SAEM EXAM QUESTIONS 2025-2026 ACTUAL EXAM 400
REAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
"Which coronary vessel is usually the cause of the myocardial infarction in a patient with ST
elevation in V1, V2, and V3?
A. left anterior descending (LAD)
B. left circumflex artery
C. posterior descending branch of the right coronary artery
D. right coronary artery (RCA)
E. right ventricular branch of the right coronary artery" correct answers "A. left anterior
descending (LAD)
The answer is A. This EKG pattern is consistent with that of anterior wall myocardial infarction
(MI). The LAD supplies the anterior wall of the myocardium. The left circumflex artery, the
LAD, or a branch of the RCA supplies the lateral wall of the left ventricle. Proximal occlusion of
the LAD will give ST elevation in leads V1-6, aVL and I (an anterolateral MI). Occlusion of a
branch of the RCA will result in an inferolateral MI (ST elevation in leads II, III, aVF and I,
aVL, V5 and V6). The RCA supplies the inferior wall and SA node. Occlusion in leads II, III and
aVF causes an inferior MI. The right ventricle is usually supplied by the RCA or, less commonly,
a dominant left circumflex. ST elevation in leads V4 and V5 of a right-side leads EKG suggests
infarction of the right ventricle. A posterior MI (ST depression in V1-V3) results from occlusion
of the RCA, its posterior descending branch, or a dominant left circumflex."
"A 51-year-old male with long-standing hypertension presents with abrupt onset of severe chest
pain radiating to the back. He describes a tearing sensation. Vital signs are HR 110, BP 175/105,
RR 20, T 37.4. EKG shows LVH. CBC, electrolytes, BUN/Creatinine are all normal. CXR is as
shown below. What diagnostic test would be most appropriate for making a definitive diagnosis
at this time?
[image shows CXR w/ wide mediastinum]
A. MRI of the thoracic spine
B. Aortogram
,C. CT of the chest with IV contrast
D. Esophagram using Gastrograffin" correct answers "C. CT of the chest with IV contrast
"CT of the chest is the test most often used to confirm the diagnosis of aortic dissection. CT is
readily available in most Emergency Departments, and has a sensitivity of 83-98% and
specificity of 87-100% for aortic dissection (highest accuracy with helical scans). Other benefits
associated with the use of CT include the ability to identify intramural thrombus, pericardial
effusion, and potentially reveal another etiology for the patient's pain. The major disadvantage of
CT is the need for iodinated contrast, which requires normal renal function.""
"A 60 year old male presented to the emergency department with chest pain. He subsequently
became unresponsive. The monitor shows the rhythm below. The rhythm is:
[image monomorphic wide QRS tachycardia with no p waves]
A. sinus tachycardia
B. ventricular tachycardia
C. atrial fibrillation with rapid ventricular response
D. atrial flutter" correct answers "B. ventricular tachycardia
The answer is B. Ventricular tachycardia is wide and complex. It is distinguished from
supraventricular tachycardia by width and morphology of the QRS complexes. (Though there are
numerous exceptions, supraventricular tachycardias usually exhibit narrow QRS complexes with
morphology similar to that when the patient is in sinus rhythm.)"
"A 64 year old female presents to the emergency department with chief complaints of occipital
headache and chest pain. Physical examination reveals a blood pressure of 200/118 as well as
edema of the optic disk. Of the diagnoses below, the most likely is:
A. hypertensive crisis
B. acute hypertensive (non-emergency/non-urgency) episode
C. hypertensive urgency
D. moderate hypertension
E. white-coat hypertension" correct answers "A. hypertensive crisis
,The answer is A. Elevated blood pressure in the setting of optic disk edema is a hallmark of
malignant hypertension (also known as hypertensive emergency or hypertensive crisis). While
hypertensive urgency is not consistently defined in the medical literature, this patient's
presentation indicates that there is some end-organ damage and thus the diagnosis is malignant
hypertension. The white-coat"" syndrome, in which patients' blood pressures are elevated only in
the clinical setting and not at home, has been shown to account for as many as a fifth of all cases
of newly diagnosed ""hypertension."" Understanding of this phenomenom is important for
emergency physicians, since its frequency explains why patients should not be given a diagnosis
of new-onset hypertension based on E.D. measurements."""
"A 14 year old presents just after smoking crack cocaine and complains of chest pain. He
describes it as sharp and stabbing in the middle of his chest. His EKG is normal. The intern reads
the CXR as "negative" but your supervising resident asks you to have another look (see Figure),
after which you make the diagnosis of:
[image: big round heart, black in mediastinum, widened]
photo courtesy of eMedicine.com
A. Pneumonia
B. Aortic dissection
C. Congestive heart failure
D. Pneumomediastinum" correct answers "D. Pneumomediastinum
The answer is D. Look closely along the right heart border and mediastinum. There is a thin strip
of air. Pneumomediastinum and pneumopericardium result from Valsalva maneuvers,
barotrauma, asthma, and cocaine inhalation from positive pressure devices. On physical exam
there may be a Hamman's sign or mediastinal crunch heard over the precordium. Westermark's
sign is dilation of pulmonary vessels proximal to a pulmonary embolism resulting in a cut-off
appearance of the vessel on CXR."
"A 22 year old presents with chest pain and the following EKG:
[image: Septal ST elevations]
, He reports no past medical history and no family history of medical problems. Which substance
should you specifically question him about using?
A. Cocaine
B. Heroin
C. Methamphetamine
D. Ecstasy" correct answers "A. Cocaine
The answer is A. Cocaine toxicity can cause a variety of cardiovascular sequelae including:
cardiac dysrhythmias, coronary artery vasospasm, myocardial
ischemia/infarction, and aortic dissection. The central nervous system is also
commonly involved with seizures, intracranial hemorrhages/infarctions and
hypertensive encephalopathy being common. Mesenteric ischemia can occur as well
as rhabdomyolysis."
"Generally speaking, a patient with a TIA history who presents with a new stroke, likely has
which kind of stroke?
A. there is equal likelihood for any stroke type
B. embolic
C. hypoperfusion
D. thrombotic
E. hemorrhagic" correct answers "D. thrombotic
The answer is D. TIAs are associated with increased risk for thrombotic strokes, the result of
ulceration of cerebral artery plaque. Patients with TIA have a 5 to 6% percent chance per year of
having a stroke. Antiplatelet therapy reduces risk of stroke in these patients."
REAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
"Which coronary vessel is usually the cause of the myocardial infarction in a patient with ST
elevation in V1, V2, and V3?
A. left anterior descending (LAD)
B. left circumflex artery
C. posterior descending branch of the right coronary artery
D. right coronary artery (RCA)
E. right ventricular branch of the right coronary artery" correct answers "A. left anterior
descending (LAD)
The answer is A. This EKG pattern is consistent with that of anterior wall myocardial infarction
(MI). The LAD supplies the anterior wall of the myocardium. The left circumflex artery, the
LAD, or a branch of the RCA supplies the lateral wall of the left ventricle. Proximal occlusion of
the LAD will give ST elevation in leads V1-6, aVL and I (an anterolateral MI). Occlusion of a
branch of the RCA will result in an inferolateral MI (ST elevation in leads II, III, aVF and I,
aVL, V5 and V6). The RCA supplies the inferior wall and SA node. Occlusion in leads II, III and
aVF causes an inferior MI. The right ventricle is usually supplied by the RCA or, less commonly,
a dominant left circumflex. ST elevation in leads V4 and V5 of a right-side leads EKG suggests
infarction of the right ventricle. A posterior MI (ST depression in V1-V3) results from occlusion
of the RCA, its posterior descending branch, or a dominant left circumflex."
"A 51-year-old male with long-standing hypertension presents with abrupt onset of severe chest
pain radiating to the back. He describes a tearing sensation. Vital signs are HR 110, BP 175/105,
RR 20, T 37.4. EKG shows LVH. CBC, electrolytes, BUN/Creatinine are all normal. CXR is as
shown below. What diagnostic test would be most appropriate for making a definitive diagnosis
at this time?
[image shows CXR w/ wide mediastinum]
A. MRI of the thoracic spine
B. Aortogram
,C. CT of the chest with IV contrast
D. Esophagram using Gastrograffin" correct answers "C. CT of the chest with IV contrast
"CT of the chest is the test most often used to confirm the diagnosis of aortic dissection. CT is
readily available in most Emergency Departments, and has a sensitivity of 83-98% and
specificity of 87-100% for aortic dissection (highest accuracy with helical scans). Other benefits
associated with the use of CT include the ability to identify intramural thrombus, pericardial
effusion, and potentially reveal another etiology for the patient's pain. The major disadvantage of
CT is the need for iodinated contrast, which requires normal renal function.""
"A 60 year old male presented to the emergency department with chest pain. He subsequently
became unresponsive. The monitor shows the rhythm below. The rhythm is:
[image monomorphic wide QRS tachycardia with no p waves]
A. sinus tachycardia
B. ventricular tachycardia
C. atrial fibrillation with rapid ventricular response
D. atrial flutter" correct answers "B. ventricular tachycardia
The answer is B. Ventricular tachycardia is wide and complex. It is distinguished from
supraventricular tachycardia by width and morphology of the QRS complexes. (Though there are
numerous exceptions, supraventricular tachycardias usually exhibit narrow QRS complexes with
morphology similar to that when the patient is in sinus rhythm.)"
"A 64 year old female presents to the emergency department with chief complaints of occipital
headache and chest pain. Physical examination reveals a blood pressure of 200/118 as well as
edema of the optic disk. Of the diagnoses below, the most likely is:
A. hypertensive crisis
B. acute hypertensive (non-emergency/non-urgency) episode
C. hypertensive urgency
D. moderate hypertension
E. white-coat hypertension" correct answers "A. hypertensive crisis
,The answer is A. Elevated blood pressure in the setting of optic disk edema is a hallmark of
malignant hypertension (also known as hypertensive emergency or hypertensive crisis). While
hypertensive urgency is not consistently defined in the medical literature, this patient's
presentation indicates that there is some end-organ damage and thus the diagnosis is malignant
hypertension. The white-coat"" syndrome, in which patients' blood pressures are elevated only in
the clinical setting and not at home, has been shown to account for as many as a fifth of all cases
of newly diagnosed ""hypertension."" Understanding of this phenomenom is important for
emergency physicians, since its frequency explains why patients should not be given a diagnosis
of new-onset hypertension based on E.D. measurements."""
"A 14 year old presents just after smoking crack cocaine and complains of chest pain. He
describes it as sharp and stabbing in the middle of his chest. His EKG is normal. The intern reads
the CXR as "negative" but your supervising resident asks you to have another look (see Figure),
after which you make the diagnosis of:
[image: big round heart, black in mediastinum, widened]
photo courtesy of eMedicine.com
A. Pneumonia
B. Aortic dissection
C. Congestive heart failure
D. Pneumomediastinum" correct answers "D. Pneumomediastinum
The answer is D. Look closely along the right heart border and mediastinum. There is a thin strip
of air. Pneumomediastinum and pneumopericardium result from Valsalva maneuvers,
barotrauma, asthma, and cocaine inhalation from positive pressure devices. On physical exam
there may be a Hamman's sign or mediastinal crunch heard over the precordium. Westermark's
sign is dilation of pulmonary vessels proximal to a pulmonary embolism resulting in a cut-off
appearance of the vessel on CXR."
"A 22 year old presents with chest pain and the following EKG:
[image: Septal ST elevations]
, He reports no past medical history and no family history of medical problems. Which substance
should you specifically question him about using?
A. Cocaine
B. Heroin
C. Methamphetamine
D. Ecstasy" correct answers "A. Cocaine
The answer is A. Cocaine toxicity can cause a variety of cardiovascular sequelae including:
cardiac dysrhythmias, coronary artery vasospasm, myocardial
ischemia/infarction, and aortic dissection. The central nervous system is also
commonly involved with seizures, intracranial hemorrhages/infarctions and
hypertensive encephalopathy being common. Mesenteric ischemia can occur as well
as rhabdomyolysis."
"Generally speaking, a patient with a TIA history who presents with a new stroke, likely has
which kind of stroke?
A. there is equal likelihood for any stroke type
B. embolic
C. hypoperfusion
D. thrombotic
E. hemorrhagic" correct answers "D. thrombotic
The answer is D. TIAs are associated with increased risk for thrombotic strokes, the result of
ulceration of cerebral artery plaque. Patients with TIA have a 5 to 6% percent chance per year of
having a stroke. Antiplatelet therapy reduces risk of stroke in these patients."
