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Question 1. Which of the following is the first‑line reperfusion strategy for a STEMI patient presenting within 90 minutes of symptom onset at a PCI‑capable hospital? A) Immediate fibrinolysis B) Primary percutaneous coronary intervention (PCI) C) Thrombus aspiration alone D) Coronary artery bypass grafting (CABG) Answer: B Explanation: Primary PCI performed within 90 minutes is superior to fibrinolysis for STEMI when a PCI‑capable center is available, providing higher patency rates and lower bleeding risk. Question 2. In the TIMI risk score for NSTEMI, which of the following variables does NOT contribute one point? A) Age ≥ 65 years B) Prior coronary artery disease (CAD) C) Elevated cardiac biomarkers D) Systolic blood pressure < 120 mm Hg Answer: D Explanation: The TIMI NSTEMI score assigns points for age ≥ 65, ≥3 CAD risk factors, known CAD, aspirin use, severe angina, ST changes, and positive biomarkers. Low systolic BP is not a component.
Question 3. A 58‑year‑old patient with SVT is unresponsive to vagal maneuvers. What is the next recommended pharmacologic step? A) Intravenous amiodarone B) Intravenous adenosine 6 mg rapid push C) Synchronized cardioversion at 50 J D) Oral beta‑blocker Answer: B Explanation: Adenosine is the drug of choice for acute termination of narrow‑complex SVT after vagal maneuvers have failed. Question 4. Which medication is contraindicated in the acute management of wide‑complex tachycardia presumed to be ventricular tachycardia with a pulse? A) Procainamide B) Amiodarone C) Lidocaine D) Metoprolol Answer: D Explanation: Beta‑blockers may worsen hypotension and are not first‑line for VT with a pulse; procainamide, amiodarone, and lidocaine are preferred. Question 5. A patient presents with symptomatic bradycardia (HR 35) and hypotension. Which of the following is the most appropriate immediate intervention?
C) Norepinephrine D) Dopamine at 5 μg/kg/min Answer: C Explanation: Norepinephrine provides potent vasoconstriction to support blood pressure while modestly increasing cardiac output, making it preferred in hypotensive cardiogenic shock. Question 8. The initial pharmacologic goal in managing a type A aortic dissection is to achieve which of the following hemodynamic targets? A) SBP < 140 mm Hg, HR < 80 bpm B) SBP < 120 mm Hg, HR < 60 bpm C) MAP < 65 mm Hg, HR < 100 bpm D) SBP < 100 mm Hg, HR < 50 bpm Answer: B Explanation: Rapid reduction of systolic BP to <120 mm Hg and HR to <60 bpm minimizes shear stress on the aortic wall and is the standard initial goal. Question 9. Which of the following is the most appropriate initial management for acute limb ischemia presenting within 6 hours of symptom onset? A) Immediate thrombolytic infusion B) Heparin bolus 80 U/kg IV followed by infusion C) Immediate surgical embolectomy without anticoagulation
D) Aspirin 325 mg PO only Answer: B Explanation: Prompt IV unfractionated heparin prevents propagation of thrombus; definitive therapy (embolectomy, thrombolysis) follows. Question 10. A hypertensive emergency with encephalopathy is best treated initially with which IV agent? A) Labetalol B) Enalapril C) Hydrochlorothiazide D) Clonidine Answer: A Explanation: IV labetalol provides rapid, titratable reduction of BP with combined α‑ and β‑blockade, suitable for hypertensive encephalopathy. Question 11. Which of the following is the most appropriate drug for rapid sequence intubation (RSI) in a hemodynamically unstable trauma patient? A) Etomidate B) Ketamine C) Propofol D) Midazolam Answer: B
Question 14. A patient with massive PE presents with hypotension. Which therapy is indicated emergently? A) Intravenous heparin only B) Thrombolytic therapy (tPA) C) Inferior vena cava filter placement only D) Oral anticoagulation with warfarin Answer: B Explanation: Massive PE with hemodynamic compromise warrants immediate systemic thrombolysis to restore pulmonary perfusion. Question 15. In severe asthma exacerbation refractory to inhaled β‑agonists, which adjunctive medication is recommended? A) Intravenous atropine B) Intravenous magnesium sulfate C) Oral theophylline D) Inhaled ipratropium only Answer: B Explanation: IV magnesium sulfate (1‑ 2 g over 20 minutes) is an effective bronchodilator for severe, refractory asthma. Question 16. The CURB‑65 score assigns one point for each of five variables. Which of the following is NOT included? A) Confusion
B) Urea > 7 mmol/L C) Respiratory rate ≥ 30/min D) Blood pressure > 140/90 mm Hg Answer: D Explanation: CURB‑65 includes confusion, urea, respiratory rate, blood pressure (systolic < 90 mm Hg or diastolic ≤ 60 mm Hg), and age ≥ 65. High BP is not a point. Question 17. A tension pneumothorax is best treated initially with: A) Chest tube placement (tube thoracostomy) B) Needle decompression in the 2nd intercostal space, mid‑clavicular line C) High‑flow oxygen only D) Immediate thoracotomy in the ED Answer: B Explanation: Immediate needle decompression relieves the pressure; tube thoracostomy follows. Question 18. In the management of a large, symptomatic empyema, the first‑line intervention is: A) Thoracentesis only B) Chest tube drainage with intrapleural fibrinolytics C) Observation and antibiotics alone
Explanation: IV alteplase is approved up to 3 hours, with an extended window to 4.5 hours in eligible patients. Question 21. A 70‑year‑old with intracerebral hemorrhage (ICH) presents with SBP 210 mm Hg. Which target BP is recommended to reduce hematoma expansion? A) SBP < 140 mm Hg B) SBP < 180 mm Hg C) SBP < 120 mm Hg D) No BP reduction needed Answer: B Explanation: The AHA/ASA guidelines suggest lowering SBP to 140‑ 180 mm Hg (often target < 180) to limit hematoma growth without causing hypoperfusion. Question 22. In status epilepticus, the first‑line medication after benzodiazepine failure is: A) Phenytoin (or fosphenytoin) B) Phenobarbital C) Propofol infusion D) Valproic acid Answer: A Explanation: After a benzodiazepine, IV phenytoin or fosphenytoin is the recommended second‑line agent.
Question 23. Which of the following is the most specific clinical feature of subarachnoid hemorrhage? A) Sudden onset of severe “thunderclap” headache B) Neck stiffness only after 24 hours C) Focal motor weakness D) Photophobia Answer: A Explanation: A sudden, severe “thunderclap” headache is classic for SAH and is highly specific. Question 24. A 30‑year‑old presents with altered mental status, fever, neck stiffness, and a CSF glucose of 30 mg/dL (serum glucose 90 mg/dL). Which organism is most likely? A) Streptococcus pneumoniae B) Neisseria meningitidis C) Listeria monocytogenes D) Viral (enterovirus) Answer: A Explanation: Low CSF glucose with elevated neutrophils is typical of bacterial meningitis; S. pneumoniae is the most common adult pathogen. Question 25. In the primary survey of trauma (ABCDE), the “C” stands for:
C) Immediate thoracotomy in the ED D) High‑dose epinephrine infusion Answer: B Explanation: Pericardiocentesis relieves the pressure; emergent thoracotomy may be indicated if pericardiocentesis fails. Question 28. In traumatic brain injury (TBI), a Glasgow Coma Scale (GCS) score of 8 or less mandates: A) Immediate intubation and airway protection B) Observation only, no imaging needed C) Administration of high‑dose steroids D) Discharge home with observation Answer: A Explanation: GCS ≤ 8 indicates loss of airway protective reflexes; endotracheal intubation is required. Question 29. Which of the following is the most accurate method to assess for a cervical spine injury in a conscious trauma patient? A) Plain cervical X‑ray only B) CT cervical spine without contrast C) MRI of the cervical spine only D) Ultrasound of the neck
Answer: B Explanation: CT cervical spine is the gold standard for detecting bony injuries in trauma patients. Question 30. The primary treatment for heat stroke is: A) Oral hydration with electrolyte solutions B) Rapid evaporative cooling (e.g., spray and fan) C) Immediate cold water immersion (20 °C) until core temperature < 39 °C D) Antipyretic medication (acetaminophen) Answer: C Explanation: Immediate cold water immersion is the most effective method to rapidly reduce core temperature in heat stroke. Question 31. In severe hypothermia (core temperature < 28 °C) with hemodynamic instability, the best rewarming strategy is: A) Warm blankets only B) Warmed humidified oxygen C) Active internal rewarming (e.g., warmed IV fluids, peritoneal lavage) D) Rapid external cooling Answer: C Explanation: Active internal rewarming provides core temperature increase and circulatory support in severe hypothermia.
Question 34. A 25‑year‑old woman presents with sudden lower abdominal pain and vaginal bleeding. Which test is most appropriate to confirm an ectopic pregnancy? A) Serum β‑hCG alone B) Transvaginal ultrasound C) Pelvic MRI D) Serum progesterone level Answer: B Explanation: Transvaginal ultrasound can directly visualize an ectopic gestation and is the diagnostic test of choice. Question 35. In upper gastrointestinal bleeding, the optimal timing for endoscopy in a hemodynamically stable patient is: A) Within 24 hours of presentation B) Within 12 hours of presentation C) Within 6 hours of presentation D) Only after blood transfusion is complete Answer: B Explanation: Early endoscopy within 12 hours improves outcomes in stable patients with upper GI bleed. Question 36. Which medication is most effective for controlling variceal bleeding in cirrhosis?
A) Intravenous proton pump inhibitor B) Intravenous octreotide infusion C) Oral ranitidine D) Intravenous metoclopramide Answer: B Explanation: Octreotide reduces portal pressure and is first‑line adjunctive therapy for variceal hemorrhage. Question 37. In small bowel obstruction (SBO) without signs of perforation, the initial management includes: A) Immediate laparotomy B) NPO, nasogastric decompression, IV fluids, and observation C) High‑dose steroids D) Oral contrast administration only Answer: B Explanation: Conservative management with bowel rest, NG decompression, and fluid resuscitation is first‑line for uncomplicated SBO. Question 38. According to the Ranson criteria, which of the following is an early prognostic factor for severe acute pancreatitis? A) Age > 55 years B) Serum calcium < 8 mg/dL (on day 3)
Answer: B Explanation: IV calcium stabilizes cardiac membranes and is given first when ECG changes are present. Question 41. A patient with severe hyponatremia (serum Na = 110 mmol/L) presents with seizures. The safest initial correction rate is: A) No more than 4 mmol/L per hour B) No more than 8 mmol/L per hour C) Immediate correction to 130 mmol/L with hypertonic saline D) No correction needed, give anticonvulsants only Answer: A Explanation: Rapid correction can cause osmotic demyelination; limiting to ≤ 4‑ 6 mmol/L per hour is recommended, especially with neurologic symptoms. Question 42. Which of the following is an absolute indication for emergent hemodialysis in acute kidney injury? A) Serum creatinine > 2.0 mg/dL B) Fluid overload refractory to diuretics C) Hyperphosphatemia D) Mild metabolic acidosis (pH 7.30) Answer: B Explanation: Refractory fluid overload, severe electrolyte disturbances, or uremic complications are absolute indications for emergent dialysis.
Question 43. The first‑line therapy for thyroid storm includes all EXCEPT: A) Propylthiouracil (PTU) B) High‑dose intravenous glucocorticoids C) Beta‑blocker (esmolol) D) Levothyroxine (T4) replacement Answer: D Explanation: Levothyroxine would worsen thyrotoxicosis; it is not part of thyroid storm management. Question 44. In adrenal crisis, the recommended immediate treatment is: A) Hydrocortisone 100 mg IV bolus, then 200 mg/24 h infusion B) Fludrocortisone 0.1 mg PO daily only C) Oral prednisone 10 mg daily D) No steroid, give only fluids Answer: A Explanation: High‑dose IV hydrocortisone promptly restores glucocorticoid activity; fludrocortisone is added later if needed. Question 45. The Pediatric Assessment Triangle (PAT) evaluates which three domains? A) Appearance, Work of Breathing, Circulation to Skin
