Emergency Medicine (EM) EOR Exam 2
Review Questions with Complete
Solutions Graded A+ 2025
1. A 59-year-old man presents to the emergency department (ED) complaining of new
onset chest pain that radiates to his left arm. He has a history of hypertension,
hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram
(ECG) is remarkable for T-wave inversions in the lateral leads. Which of the following is
the most appropriate next step in management?
a. Give the patient two nitroglycerin tablets sublingually and observe if his chest
pain resolves.
b. Place the patient on a cardiac monitor, administer oxygen, and give aspirin.
c. Call the cardiac catheterization laboratory for immediate percutaneous
intervention (PCI).
d. Order a chest x-ray; administer aspirin, clopidogrel, and heparin.
e. Start a β-blocker immediately.
- *B*. (Rosen, pp 1039-1044.) The patient's presentation is classic for an ACS.
He has multiple risk factors with T-wave abnormalities on his ECG. The most
appropriate initial management includes placing the patient on a cardiac monitor
to detect dysrhythmias, establish intravenous access, provide supplemental
oxygen, and administer aspirin. If the patient is having active chest pain in the
ED, sublingual nitroglycerin or morphine should be administered until the pain
resolves. This decreases wall tension and myocardial oxygen demand. A
common mnemonic used is MONA(Morphine, Oxygen, Nitroglycerin, Aspirin)
greets chest pain patients at the door.
(a) Although nitroglycerin is one of the early agents used in ACS, it is
prudent to first rule out a right ventricular infarct, which if present,
may lead to hypotension.
(b) PCI is warranted if the patient's ECG showed ST segment
elevation.
(c) The patient will require a chest x-ray and most likely receive
clopidogrel and heparin; however this is done only after being on a
monitor with oxygen and chewing an aspirin.
(e) β-Blockers are usually added for tachycardia, hypertension, and
persistent pain and only given once the patient is evaluated for
contraindications. Relative contraindications to the use of β- blockers
include asthma or chronic obstructive lung disease, CHF, and third-
trimester pregnancy.
2. A 36-year-old woman presents to the ED with sudden onset of left-sided chest pain
and mild shortness of breath that began the night before. She was able to
, fall asleep without difficulty but woke up in the morning with persistent pain that is
worsened upon taking a deep breath. She walked up the stairs at home and became very
short of breath, which made her come to the ED. Two weeks ago, she took a 7-hour
flight from Europe and since then has left-sided calf pain and swelling. What is the most
common ECG finding for this patient's presentation?
a. S1Q3T3 pattern
b. Atrial fibrillation
c. Right-axis deviation
d. Right-atrial enlargement
e. Tachycardia or nonspecific ST-T-wave changes
- *E* The patient most likely has a pulmonary thromboembolism (PE) that
embolized from a thrombus in her left calf. The diagnosis of PE is usually made
with a CT angiogram, echocardiogram, or a ventilation-perfusion scan. The
most common ECG abnormalities in the setting of PE are tachycardia and
nonspecific ST-T- wave abnormalities.
3. A 51-year-old man with a long history of hypertension presents to the ED complaining
of intermittent chest palpitations lasting for a week. He denies chest pain, shortness of
breath, nausea, and vomiting. He recalls feeling similar episodes of palpitations a few
months ago but they resolved. His blood pressure (BP) is 130/75 mm Hg, heart rate
(HR) is 130 beats per minute, respiratory rate (RR) is 16 breaths per minute, and
oxygen saturation is 99% on room air. An ECG shows a fib. Which of the following is
the most appropriate next step in management?
a. Sedate patient for immediate synchronized cardioversion with 100 Joules
b. Prepare patient for the cardiac catheterization laboratory
c. Administer Coumadin
d. Administer amiodarone
e. Administer diltiazem
- *E* Atrial fibrillation (AF) is a rhythm disturbance of the atria that results in
irregular, chaotic, ventricular waveforms. This chaotic activity can lead to
reduced cardiac output from a loss of coordinated atrial contractions and a
rapid ventricular rate, both of which may limit diastolic filling and stroke volume
of the ventricles. Atrial fibrillation may be chronic or paroxysmal, lasting
minutes to days. On the ECG, fibrillatory waves are seen and accompanied by an
irregular QRS pattern. The main ED treatment for atrial fibrillation is rate
control. This can be accomplished by many agents, but the agent most
commonly used is diltiazem, a CCB with excellent AV nodal blocking effects
4. A 54-year-old woman presents to the ED because of a change in behavior at home. For
the past 3 years she has end-stage renal disease requiring dialysis. Her daughter states
that the patient has been increasingly tired and occasionally confused for the past 3
days and has not been eating her usual diet. On examination, the patient is alert and
oriented to person only. The remainder of
, her examination is normal. An initial 12-lead ECG shows peaked T waves. Which of the
following electrolyte abnormalities best explains these findings?
a. Hypokalemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypercalcemia
e. Hyponatremia`
- *B.* Patients with end-stage renal disease, who require dialysis, are prone to
electrolyte disturbances. This patient's clinical picture is consistent with
hyperkalemia. The ECG can provide valuable clues to the presence of
hyperkalemia. As potassium levels rise, peaked T waves are the first
characteristic manifestation. Further rises are associated with progressive ECG
changes, including loss of P waves and widening of the QRS complex.
Eventually the tracing assumes a sinewave pattern, followed by ventricular
fibrillation or asystole
5. A 29-year-old tall, thin man presents to the ED after feeling short of breath for 2 days.
In the ED, he is in no acute distress. His BP is 115/70 mm Hg, HR is 81 beats per
minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air.
Cardiac, lung, and abdominal examinations are normal. An ECG reveals sinus rhythm at
a rate of 79. A chest radiograph shows a small right- sided (less than 10% of the
hemithorax) spontaneous pneumothorax. A repeat chest x-ray 6 hours later reveals a
decreased pneumothorax. Which of the following is the most appropriate next step in
management?
a. Discharge the patient with follow-up in 24 hours
b. Perform needle decompression in the second intercostal space,
midclavicular line
c. Insert a 20F chest tube into right hemithorax
d. Observe for another 6 hours
e. Admit for pleurodesis - *A* The patient presents with a primary spontaneous
pneumothorax (PTX), which occurs in individuals without clinically apparent
lung disease. In contrast, secondary spontaneous pneumothorax occurs in
individuals with underlying lung disease, especially chronic obstructive
pulmonary disease (COPD). For otherwise healthy, young patients with a small
primary spontaneous PTX (less than 20% of the hemithorax), observation alone
may be appropriate. The intrinsic reabsorption rate is approximately 1% to 2% a
day, and accelerated with the administration of 100% oxygen. Many physicians
observe these patients for 6 hours and then repeat the chest x-ray. If the
repeat chest x-ray shows no increase in the size of the PTX, the patient can be
discharged with follow-up in 24 hours. Air travel and underwater diving
(changes in atmospheric pressure) must be avoided until the PTX completely
resolves.
6. A 42-year-old man found vomiting in the street is brought to the ED by EMS. He has a
known history of alcohol abuse with multiple presentations for intoxication.
, Today, the patient complains of acute onset, persistent chest pain associated with
dysphagia, and pain upon flexing his neck. His BP is 115/70 mm Hg, HR is 101 beats
per minute, RR is 18 breaths per minute, and oxygen saturation is 97% on room air. As
you listen to his heart, you hear a crunching sound. His abdomen is soft with mild
epigastric tenderness. The ECG is sinus tachycardia without ST-T-wave abnormalities.
On chest x-ray, you note lateral displacement of the left mediastinal pleural. What is
the most likely diagnosis?
a. Aspiration pneumonia
b. Acute pancreatitis
c. Pericarditis
d. Esophageal perforation
e. Aortic dissection
- *D.* Esophageal perforation is a potentially life-threatening condition that can
result from any Valsalva-like maneuver, including childbirth, coughing, and
heavy lifting. Alcoholics are at risk as a result of their frequent vomiting. The
most common cause of esophageal perforation is from iatrogenic causes, such
as a complication from upper endoscopy. The classic physical examination
finding is mediastinal or cervical emphysema. This is noted by feeling air under
the skin on palpation of the chest wall or by a *crunching sound heard on
auscultation, also known as Hamman sign*. Radiographic signs of
pneumomediastinum can be subtle. Lateral displacement of the mediastinal
pleura by mediastinal air creates a linear density paralleling the mediastinal
contour. On the lateral projection, mediastinal air can be seen in the retrocardiac
space
7. A 65-year-old man with a history of chronic hypertension presents to the ED with
sudden-onset tearing chest pain that radiates to his jaw. His BP is 205/110 mm Hg, HR
is 90 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 97% on
room air. He appears apprehensive. On cardiac examination you hear a diastolic
murmur at the right sternal border. A chest x-ray reveals a widened mediastinum.
Which of the following is the preferred study of choice to diagnose this patient's
condition?
a. Electrocardiogram (ECG)
b. Transthoracic echocardiography (TTE)
c. Transesophageal echocardiography (TEE)
d. Computed tomography (CT) scan
e. Magnetic resonance imaging (MRI)
- *C* The patient's clinical picture of chronic hypertension, acute onset tearing
chest pain, diastolic murmur of aortic insufficiency, and chest x-ray with a
widened mediastinum is consistent with an aortic dissection. The preferred
study of choice is a transesophageal echocardiogram (TEE), which is highly
sensitive. It can be quickly performed at the bedside and does not require
radiation or contrast.
(b) A TTE is limited in diagnosing aortic dissections because wave transmission
is hindered by the overlying sternum. It can be useful to see pericardial fluid as
Review Questions with Complete
Solutions Graded A+ 2025
1. A 59-year-old man presents to the emergency department (ED) complaining of new
onset chest pain that radiates to his left arm. He has a history of hypertension,
hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram
(ECG) is remarkable for T-wave inversions in the lateral leads. Which of the following is
the most appropriate next step in management?
a. Give the patient two nitroglycerin tablets sublingually and observe if his chest
pain resolves.
b. Place the patient on a cardiac monitor, administer oxygen, and give aspirin.
c. Call the cardiac catheterization laboratory for immediate percutaneous
intervention (PCI).
d. Order a chest x-ray; administer aspirin, clopidogrel, and heparin.
e. Start a β-blocker immediately.
- *B*. (Rosen, pp 1039-1044.) The patient's presentation is classic for an ACS.
He has multiple risk factors with T-wave abnormalities on his ECG. The most
appropriate initial management includes placing the patient on a cardiac monitor
to detect dysrhythmias, establish intravenous access, provide supplemental
oxygen, and administer aspirin. If the patient is having active chest pain in the
ED, sublingual nitroglycerin or morphine should be administered until the pain
resolves. This decreases wall tension and myocardial oxygen demand. A
common mnemonic used is MONA(Morphine, Oxygen, Nitroglycerin, Aspirin)
greets chest pain patients at the door.
(a) Although nitroglycerin is one of the early agents used in ACS, it is
prudent to first rule out a right ventricular infarct, which if present,
may lead to hypotension.
(b) PCI is warranted if the patient's ECG showed ST segment
elevation.
(c) The patient will require a chest x-ray and most likely receive
clopidogrel and heparin; however this is done only after being on a
monitor with oxygen and chewing an aspirin.
(e) β-Blockers are usually added for tachycardia, hypertension, and
persistent pain and only given once the patient is evaluated for
contraindications. Relative contraindications to the use of β- blockers
include asthma or chronic obstructive lung disease, CHF, and third-
trimester pregnancy.
2. A 36-year-old woman presents to the ED with sudden onset of left-sided chest pain
and mild shortness of breath that began the night before. She was able to
, fall asleep without difficulty but woke up in the morning with persistent pain that is
worsened upon taking a deep breath. She walked up the stairs at home and became very
short of breath, which made her come to the ED. Two weeks ago, she took a 7-hour
flight from Europe and since then has left-sided calf pain and swelling. What is the most
common ECG finding for this patient's presentation?
a. S1Q3T3 pattern
b. Atrial fibrillation
c. Right-axis deviation
d. Right-atrial enlargement
e. Tachycardia or nonspecific ST-T-wave changes
- *E* The patient most likely has a pulmonary thromboembolism (PE) that
embolized from a thrombus in her left calf. The diagnosis of PE is usually made
with a CT angiogram, echocardiogram, or a ventilation-perfusion scan. The
most common ECG abnormalities in the setting of PE are tachycardia and
nonspecific ST-T- wave abnormalities.
3. A 51-year-old man with a long history of hypertension presents to the ED complaining
of intermittent chest palpitations lasting for a week. He denies chest pain, shortness of
breath, nausea, and vomiting. He recalls feeling similar episodes of palpitations a few
months ago but they resolved. His blood pressure (BP) is 130/75 mm Hg, heart rate
(HR) is 130 beats per minute, respiratory rate (RR) is 16 breaths per minute, and
oxygen saturation is 99% on room air. An ECG shows a fib. Which of the following is
the most appropriate next step in management?
a. Sedate patient for immediate synchronized cardioversion with 100 Joules
b. Prepare patient for the cardiac catheterization laboratory
c. Administer Coumadin
d. Administer amiodarone
e. Administer diltiazem
- *E* Atrial fibrillation (AF) is a rhythm disturbance of the atria that results in
irregular, chaotic, ventricular waveforms. This chaotic activity can lead to
reduced cardiac output from a loss of coordinated atrial contractions and a
rapid ventricular rate, both of which may limit diastolic filling and stroke volume
of the ventricles. Atrial fibrillation may be chronic or paroxysmal, lasting
minutes to days. On the ECG, fibrillatory waves are seen and accompanied by an
irregular QRS pattern. The main ED treatment for atrial fibrillation is rate
control. This can be accomplished by many agents, but the agent most
commonly used is diltiazem, a CCB with excellent AV nodal blocking effects
4. A 54-year-old woman presents to the ED because of a change in behavior at home. For
the past 3 years she has end-stage renal disease requiring dialysis. Her daughter states
that the patient has been increasingly tired and occasionally confused for the past 3
days and has not been eating her usual diet. On examination, the patient is alert and
oriented to person only. The remainder of
, her examination is normal. An initial 12-lead ECG shows peaked T waves. Which of the
following electrolyte abnormalities best explains these findings?
a. Hypokalemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypercalcemia
e. Hyponatremia`
- *B.* Patients with end-stage renal disease, who require dialysis, are prone to
electrolyte disturbances. This patient's clinical picture is consistent with
hyperkalemia. The ECG can provide valuable clues to the presence of
hyperkalemia. As potassium levels rise, peaked T waves are the first
characteristic manifestation. Further rises are associated with progressive ECG
changes, including loss of P waves and widening of the QRS complex.
Eventually the tracing assumes a sinewave pattern, followed by ventricular
fibrillation or asystole
5. A 29-year-old tall, thin man presents to the ED after feeling short of breath for 2 days.
In the ED, he is in no acute distress. His BP is 115/70 mm Hg, HR is 81 beats per
minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air.
Cardiac, lung, and abdominal examinations are normal. An ECG reveals sinus rhythm at
a rate of 79. A chest radiograph shows a small right- sided (less than 10% of the
hemithorax) spontaneous pneumothorax. A repeat chest x-ray 6 hours later reveals a
decreased pneumothorax. Which of the following is the most appropriate next step in
management?
a. Discharge the patient with follow-up in 24 hours
b. Perform needle decompression in the second intercostal space,
midclavicular line
c. Insert a 20F chest tube into right hemithorax
d. Observe for another 6 hours
e. Admit for pleurodesis - *A* The patient presents with a primary spontaneous
pneumothorax (PTX), which occurs in individuals without clinically apparent
lung disease. In contrast, secondary spontaneous pneumothorax occurs in
individuals with underlying lung disease, especially chronic obstructive
pulmonary disease (COPD). For otherwise healthy, young patients with a small
primary spontaneous PTX (less than 20% of the hemithorax), observation alone
may be appropriate. The intrinsic reabsorption rate is approximately 1% to 2% a
day, and accelerated with the administration of 100% oxygen. Many physicians
observe these patients for 6 hours and then repeat the chest x-ray. If the
repeat chest x-ray shows no increase in the size of the PTX, the patient can be
discharged with follow-up in 24 hours. Air travel and underwater diving
(changes in atmospheric pressure) must be avoided until the PTX completely
resolves.
6. A 42-year-old man found vomiting in the street is brought to the ED by EMS. He has a
known history of alcohol abuse with multiple presentations for intoxication.
, Today, the patient complains of acute onset, persistent chest pain associated with
dysphagia, and pain upon flexing his neck. His BP is 115/70 mm Hg, HR is 101 beats
per minute, RR is 18 breaths per minute, and oxygen saturation is 97% on room air. As
you listen to his heart, you hear a crunching sound. His abdomen is soft with mild
epigastric tenderness. The ECG is sinus tachycardia without ST-T-wave abnormalities.
On chest x-ray, you note lateral displacement of the left mediastinal pleural. What is
the most likely diagnosis?
a. Aspiration pneumonia
b. Acute pancreatitis
c. Pericarditis
d. Esophageal perforation
e. Aortic dissection
- *D.* Esophageal perforation is a potentially life-threatening condition that can
result from any Valsalva-like maneuver, including childbirth, coughing, and
heavy lifting. Alcoholics are at risk as a result of their frequent vomiting. The
most common cause of esophageal perforation is from iatrogenic causes, such
as a complication from upper endoscopy. The classic physical examination
finding is mediastinal or cervical emphysema. This is noted by feeling air under
the skin on palpation of the chest wall or by a *crunching sound heard on
auscultation, also known as Hamman sign*. Radiographic signs of
pneumomediastinum can be subtle. Lateral displacement of the mediastinal
pleura by mediastinal air creates a linear density paralleling the mediastinal
contour. On the lateral projection, mediastinal air can be seen in the retrocardiac
space
7. A 65-year-old man with a history of chronic hypertension presents to the ED with
sudden-onset tearing chest pain that radiates to his jaw. His BP is 205/110 mm Hg, HR
is 90 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 97% on
room air. He appears apprehensive. On cardiac examination you hear a diastolic
murmur at the right sternal border. A chest x-ray reveals a widened mediastinum.
Which of the following is the preferred study of choice to diagnose this patient's
condition?
a. Electrocardiogram (ECG)
b. Transthoracic echocardiography (TTE)
c. Transesophageal echocardiography (TEE)
d. Computed tomography (CT) scan
e. Magnetic resonance imaging (MRI)
- *C* The patient's clinical picture of chronic hypertension, acute onset tearing
chest pain, diastolic murmur of aortic insufficiency, and chest x-ray with a
widened mediastinum is consistent with an aortic dissection. The preferred
study of choice is a transesophageal echocardiogram (TEE), which is highly
sensitive. It can be quickly performed at the bedside and does not require
radiation or contrast.
(b) A TTE is limited in diagnosing aortic dissections because wave transmission
is hindered by the overlying sternum. It can be useful to see pericardial fluid as
