A heart rate of 118/min fulfills one criterion, and the respiratory rate of 22/min fulfills another. Blood pressure and oxygen saturation are not SIRS criteria.

Question 27Emergency Medicine

A patient with septic shock remains hypotensive after 30 mL/kg of crystalloid. Which vasopressor is recommended as the first-line agent to maintain mean arterial pressure?

  1. Dopamine
  2. Vasopressin
  3. Phenylephrine
  4. Norepinephrine Correct answer.

Explanation

Norepinephrine is the recommended first-line vasopressor in septic shock because it raises mean arterial pressure with less arrhythmogenicity than dopamine. Vasopressin is typically added as a second agent to reduce norepinephrine requirements. Phenylephrine is reserved for specific situations such as tachyarrhythmias.

Question 28Emergency Medicine

A patient with an acute ST-elevation myocardial infarction needs reperfusion. Which factor most strongly determines whether primary percutaneous coronary intervention can be offered within the recommended time window?

  1. The presence of a nearby PCI-capable center with timely transfer Correct answer.
  2. The number of coronary stents available
  3. The patient's baseline troponin level
  4. The patient's age and sex

Explanation

Primary PCI is preferred when it can be delivered within 90 minutes of first medical contact at a PCI-capable center, or within 120 minutes when transfer is required. Access to a capable facility and timely transfer therefore drive the reperfusion decision. Troponin, demographics, and stent inventory do not determine the time window.

Question 29Emergency Medicine

A patient with atrial fibrillation has been in symptomatic rapid ventricular response for 48 hours. Which management approach is most appropriate for restoring sinus rhythm?

  1. Rate control with anticoagulation and delayed elective cardioversion Correct answer.
  2. Initiation of flecainide without anticoagulation
  3. Immediate electrical cardioversion without anticoagulation
  4. Adenosine administration to terminate the rhythm

Explanation

When atrial fibrillation has persisted beyond 48 hours, atrial thrombi may have formed, so immediate cardioversion risks embolic stroke. The standard approach is rate control with anticoagulation, followed by delayed cardioversion after adequate anticoagulation or a negative transesophageal echocardiogram. Adenosine does not terminate atrial fibrillation.

Question 30Emergency Medicine

A patient is found unresponsive with agonal breathing and no palpable carotid pulse. After activating the emergency response and starting chest compressions, what is the recommended compression-to-ventilation ratio for a single rescuer with a bag-valve mask available?

  1. 10:1
  2. 30:2 Correct answer.
  3. 5:1
  4. 15:2

Explanation

For adult cardiac arrest with a single rescuer, the recommended ratio is 30 compressions to 2 ventilations. This ratio applies regardless of whether a bag-valve mask is available, and minimizes interruptions in compressions. Pediatric ratios with two rescuers differ, but the adult single-rescuer standard is 30:2.

Question 31Emergency Medicine

A patient is in cardiac arrest with a shockable rhythm and has already received one defibrillation attempt and epinephrine. Which medication is recommended next for refractory ventricular fibrillation?

  1. Sodium bicarbonate
  2. Calcium chloride
  3. Amiodarone Correct answer.
  4. Atropine

Explanation

Amiodarone is recommended for shock-refractory ventricular fibrillation or pulseless ventricular tachycardia after defibrillation and epinephrine. It stabilizes myocardial membranes and reduces recurrence of the arrhythmia. Atropine is used for symptomatic bradycardia, and routine bicarbonate or calcium is not recommended in cardiac arrest.

Question 32Emergency Medicine

A patient develops sudden pleuritic chest pain, tachycardia, and hypoxemia three days after hip replacement surgery. Which diagnostic test is most appropriate as the initial step when the patient is hemodynamically stable?

  1. Transthoracic echocardiography
  2. Chest radiograph alone
  3. CT pulmonary angiography Correct answer.
  4. D-dimer assay

Explanation

For a stable patient with high clinical probability of pulmonary embolism after recent surgery, CT pulmonary angiography is the preferred confirmatory test. D-dimer is less useful because it is frequently elevated after surgery and lacks specificity. Echocardiography is reserved for unstable patients who cannot undergo CT.

Question 33Emergency Medicine

A patient with a large upper gastrointestinal bleed has a hemoglobin of 6.8 g/dL, is tachycardic, and remains hypotensive after initial crystalloid. Which blood product strategy is most appropriate?

  1. Crystalloid only until hemoglobin falls below 5 g/dL
  2. Restrictive red cell transfusion with a target of 7 to 8 g/dL Correct answer.
  3. Platelet transfusion regardless of count
  4. Fresh frozen plasma alone without red cells

Explanation

In acute upper gastrointestinal bleeding, restrictive red cell transfusion targeting hemoglobin of 7 to 8 g/dL reduces rebleeding and mortality compared with liberal strategies. Ongoing massive hemorrhage may require activation of a massive transfusion protocol with balanced products. Platelets and plasma are guided by specific deficits rather than given alone.

Question 34Emergency Medicine

A patient with severe acute pancreatitis has persistent organ failure beyond 48 hours. Which finding best indicates severe disease according to the revised Atlanta classification?

  1. Persistent organ failure lasting more than 48 hours Correct answer.
  2. Moderate abdominal pain requiring opioids
  3. Serum lipase elevation above three times the upper limit
  4. Presence of gallstones on ultrasound

Explanation

The revised Atlanta classification defines severe acute pancreatitis by persistent organ failure lasting more than 48 hours. Lipase elevation and gallstones establish the diagnosis and etiology but do not grade severity. Pain intensity is not a classification criterion.

Question 35Emergency Medicine

A patient with a suspected acetaminophen overdose presents 6 hours after ingestion. Which test best predicts hepatotoxicity when interpreted with the Rumack-Matthew nomogram?

  1. Serum acetaminophen concentration Correct answer.
  2. Urine toxicology screen
  3. Serum amylase
  4. Serum creatine kinase

Explanation

The Rumack-Matthew nomogram plots serum acetaminophen concentration against time since ingestion to guide N-acetylcysteine therapy. Amylase, urine toxicology, and creatine kinase do not assess acetaminophen hepatotoxicity risk. Liver enzymes may become abnormal later but do not replace the nomogram.

Question 36Emergency Medicine

A patient presents with altered mental status, miosis, bradycardia, and bronchorrhea after exposure to an organophosphate insecticide. In addition to atropine, which medication is indicated?

  1. Pralidoxime Correct answer.
  2. Naloxone
  3. Flumazenil
  4. N-acetylcysteine

Explanation

Organophosphate poisoning causes acetylcholinesterase inhibition with cholinergic crisis. Atropine controls muscarinic effects, while pralidoxime reactivates acetylcholinesterase before enzyme aging occurs. Naloxone, flumazenil, and N-acetylcysteine treat unrelated toxidromes.

Question 37Emergency Medicine

A patient with a suspected opioid overdose has been given naloxone with improvement but develops recurrent respiratory depression 40 minutes later. What is the most appropriate next step?

  1. Give activated charcoal regardless of time since ingestion
  2. Repeat naloxone dosing or start an infusion and observe for recurrence Correct answer.
  3. Discharge home because naloxone was effective
  4. Administer flumazenil

Explanation

Naloxone has a shorter half-life than many opioids, so respiratory depression can recur after initial reversal. Repeated boluses or a continuous infusion with extended observation are appropriate. Discharge after a single response is unsafe, and flumazenil is unrelated.

Question 38Emergency Medicine

A patient with severe alcohol withdrawal has a CIWA-Ar score of 18 with tremor, diaphoresis, and tachycardia. Which medication class is first-line for symptom control and seizure prevention?

  1. Opioids
  2. Antipsychotics
  3. Benzodiazepines Correct answer.
  4. Beta blockers

Explanation

Benzodiazepines are first-line for alcohol withdrawal because they increase GABA activity and reduce the risk of seizures and delirium tremens. Beta blockers and antipsychotics may control selected symptoms but do not prevent withdrawal seizures. Opioids are not indicated.

Question 39Emergency Medicine

A patient with a blood glucose of 42 mg/dL is confused but able to swallow safely. Which initial treatment is most appropriate?

  1. Oral glucose Correct answer.
  2. Intravenous glucagon
  3. Subcutaneous insulin
  4. Intravenous 50% dextrose

Explanation

In a hypoglycemic patient who can swallow safely, oral glucose is the least invasive effective treatment. Intravenous dextrose is reserved for patients unable to take oral intake or with severe symptoms. Insulin would worsen hypoglycemia, and glucagon is used when intravenous access is unavailable.

Question 40Emergency Medicine

A patient with hyperkalemia and ECG changes has received calcium gluconate. Which additional measure most effectively shifts potassium into cells while definitive removal is arranged?

  1. Oral potassium binder
  2. Insulin with glucose Correct answer.
  3. Loop diuretic in a volume-depleted patient
  4. Normal saline bolus

Explanation

Insulin with glucose shifts potassium intracellularly and is a standard temporizing measure for hyperkalemia with ECG changes. Potassium binders remove potassium slowly and are not for acute stabilization. Loop diuretics are less useful in volume depletion, and saline does not shift potassium.

Question 41Emergency Medicine

A patient with a suspected upper airway obstruction from angioedema has stridor and progressive hoarseness. Which intervention should be prioritized?

  1. Observation with serial examinations
  2. Nebulized albuterol alone
  3. Early airway management with preparations for a difficult airway Correct answer.
  4. Oral antihistamines as sole therapy

Explanation

Progressive stridor and hoarseness in angioedema signal impending airway compromise. Early airway management with a plan for difficult intubation or surgical airway is critical before obstruction becomes complete. Observation and oral antihistamines alone are inadequate.

Question 42Emergency Medicine

A patient has a deep partial-thickness burn to the anterior chest and both arms. Using the rule of nines, what is the estimated total body surface area involved?

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

Explanation

The rule of nines assigns 18% to the anterior trunk and 9% to each entire arm. Anterior chest (18%) plus both arms (9% each) totals 36%. The options should be checked carefully against the specific regions named.

Question 43Emergency Medicine

A patient with a suspected open globe injury after a projectile injury has a distorted pupil and a positive Seidel test. Which action is most appropriate?

  1. Irrigate the eye copiously with saline
  2. Remove any protruding foreign body
  3. Instill fluorescein and apply pressure patch
  4. Apply a rigid shield and arrange urgent ophthalmologic evaluation Correct answer.

Explanation

Suspected open globe injury requires a rigid eye shield to avoid pressure on the globe and urgent ophthalmologic consultation. Irrigation, removal of protruding objects, and pressure patching can worsen extrusion of intraocular contents.

Question 44Emergency Medicine

A patient with a suspected epidural hematoma after head trauma has a brief loss of consciousness followed by a lucid interval and then rapid deterioration. Which finding on CT best explains this course?

  1. Enlarged ventricles with transependymal flow
  2. Biconvex hyperdense collection Correct answer.
  3. Diffuse punctate hemorrhages
  4. Crescent-shaped collection crossing suture lines

Explanation

An epidural hematoma classically appears as a biconvex hyperdense collection bounded by skull sutures, often from middle meningeal artery injury. The lucid interval reflects initial compensation before arterial expansion causes rapid deterioration. Subdural hematomas are crescent-shaped and cross suture lines.

Question 45Emergency Medicine

A patient with a suspected acute ischemic stroke is being screened for thrombolysis. Which finding is an absolute contraindication to intravenous thrombolytic therapy?

  1. Blood pressure of 150/90 mmHg
  2. Age greater than 80 years
  3. History of well-controlled diabetes
  4. Intracranial hemorrhage on imaging Correct answer.

Explanation

Intracranial hemorrhage on imaging is an absolute contraindication to intravenous thrombolysis in acute ischemic stroke. Advanced age and well-controlled diabetes are not absolute contraindications, and blood pressure of 150/90 mmHg is below the treatment threshold requiring correction.

Question 46Emergency Medicine

A patient presents with a first episode of generalized tonic-clonic seizure and has returned to baseline. Which initial diagnostic test is most useful to identify a reversible cause?

  1. Serum glucose and electrolytes Correct answer.
  2. Carotid ultrasound
  3. Electroencephalogram immediately
  4. Lumbar puncture

Explanation

Serum glucose and electrolytes identify common reversible causes of first-time seizures such as hypoglycemia and hyponatremia. Lumbar puncture is reserved for suspected infection, EEG is used for ongoing or recurrent seizures, and carotid ultrasound is not an initial test.

Question 47Emergency Medicine

A patient with suspected acute aortic dissection has severe tearing chest pain and a widened mediastinum on radiograph. Which diagnostic study is most appropriate for a hemodynamically stable patient?

  1. CT angiography of the chest Correct answer.
  2. D-dimer assay alone
  3. Exercise stress testing
  4. Transthoracic echocardiography alone

Explanation

CT angiography of the chest is the preferred initial imaging study for a hemodynamically stable patient with suspected aortic dissection. Transthoracic echocardiography alone cannot reliably visualize the entire aorta, and stress testing is contraindicated. D-dimer alone cannot exclude dissection reliably.

Question 48Emergency Medicine

A patient with a suspected tension pneumothorax has undergone needle decompression with minimal improvement. What is the most appropriate next step?

  1. Observation
  2. Chest radiograph before further intervention
  3. Immediate tube thoracostomy Correct answer.
  4. Repeat needle decompression at the same site

Explanation

After needle decompression, definitive management of tension pneumothorax is tube thoracostomy. If the initial needle decompression fails, a second attempt at an alternate site may be considered, but definitive decompression with a chest tube is the priority. Delaying for imaging in an unstable patient is inappropriate.

Question 49Emergency Medicine

A patient with suspected diabetic ketoacidosis has a blood glucose of 480 mg/dL, arterial pH of 7.12, and serum bicarbonate of 9 mEq/L. Which initial fluid is most appropriate?

  1. Sodium bicarbonate infusion
  2. Hypertonic saline
  3. 5% dextrose in water
  4. 0.9% sodium chloride Correct answer.

Explanation

Isotonic 0.9% sodium chloride is the initial fluid for diabetic ketoacidosis to restore volume and improve perfusion. Dextrose-containing fluids are added later when glucose falls, and bicarbonate is reserved for severe acidosis with hemodynamic compromise. Hypertonic saline is not indicated.

Question 50Emergency Medicine

A patient with a suspected acute compartment syndrome of the lower leg after a tibial fracture has severe pain with passive stretch and a tense compartment. Which statement about diagnosis is most accurate?

  1. A normal creatine kinase excludes compartment syndrome
  2. Magnetic resonance imaging is the first-line emergency test
  3. Compartment pressure measurement supports but does not replace clinical assessment Correct answer.
  4. Absent pulses are required to confirm the diagnosis

Explanation

Acute compartment syndrome is a clinical diagnosis based on pain out of proportion, pain with passive stretch, and a tense compartment. Compartment pressure measurement supports the diagnosis, but pulses are often preserved and normal creatine kinase does not exclude the condition. Emergent fasciotomy should not be delayed for imaging.