SAEM M4 Emergency Medicine Exam –
Complete Study Guide & Practice Questions
Question 1: A 65-year-old male presents with sudden onset crushing substernal chest pain radiating to
the left arm. ECG shows ST-segment elevation in leads II, III, and aVF. Which of the following is the
most appropriate immediate management step?
A. Administer sublingual nitroglycerin
B. Perform immediate cardioversion
C. Activate the catheterization laboratory
D. Order a CT angiogram of the chest
CORRECT ANSWER: C. Activate the catheterization laboratory
RATIONALE: This patient presents with an inferior ST-elevation myocardial infarction (STEMI). The
standard of care for STEMI is immediate reperfusion therapy, preferably via percutaneous coronary
intervention (PCI). Activating the catheterization laboratory is the priority. Nitroglycerin should be used
with caution in inferior MI due to the risk of right ventricular involvement and hypotension.
Question 2: A 24-year-old female presents with palpitations and lightheadedness. Her heart rate is
180 bpm, regular, and narrow complex. Vagal maneuvers fail to convert the rhythm. What is the next
best step in management?
A. Administer adenosine 6 mg IV push
B. Administer amiodarone 150 mg IV
C. Perform synchronized cardioversion
D. Administer metoprolol 5 mg IV
CORRECT ANSWER: A. Administer adenosine 6 mg IV push
RATIONALE: The patient has stable supraventricular tachycardia (SVT). After failed vagal maneuvers,
the first-line pharmacologic treatment is adenosine. Cardioversion is reserved for unstable patients.
Beta-blockers or calcium channel blockers are second-line if adenosine fails or is contraindicated.
Question 3: A 55-year-old male with a history of hypertension presents with severe headache and
blood pressure of 220/120 mmHg. He has no focal neurologic deficits. What is the most appropriate
initial goal for blood pressure reduction?
A. Reduce MAP by 50% within 1 hour
B. Reduce systolic BP by 20-25% within the first hour
C. Normalize blood pressure immediately
D. Maintain current blood pressure until MRI is completed
CORRECT ANSWER: B. Reduce systolic BP by 20-25% within the first hour
RATIONALE: This patient is experiencing a hypertensive urgency or emergency without end-organ
damage (no focal deficits). In hypertensive emergency, the goal is to reduce mean arterial pressure by
no more than 20-25% in the first hour to avoid hypoperfusion. Rapid normalization can cause ischemic
stroke or renal failure.
,Question 4: A 30-year-old male presents with pleuritic chest pain and dyspnea after a long flight.
Wells score is moderate. D-dimer is elevated. What is the definitive diagnostic test?
A. Chest X-ray
B. CT Pulmonary Angiography (CTPA)
C. Ventilation-Perfusion (V/Q) scan
D. Lower extremity Doppler ultrasound
CORRECT ANSWER: B. CT Pulmonary Angiography (CTPA)
RATIONALE: In a patient with a moderate pre-test probability for pulmonary embolism (PE) and an
elevated D-dimer, CT Pulmonary Angiography is the gold standard diagnostic test. V/Q scan is an
alternative if contrast is contraindicated. Doppler evaluates DVT but does not diagnose PE directly.
Question 5: A 70-year-old female presents with acute onset shortness of breath. Lung exam reveals
bilateral crackles. BNP is elevated. Chest X-ray shows pulmonary edema. What is the first-line
pharmacologic intervention?
A. Furosemide IV
B. Morphine IV
C. Nitroglycerin IV
D. Intubation
CORRECT ANSWER: A. Furosemide IV
RATIONALE: This patient presents with acute decompensated heart failure (ADHF). IV loop diuretics
(furosemide) are the cornerstone of therapy to reduce volume overload. Nitroglycerin is useful if
hypertensive, but diuresis is primary. Morphine is no longer routinely recommended due to respiratory
depression risks.
Question 6: A 45-year-old male presents with tearing chest pain radiating to the back. Blood pressure
is 190/110 mmHg in the right arm and 160/90 mmHg in the left arm. What is the most likely
diagnosis?
A. Acute Myocardial Infarction
B. Aortic Dissection
C. Pulmonary Embolism
D. Pericarditis
CORRECT ANSWER: B. Aortic Dissection
RATIONALE: Tearing chest pain radiating to the back combined with a blood pressure discrepancy
between arms is classic for aortic dissection. Immediate blood pressure control and imaging (CTA) are
required. MI typically presents with pressure-like pain without arm BP discrepancy.
Question 7: A 60-year-old male presents with syncope. ECG shows a wide complex tachycardia. He is
hypotensive. What is the immediate treatment?
A. Adenosine
B. Amiodarone
,C. Synchronized Cardioversion
D. Lidocaine
CORRECT ANSWER: C. Synchronized Cardioversion
RATIONALE: Unstable wide complex tachycardia requires immediate synchronized cardioversion.
Pharmacologic management is reserved for stable patients. Adenosine is generally contraindicated in
wide complex tachycardia unless SVT with aberrancy is certain.
Question 8: A 50-year-old female presents with chest pain. ECG shows diffuse ST elevation and PR
depression. What is the diagnosis?
A. STEMI
B. Pericarditis
C. Myocarditis
D. Early Repolarization
CORRECT ANSWER: B. Pericarditis
RATIONALE: Diffuse ST elevation and PR depression are hallmark ECG findings of acute pericarditis.
STEMI usually shows regional ST elevation with reciprocal changes. Pericarditis pain is often pleuritic and
positional.
Question 9: A 25-year-old male presents with palpitations. ECG shows a delta wave and short PR
interval. What is the underlying condition?
A. Long QT Syndrome
B. Wolff-Parkinson-White (WPW) Syndrome
C. Brugada Syndrome
D. Sick Sinus Syndrome
CORRECT ANSWER: B. Wolff-Parkinson-White (WPW) Syndrome
RATIONALE: Delta waves and a short PR interval are pathognomonic for WPW syndrome, indicating an
accessory pathway. This predisposes patients to SVT and atrial fibrillation with rapid conduction.
Question 10: A 75-year-old male presents with dizziness. Heart rate is 35 bpm. ECG shows complete
heart block. What is the definitive treatment?
A. Atropine
B. Transcutaneous pacing
C. Permanent pacemaker implantation
D. Epinephrine infusion
CORRECT ANSWER: C. Permanent pacemaker implantation
RATIONALE: Complete heart block (Third-degree AV block) is a surgical emergency requiring
permanent pacing. Atropine and transcutaneous pacing are temporizing measures for unstable patients
while awaiting definitive management.
, Question 11: A 40-year-old female presents with sudden onset dyspnea. CXR shows a deep sulcus
sign. What injury is suspected?
A. Hemothorax
B. Pneumothorax
C. Pulmonary Contusion
D. Diaphragmatic Rupture
CORRECT ANSWER: B. Pneumothorax
RATIONALE: The deep sulcus sign on a supine chest X-ray is indicative of a pneumothorax, where air
collects in the costophrenic angle. This is often seen in trauma patients who cannot stand for an upright
film.
Question 12: A 30-year-old male presents with asthma exacerbation. He is using accessory muscles
and has silent chest on auscultation. What is the most concerning sign?
A. Wheezing
B. Silent Chest
C. Tachycardia
D. Cough
CORRECT ANSWER: B. Silent Chest
RATIONALE: A "silent chest" in asthma indicates severe airflow obstruction where not enough air is
moving to generate wheezes. This is a pre-arrest sign requiring immediate aggressive management and
potential intubation.
Question 13: A 55-year-old male with COPD presents with increased dyspnea and purulent sputum.
ABG shows pH 7.25, PaCO2 65, PaO2 55. What is the preferred initial respiratory support?
A. Intubation
B. Non-invasive Positive Pressure Ventilation (NIPPV)
C. High-flow nasal cannula
D. Supplemental oxygen via nasal cannula
CORRECT ANSWER: B. Non-invasive Positive Pressure Ventilation (NIPPV)
RATIONALE: In COPD exacerbation with respiratory acidosis (pH < 7.35), NIPPV (BiPAP) is the first-line
intervention to reduce work of breathing and improve ventilation. Intubation is reserved for NIPPV
failure or inability to protect the airway.
Question 14: A 20-year-old female presents with sudden onset pleuritic chest pain and dyspnea. CXR
shows a visceral pleural line. What is the treatment for a small primary spontaneous pneumothorax?
A. Immediate chest tube
B. Observation and oxygen
C. Needle decompression
D. Thoracotomy
Complete Study Guide & Practice Questions
Question 1: A 65-year-old male presents with sudden onset crushing substernal chest pain radiating to
the left arm. ECG shows ST-segment elevation in leads II, III, and aVF. Which of the following is the
most appropriate immediate management step?
A. Administer sublingual nitroglycerin
B. Perform immediate cardioversion
C. Activate the catheterization laboratory
D. Order a CT angiogram of the chest
CORRECT ANSWER: C. Activate the catheterization laboratory
RATIONALE: This patient presents with an inferior ST-elevation myocardial infarction (STEMI). The
standard of care for STEMI is immediate reperfusion therapy, preferably via percutaneous coronary
intervention (PCI). Activating the catheterization laboratory is the priority. Nitroglycerin should be used
with caution in inferior MI due to the risk of right ventricular involvement and hypotension.
Question 2: A 24-year-old female presents with palpitations and lightheadedness. Her heart rate is
180 bpm, regular, and narrow complex. Vagal maneuvers fail to convert the rhythm. What is the next
best step in management?
A. Administer adenosine 6 mg IV push
B. Administer amiodarone 150 mg IV
C. Perform synchronized cardioversion
D. Administer metoprolol 5 mg IV
CORRECT ANSWER: A. Administer adenosine 6 mg IV push
RATIONALE: The patient has stable supraventricular tachycardia (SVT). After failed vagal maneuvers,
the first-line pharmacologic treatment is adenosine. Cardioversion is reserved for unstable patients.
Beta-blockers or calcium channel blockers are second-line if adenosine fails or is contraindicated.
Question 3: A 55-year-old male with a history of hypertension presents with severe headache and
blood pressure of 220/120 mmHg. He has no focal neurologic deficits. What is the most appropriate
initial goal for blood pressure reduction?
A. Reduce MAP by 50% within 1 hour
B. Reduce systolic BP by 20-25% within the first hour
C. Normalize blood pressure immediately
D. Maintain current blood pressure until MRI is completed
CORRECT ANSWER: B. Reduce systolic BP by 20-25% within the first hour
RATIONALE: This patient is experiencing a hypertensive urgency or emergency without end-organ
damage (no focal deficits). In hypertensive emergency, the goal is to reduce mean arterial pressure by
no more than 20-25% in the first hour to avoid hypoperfusion. Rapid normalization can cause ischemic
stroke or renal failure.
,Question 4: A 30-year-old male presents with pleuritic chest pain and dyspnea after a long flight.
Wells score is moderate. D-dimer is elevated. What is the definitive diagnostic test?
A. Chest X-ray
B. CT Pulmonary Angiography (CTPA)
C. Ventilation-Perfusion (V/Q) scan
D. Lower extremity Doppler ultrasound
CORRECT ANSWER: B. CT Pulmonary Angiography (CTPA)
RATIONALE: In a patient with a moderate pre-test probability for pulmonary embolism (PE) and an
elevated D-dimer, CT Pulmonary Angiography is the gold standard diagnostic test. V/Q scan is an
alternative if contrast is contraindicated. Doppler evaluates DVT but does not diagnose PE directly.
Question 5: A 70-year-old female presents with acute onset shortness of breath. Lung exam reveals
bilateral crackles. BNP is elevated. Chest X-ray shows pulmonary edema. What is the first-line
pharmacologic intervention?
A. Furosemide IV
B. Morphine IV
C. Nitroglycerin IV
D. Intubation
CORRECT ANSWER: A. Furosemide IV
RATIONALE: This patient presents with acute decompensated heart failure (ADHF). IV loop diuretics
(furosemide) are the cornerstone of therapy to reduce volume overload. Nitroglycerin is useful if
hypertensive, but diuresis is primary. Morphine is no longer routinely recommended due to respiratory
depression risks.
Question 6: A 45-year-old male presents with tearing chest pain radiating to the back. Blood pressure
is 190/110 mmHg in the right arm and 160/90 mmHg in the left arm. What is the most likely
diagnosis?
A. Acute Myocardial Infarction
B. Aortic Dissection
C. Pulmonary Embolism
D. Pericarditis
CORRECT ANSWER: B. Aortic Dissection
RATIONALE: Tearing chest pain radiating to the back combined with a blood pressure discrepancy
between arms is classic for aortic dissection. Immediate blood pressure control and imaging (CTA) are
required. MI typically presents with pressure-like pain without arm BP discrepancy.
Question 7: A 60-year-old male presents with syncope. ECG shows a wide complex tachycardia. He is
hypotensive. What is the immediate treatment?
A. Adenosine
B. Amiodarone
,C. Synchronized Cardioversion
D. Lidocaine
CORRECT ANSWER: C. Synchronized Cardioversion
RATIONALE: Unstable wide complex tachycardia requires immediate synchronized cardioversion.
Pharmacologic management is reserved for stable patients. Adenosine is generally contraindicated in
wide complex tachycardia unless SVT with aberrancy is certain.
Question 8: A 50-year-old female presents with chest pain. ECG shows diffuse ST elevation and PR
depression. What is the diagnosis?
A. STEMI
B. Pericarditis
C. Myocarditis
D. Early Repolarization
CORRECT ANSWER: B. Pericarditis
RATIONALE: Diffuse ST elevation and PR depression are hallmark ECG findings of acute pericarditis.
STEMI usually shows regional ST elevation with reciprocal changes. Pericarditis pain is often pleuritic and
positional.
Question 9: A 25-year-old male presents with palpitations. ECG shows a delta wave and short PR
interval. What is the underlying condition?
A. Long QT Syndrome
B. Wolff-Parkinson-White (WPW) Syndrome
C. Brugada Syndrome
D. Sick Sinus Syndrome
CORRECT ANSWER: B. Wolff-Parkinson-White (WPW) Syndrome
RATIONALE: Delta waves and a short PR interval are pathognomonic for WPW syndrome, indicating an
accessory pathway. This predisposes patients to SVT and atrial fibrillation with rapid conduction.
Question 10: A 75-year-old male presents with dizziness. Heart rate is 35 bpm. ECG shows complete
heart block. What is the definitive treatment?
A. Atropine
B. Transcutaneous pacing
C. Permanent pacemaker implantation
D. Epinephrine infusion
CORRECT ANSWER: C. Permanent pacemaker implantation
RATIONALE: Complete heart block (Third-degree AV block) is a surgical emergency requiring
permanent pacing. Atropine and transcutaneous pacing are temporizing measures for unstable patients
while awaiting definitive management.
, Question 11: A 40-year-old female presents with sudden onset dyspnea. CXR shows a deep sulcus
sign. What injury is suspected?
A. Hemothorax
B. Pneumothorax
C. Pulmonary Contusion
D. Diaphragmatic Rupture
CORRECT ANSWER: B. Pneumothorax
RATIONALE: The deep sulcus sign on a supine chest X-ray is indicative of a pneumothorax, where air
collects in the costophrenic angle. This is often seen in trauma patients who cannot stand for an upright
film.
Question 12: A 30-year-old male presents with asthma exacerbation. He is using accessory muscles
and has silent chest on auscultation. What is the most concerning sign?
A. Wheezing
B. Silent Chest
C. Tachycardia
D. Cough
CORRECT ANSWER: B. Silent Chest
RATIONALE: A "silent chest" in asthma indicates severe airflow obstruction where not enough air is
moving to generate wheezes. This is a pre-arrest sign requiring immediate aggressive management and
potential intubation.
Question 13: A 55-year-old male with COPD presents with increased dyspnea and purulent sputum.
ABG shows pH 7.25, PaCO2 65, PaO2 55. What is the preferred initial respiratory support?
A. Intubation
B. Non-invasive Positive Pressure Ventilation (NIPPV)
C. High-flow nasal cannula
D. Supplemental oxygen via nasal cannula
CORRECT ANSWER: B. Non-invasive Positive Pressure Ventilation (NIPPV)
RATIONALE: In COPD exacerbation with respiratory acidosis (pH < 7.35), NIPPV (BiPAP) is the first-line
intervention to reduce work of breathing and improve ventilation. Intubation is reserved for NIPPV
failure or inability to protect the airway.
Question 14: A 20-year-old female presents with sudden onset pleuritic chest pain and dyspnea. CXR
shows a visceral pleural line. What is the treatment for a small primary spontaneous pneumothorax?
A. Immediate chest tube
B. Observation and oxygen
C. Needle decompression
D. Thoracotomy
