SAEM EXAM QUESTIONS
"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" - Answer-"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" - Answer-"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" - Answer-"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" - Answer-"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" - Answer-"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" - Answer-"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" - Answer-"D. thrombotic
"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" - Answer-"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" - Answer-"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" - Answer-"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" - Answer-"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" - Answer-"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" - Answer-"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" - Answer-"D. thrombotic
