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ABEM EMERGENCY MEDICINE FORM 168 EXAM – QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS | PLUS RATIONALES | DOWNLOAD AND PASS | LATEST EXAM UPDATE 2026/
- A 45-year-old male presents with acute onset of severe, tearing chest pain radiating to his back. His blood pressure is 180/110 mmHg in the right arm and 140/90 mmHg in the left arm. Which of the following is the most appropriate next step in management?
A. Administer sublingual nitroglycerin B. Obtain a computed tomography angiography (CTA) of the chest C. Start a continuous infusion of intravenous nitroprusside D. Perform a bedside transthoracic echocardiogram
Correct Answer: B. Obtain a computed tomography angiography (CTA) of the chest
Rationale: * This patient's presentation is classic for an acute aortic dissection, characterized by severe tearing pain, pulse deficit, and a blood pressure differential. The definitive diagnostic study of choice is a CTA of the chest, which has high sensitivity and specificity for detecting an intimal flap. Administering nitroglycerin or nitroprusside without first confirming the diagnosis and controlling the heart rate could be dangerous. A bedside echo may show an intimal flap or pericardial effusion, but a negative study does not rule out dissection, and the CTA is more definitive.
- A 6-year-old child is brought to the emergency department after ingesting an unknown amount of a liquid found under the kitchen sink. The child is drowsy but arousable and has a fruity odor on their breath. Which of the following is the most critical initial step in the management of this patient?
A. Administer activated charcoal B. Administer naloxone C. Assess the airway and provide supplemental oxygen D. Perform a gastric lavage
Correct Answer: C. Assess the airway and provide supplemental oxygen
Rationale: * The primary survey and stabilization of airway, breathing, and circulation (ABCs) are always the first priority in any poisoned patient. The fruity odor suggests a hydrocarbon or ketone ingestion, which can cause central nervous system depression and respiratory compromise. Intubating prophylactically is not always necessary, but assessing the airway and providing oxygen is crucial. Activated charcoal is contraindicated for hydrocarbon ingestion due to aspiration risk, and gastric lavage is rarely indicated.
- A 72-year-old woman presents with acute shortness of breath and hypotension. Her ECG shows a new right bundle branch block and ST-elevations in leads V1-V3. Which of the following is the most appropriate immediate intervention?
C. Green (Minor) D. Black (Deceased/Expectant)
Correct Answer: D. Black (Deceased/Expectant)
Rationale: * The START triage system dictates that any patient who is apneic after opening the airway should be tagged black, indicating deceased or expectant. This is a resource-constrained decision during an MCI, as these patients require extensive resources with a very low probability of survival. Red tags are for patients with life-threatening conditions requiring immediate intervention. Yellow tags are for serious but not immediately life-threatening injuries. Green tags are for minor injuries.
- A 25-year-old female presents with palpitations, diaphoresis, and anxiety. Her ECG shows a narrow-complex tachycardia at a rate of 180 bpm. She is hemodynamically stable. Which of the following is the most appropriate next step in management?
A. Immediate synchronized cardioversion B. Vagal maneuvers C. Administration of intravenous adenosine D. Administration of intravenous amiodarone
Correct Answer: B. Vagal maneuvers
Rationale: * For a stable patient with a narrow-complex tachycardia, the initial management is to attempt vagal maneuvers. These are non-invasive and can effectively terminate a re-entrant arrhythmia like AVNRT or AVRT. If vagal maneuvers fail, intravenous adenosine is typically the next pharmacological agent of choice. Synchronized cardioversion is only indicated for unstable patients. Amiodarone is generally reserved for more refractory or wide- complex tachyarrhythmias.
- A 10-year-old child is brought in with a fever, neck stiffness, and a petechial rash. The child appears toxic and is difficult to arouse. Which of the following is the most critical immediate management step?
A. Obtain a computed tomography (CT) scan of the head B. Administer a third-generation cephalosporin and vancomycin C. Perform a lumbar puncture D. Administer intravenous fluids for suspected sepsis
Correct Answer: B. Administer a third-generation cephalosporin and vancomycin
Rationale: * This presentation is highly suggestive of bacterial meningitis, which is a medical emergency. Prompt administration of empiric antibiotics is the most critical intervention to reduce mortality and morbidity. In a child with a
gastric insufflation. High-flow nasal cannula is not the standard of care for hypercapnic respiratory failure. Endotracheal intubation is reserved for patients who fail NIPPV or are unable to protect their airway.
- A 34-year-old female is involved in a high-speed motor vehicle collision. She is awake and complaining of severe pelvic pain. Her blood pressure is 85/60 mmHg, and heart rate is 130 bpm. On examination, there is pelvic instability. Which of the following is the most appropriate immediate intervention for her pelvic fracture?
A. Application of a pelvic binder B. Administration of intravenous fluids C. Initiation of a massive transfusion protocol D. Application of a traction splint
Correct Answer: A. Application of a pelvic binder
Rationale: * In a hemodynamically unstable patient with a pelvic fracture, the immediate intervention is to apply a pelvic binder. This reduces pelvic volume, stabilizes the fracture, and diminishes hemorrhage from the pelvic venous plexus and fractured bone edges. While fluid resuscitation and a massive transfusion protocol are essential, the pelvic binder is a specific, life-saving mechanical intervention that should be applied promptly during the primary survey. Traction splints are for femoral fractures, not pelvic fractures.
- Which of the following findings on a non-contrast head CT is most indicative of an acute subarachnoid hemorrhage?
A. A hyperdense, crescent-shaped collection over the cerebral convexity B. A hyperdense, biconvex-shaped collection adjacent to the skull C. An isodense collection in the subdural space D. A hyperdense collection in the basilar cisterns
Correct Answer: D. A hyperdense collection in the basilar cisterns
Rationale: * An acute subarachnoid hemorrhage appears as a hyperdense (bright) area in the subarachnoid spaces, which include the basilar cisterns and Sylvian fissures. The hyperdensity represents the high protein content of clotted blood. A crescent-shaped hyperdensity is characteristic of a subdural hematoma. A biconvex hyperdensity is typical of an epidural hematoma. An isodense collection is more chronic.
- A 50-year-old diabetic male presents with a 2-day history of severe, deep pain in his right foot. The foot is erythematous, edematous, and a black, necrotic lesion is visible on the third toe. No crepitus is palpated. Which of the following is the most likely diagnosis?
C. The patient's history of a seizure disorder D. The presence of a fever
Correct Answer: B. The duration of the seizure
Rationale: * The most critical factor in determining the need for acute anti-epileptic therapy is the duration of the seizure or if the patient is experiencing status epilepticus (seizure lasting more than 5 minutes, or multiple seizures without return to baseline). A known history of epilepsy does not preclude the need for treatment if the seizure is prolonged. The patient's age and fever are relevant to the etiology but are not the primary determinants for acute treatment. The post-ictal state is a natural recovery phase, and if the seizure has terminated, treatment may not be needed.
- A 62-year-old female presents with acute onset of right-sided weakness and difficulty speaking. Her symptoms started 45 minutes ago. Her blood pressure is 185/105 mmHg. Which of the following is the most appropriate blood pressure target before considering thrombolytic therapy?
A. Less than 140/90 mmHg B. Less than 160/95 mmHg C. Less than 185/110 mmHg D. No blood pressure target is needed; thrombolytics can be given at current pressures
Correct Answer: C. Less than 185/110 mmHg
Rationale: * Before administering intravenous alteplase (tPA) for an acute ischemic stroke, blood pressure must be carefully managed to reduce the risk of intracranial hemorrhage. The guideline-recommended target is to lower the systolic blood pressure to below 185 mmHg and the diastolic pressure to below 110 mmHg. This is typically done using agents like labetalol or nicardipine. A target of 140/90 mmHg is too aggressive for the acute phase. Thrombolytics are contraindicated at a pressure of 185/105 mmHg.
- A 2-year-old child is in respiratory distress with a barking cough and stridor. The child is sitting upright and drooling. Which of the following is the most appropriate diagnostic or therapeutic intervention?
A. Perform a lateral neck radiograph B. Administer nebulized racemic epinephrine C. Prepare for an awake, direct laryngoscopy in the operating room D. Administer oral dexamethasone
Correct Answer: C. Prepare for an awake, direct laryngoscopy in the operating room
Rationale: * This presentation (barking cough, stridor, drooling, and tripod positioning) is classic for epiglottitis, a life- threatening airway emergency. A child with suspected epiglottitis should not be agitated or have invasive procedures
- A 30-year-old female presents with acute onset of sharp chest pain and dyspnea. She is on oral contraceptives. Her heart rate is 110 bpm, and respiratory rate is 26/min. An ECG shows sinus tachycardia and an S1Q3T3 pattern. Which of the following is the most definitive diagnostic test for the most likely diagnosis?
A. D-dimer B. Computed tomography pulmonary angiography (CTPA) C. Ventilation-perfusion (V/Q) scan D. Lower extremity ultrasound
Correct Answer: B. Computed tomography pulmonary angiography (CTPA)
Rationale: * This patient's presentation is suspicious for a pulmonary embolism (PE) given the acute onset of dyspnea and pleuritic chest pain, tachycardia, and the presence of oral contraceptive use. The ECG findings of an S1Q3T pattern are a classic but non-specific sign of right heart strain. A CTPA is the current gold standard for diagnosing a PE and is the most definitive test. A D-dimer is a screening test with high sensitivity but low specificity. A V/Q scan is an alternative but less definitive. A lower extremity ultrasound can identify a DVT but does not confirm a PE.
- A 7-year-old child is brought in with a sudden onset of severe, crampy abdominal pain, vomiting, and "currant jelly" stools. On abdominal examination, a sausage-shaped mass is palpated in the right upper quadrant. Which
of the following is the most likely diagnosis?
A. Acute appendicitis B. Intussusception C. Volvulus D. Gastroenteritis
Correct Answer: B. Intussusception
Rationale: * This is a classic presentation of intussusception, where a segment of the bowel telescopes into an adjacent segment. The characteristic clinical features include sudden, severe, intermittent abdominal pain, vomiting, and "currant jelly" stools (blood and mucus). A sausage-shaped mass in the right upper quadrant is a common finding. Appendicitis presents with right lower quadrant pain, often with anorexia and fever. Volvulus often presents with sudden onset and bilious vomiting. Gastroenteritis typically presents with diarrhea and less specific pain.
- A 42-year-old male with a known history of atrial fibrillation presents with acute onset of severe, constant abdominal pain out of proportion to physical examination. Which of the following is the most likely diagnosis?
A. Acute pancreatitis B. Mesenteric ischemia
Correct Answer: B. Non-contrast head CT
Rationale: * The patient's presentation is classic for an acute subarachnoid hemorrhage. The first line of imaging is a non-contrast head CT, which is very sensitive for detecting blood in the subarachnoid space within the first 24 hours of symptom onset. If the CT is negative but clinical suspicion remains high, a lumbar puncture is performed to look for xanthochromia. A CT angiography or MRI is usually performed after the diagnosis is made or to rule out an aneurysm as the cause.
- A 28-year-old female presents with a painful, swollen, and erythematous left lower extremity after a 10-hour international flight. She has no calf pain on palpation but has a positive Homan's sign. Which of the following is the most appropriate diagnostic study?
A. D-dimer B. Lower extremity venous duplex ultrasound C. Contrast venography D. Computed tomography venography (CTV)
Correct Answer: B. Lower extremity venous duplex ultrasound
Rationale: * The patient has risk factors for a deep vein thrombosis (DVT) and presents with clinical signs of it. A D- dimer is a good screening test but has a low specificity; the most appropriate first diagnostic study is a lower extremity venous duplex ultrasound. It is non-invasive, has high sensitivity and specificity, and is the standard imaging modality for DVT. Contrast venography is invasive and rarely used. CTV is used for suspected iliac vein or vena cava thrombosis.
- A 50-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents with increasing dyspnea and purulent sputum. He is using accessory muscles. His arterial blood gas shows a pH of 7.31, PaCO2 of 60 mmHg, and PaO2 of 55 mmHg. Which of the following is the most appropriate initial intervention?
A. Intubate and initiate mechanical ventilation B. Administer a bronchodilator C. Start antibiotics and corticosteroids D. Initiate non-invasive positive pressure ventilation (NIPPV)
Correct Answer: D. Initiate non-invasive positive pressure ventilation (NIPPV)
Rationale: * The patient is in acute hypercapnic respiratory failure due to a COPD exacerbation. NIPPV is the first-line treatment. It improves ventilation, reduces PaCO2, and can prevent the need for intubation. A bronchodilator and antibiotics/corticosteroids are also necessary, but the immediate intervention for respiratory failure is NIPPV. Intubation is indicated if NIPPV fails or if the patient cannot protect their airway.
A. Apply direct pressure B. Administer protamine sulfate C. Administer vitamin K D. Obtain a vascular surgery consult
Correct Answer: A. Apply direct pressure
Rationale: * The immediate management of a bleeding dialysis access site is to apply direct pressure to the site. This is a basic but effective measure to control local hemorrhage. If the patient is on heparin, protamine sulfate may be indicated. Vitamin K is for warfarin reversal. A vascular surgery consult is important but is a subsequent step after initial hemorrhage control.
- A 9-year-old child presents with a sore throat, fever, and a "sandpaper-like" rash. The child has difficulty swallowing and a strawberry tongue. Which of the following is the most appropriate treatment?
A. Amoxicillin B. Acyclovir C. Penicillin or amoxicillin D. Clindamycin
Correct Answer: C. Penicillin or amoxicillin
Rationale: * This presentation is classic for scarlet fever, caused by group A Streptococcus. Penicillin is the treatment of choice for strep throat and scarlet fever. Amoxicillin is an appropriate alternative. Amoxicillin is the correct answer, but penicillin is also acceptable. Both are the standard of care. Acyclovir is for viral infections. Clindamycin is a second-line agent for those with penicillin allergy.
- A 32-year-old female is involved in a motor vehicle collision. She is 32 weeks pregnant. She is complaining of abdominal pain and has a tender, rigid abdomen. Her blood pressure is 90/60 mmHg. Which of the following is the most appropriate management of her hypotension?
A. Administer a bolus of crystalloid B. Administer a bolus of crystalloid and transfer to the operating room for an exploratory laparotomy C. Administer phenylephrine D. Perform a bedside FAST exam
Correct Answer: B. Administer a bolus of crystalloid and transfer to the operating room for an exploratory laparotomy
