ABEM Qualifying Examination (QE) — Questions and Answers

Question 1: A 28-year-old male twists his ankle and has tenderness over the lateral malleolus but can bear weight in the ED. According to the Ottawa Ankle Rules, which finding independently mandates an X-ray?

Inability to bear weight both immediately after injury and in the ED (Correct answer)
Lateral malleolus tenderness alone
Mild swelling over the lateral ankle
Pain with passive inversion of the foot

Correct answer: Inability to bear weight both immediately after injury and in the ED

Ottawa Ankle Rules require X-ray if there is bony tenderness at specific malleolar zones OR inability to bear weight (4 steps) both immediately after injury and in the ED.

Question 2: A 40-year-old presents with sudden unilateral vision loss, described as a 'shade coming down' over the eye that resolved in 10 minutes. What is this phenomenon called and what does it indicate?

Retinal detachment — requires immediate ophthalmology referral
Central retinal artery occlusion — requires tPA
Ocular migraine — indicates cortical spreading depression
Amaurosis fugax — indicates carotid artery disease (Correct answer)

Correct answer: Amaurosis fugax — indicates carotid artery disease

Amaurosis fugax (transient monocular blindness) is caused by emboli from ipsilateral carotid stenosis temporarily occluding retinal blood flow.

Question 3: A patient presents with confusion, serum sodium of 118 mEq/L, and euvolemia. What is the safest correction rate for chronic hyponatremia?

Correct to 130 within 4 hours
No more than 8–10 mEq/L in 24 hours (Correct answer)
Give 3% saline at rapid rate
Correct as fast as possible

Correct answer: No more than 8–10 mEq/L in 24 hours

Overcorrecting chronic hyponatremia faster than 8–10 mEq/L per 24 hours risks osmotic demyelination syndrome (central pontine myelinolysis).

Question 4: Which ECG finding in a patient with digoxin toxicity is MOST specific for toxicity rather than therapeutic effect?

PR prolongation
QT shortening
Bidirectional ventricular tachycardia (Correct answer)
Scooped ST depression

Correct answer: Bidirectional ventricular tachycardia

Bidirectional ventricular tachycardia is highly specific for digoxin (and aconitine) toxicity and is not a therapeutic ECG change.

Question 5: After a house fire, a victim presents with confusion, cherry-red skin, and carboxyhemoglobin of 28%. What is the half-life of COHb with 100% normobaric oxygen?

~4–5 hours without oxygen treatment
~60–90 minutes (Correct answer)
~30 minutes
~5 hours

Correct answer: ~60–90 minutes

100% normobaric oxygen reduces the carboxyhemoglobin half-life from ~5 hours on room air to approximately 60–90 minutes.

Question 6: A 70-year-old presents with sudden loss of pain and temperature sensation over his right arm and leg, with left-sided face numbness, and left-sided Horner syndrome. Which vessel is most likely occluded?

Right anterior cerebral artery
Left anterior inferior cerebellar artery
Left posterior inferior cerebellar artery (Correct answer)
Right middle cerebral artery

Correct answer: Left posterior inferior cerebellar artery

Left PICA occlusion causes lateral medullary (Wallenberg) syndrome with left-sided Horner and facial sensory loss, and crossed (right-sided) body pain/temperature loss via spinothalamic tract.

Question 7: What is the PRIMARY purpose of obtaining ABEM certification in American Board of Emergency Medicine?

To satisfy a personal achievement goal
To demonstrate verified competency and adherence to professional standards (Correct answer)
To guarantee employment in the field
To bypass educational requirements

Correct answer: To demonstrate verified competency and adherence to professional standards

Professional certification demonstrates that an individual has met established competency standards through verified assessment. It provides assurance to employers, clients, and the public that the certified professional possesses the knowledge and skills required for competent practice.

Question 8: A 58-year-old male presents with acute onset tearing chest pain radiating to the back, BP 180/100 in the right arm and 140/85 in the left arm. The most likely diagnosis is:

Pulmonary embolism
STEMI
Aortic dissection (Correct answer)
Esophageal rupture

Correct answer: Aortic dissection

Aortic dissection classically presents with tearing back pain and a blood pressure differential >20 mmHg between arms.

Question 9: Which arrhythmia is MOST commonly associated with Wolff-Parkinson-White syndrome presenting as a wide-complex tachycardia?

Atrial fibrillation with accessory pathway conduction (Correct answer)
Atrial flutter with 2:1 block
Junctional tachycardia
Ventricular tachycardia

Correct answer: Atrial fibrillation with accessory pathway conduction

Atrial fibrillation conducting rapidly down an accessory pathway in WPW produces a wide, irregular, potentially life-threatening tachycardia.

Question 10: A 4-year-old swallowed a button battery 3 hours ago. X-ray shows it in the esophagus. What is the correct management?

Induce vomiting
Administer activated charcoal
Immediate endoscopic removal (Correct answer)
Observe 24 hours and repeat X-ray

Correct answer: Immediate endoscopic removal

Esophageal button batteries require immediate endoscopic removal due to rapid tissue necrosis from electrical current and alkaline injury.

Question 11: In cardiac tamponade, Beck's triad includes hypotension, muffled heart sounds, and:

Bradycardia
Tracheal deviation
Jugular venous distension (Correct answer)
Pulsus alternans

Correct answer: Jugular venous distension

Beck's triad consists of hypotension, muffled heart sounds, and jugular venous distension (JVD) due to impaired cardiac filling.

Question 12: A 60-year-old woman presents with painless diplopia, ptosis, and a dilated pupil. She has a known posterior communicating artery aneurysm. What is the most urgent next step?

Administer IV methylprednisolone
Prescribe eye patch and outpatient follow-up
Emergent neurosurgical or interventional neuroradiology consultation (Correct answer)
MRI orbits with contrast

Correct answer: Emergent neurosurgical or interventional neuroradiology consultation

Third nerve palsy with pupil involvement from a PComm aneurysm represents a surgical emergency due to risk of rupture and subarachnoid hemorrhage.

Question 13: Which foundational principle is MOST important for success in the American Board of Emergency Medicine profession?

Specializing in only one narrow area of practice
Commitment to continuous learning, ethical practice, and quality outcomes (Correct answer)
Maximizing financial returns on every engagement
Maintaining the minimum requirements for certification

Correct answer: Commitment to continuous learning, ethical practice, and quality outcomes

Success in any professional field requires a commitment to continuous learning to stay current, ethical practice to maintain trust and integrity, and a focus on quality outcomes that serve stakeholders and the public interest.

Question 14: A 65-year-old diabetic presents with painful ophthalmoplegia, ptosis, and normal pupillary response. What is the most likely etiology?

Myasthenia gravis
Posterior communicating artery aneurysm
Cavernous sinus thrombosis
Microvascular ischemic CN III palsy (Correct answer)

Correct answer: Microvascular ischemic CN III palsy

Diabetic microvascular ischemia causes pupil-sparing CN III palsy because the pupillomotor fibers travel on the outside of the nerve and are spared by ischemia that affects the inner fibers.

Question 15: What is the correct placement site for an intraosseous (IO) needle in an adult trauma patient when IV access is unavailable?

Proximal tibia 2 cm below tibial tuberosity medially (Correct answer)
Calcaneus
Distal radius
Greater trochanter of femur

Correct answer: Proximal tibia 2 cm below tibial tuberosity medially

The proximal tibia 2 cm below and medial to the tibial tuberosity is the preferred IO site in adults.

Question 16: A 6-week-old male presents with projectile non-bilious vomiting after feeding. What is the most likely diagnosis?

GERD
Volvulus
Pyloric stenosis (Correct answer)
Intussusception

Correct answer: Pyloric stenosis

Pyloric stenosis classically presents in 2–8 week old males with projectile, non-bilious vomiting and a palpable olive-shaped mass.

Question 17: What is the PRIMARY ethical obligation of a certified American Board of Emergency Medicine professional regarding confidential information?

Share it with colleagues who might benefit
Use it to advance career opportunities
Protect it from unauthorized disclosure at all times (Correct answer)
Discuss it informally during professional networking

Correct answer: Protect it from unauthorized disclosure at all times

Confidentiality is a fundamental ethical obligation. Certified professionals must protect confidential information from unauthorized disclosure, regardless of circumstances. Breach of confidentiality can result in loss of certification and legal liability.

Question 18: A patient presents with respiratory failure, miosis, bradycardia, and excessive secretions after a farmworker exposure. What is the appropriate initial dose of atropine?

0.04 mg/kg IM as a single dose
10 mg IV single bolus
0.5 mg IV, titrate slowly
2–4 mg IV, repeat every 5–10 min until secretions dry (Correct answer)

Correct answer: 2–4 mg IV, repeat every 5–10 min until secretions dry

Organophosphate poisoning requires aggressive atropinization starting at 2–4 mg IV titrated to drying of secretions, which is the clinical endpoint.

Question 19: Which finding on bedside ultrasound is MOST diagnostic of pneumothorax?

Absence of lung sliding with A-lines (Correct answer)
B-lines bilaterally
Mirror image artifact
Hepatization of lung tissue

Correct answer: Absence of lung sliding with A-lines

Absence of lung sliding combined with A-lines (and a lung point) on ultrasound is highly sensitive and specific for pneumothorax.

Question 20: Which landmark is used for needle decompression of tension pneumothorax using the 4th or 5th intercostal space approach?

Mid-axillary line (Correct answer)
Mid-clavicular line
Posterior axillary line
Anterior axillary line

Correct answer: Mid-axillary line

The mid-axillary line at the 4th–5th ICS is the preferred alternate site, especially in obese patients where MCL decompression may fail.

Question 21: What causes altered mental status?

Only drugs
Anxiety
Multiple causes (Correct answer)
Blood loss

Correct answer: Multiple causes

Altered mental status (AMS) is a broad term indicating a change in a person's usual level of awareness or responsiveness. It can be caused by a wide array of medical conditions, including metabolic disturbances (e.g., hypoglycemia, electrolyte imbalances), infections, drug overdose, head injuries, stroke, hypoxia, and psychiatric conditions. Therefore, a thorough diagnostic workup is essential to identify the underlying cause.

Question 22: A 5-year-old presents after a seizure lasting 4 minutes that has now stopped. Temperature is 39.2°C. What is the most appropriate management?

EEG immediately
Admit for 24-hour observation
Lumbar puncture in all cases
Reassurance and antipyretics for a simple febrile seizure (Correct answer)

Correct answer: Reassurance and antipyretics for a simple febrile seizure

A simple febrile seizure (single, brief, generalized) in a child 6 months–5 years requires reassurance and treatment of the fever.

Question 23: What distinguishes a American Board of Emergency Medicine certified professional from a non-certified practitioner?

Certified professionals exclusively work in larger organizations
Certified professionals always have more years of experience
There is no meaningful difference in competency
Certification validates competency through standardized assessment against established benchmarks (Correct answer)

Correct answer: Certification validates competency through standardized assessment against established benchmarks

Certification provides objective validation of competency through standardized assessment. While non-certified practitioners may be skilled, certification offers verified evidence that a professional meets established benchmarks for knowledge and performance.

Question 24: A hiker returns from the Appalachian Trail with fever, headache, and a petechial rash spreading centripetally from the wrists and ankles. What is the treatment of choice?

Doxycycline (Correct answer)
Azithromycin
Ceftriaxone
Amoxicillin-clavulanate

Correct answer: Doxycycline

Doxycycline is the drug of choice for Rocky Mountain Spotted Fever (Rickettsia rickettsii) in all age groups, including children.

Question 25: What tool evaluates mental status?

ABG
CBC
GCS (Correct answer)
BMI

Correct answer: GCS

The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool used to objectively measure a person's level of consciousness. It evaluates eye-opening, verbal response, and motor response, providing a numerical score that helps clinicians assess the severity of brain injury or altered mental status and monitor changes over time.

Question 26: What condition follows prolonged cold exposure?

Dehydration
Hypothermia (Correct answer)
Shock
Hyperglycemia

Correct answer: Hypothermia

Hypothermia is a dangerous drop in body temperature, typically below 95°F (35°C), caused by prolonged exposure to cold environments. When the body loses heat faster than it can produce it, vital systems begin to shut down, leading to symptoms like shivering, confusion, and eventually loss of consciousness and cardiac arrest if not treated.

Question 27: A patient presents with bradycardia, hypotension, and hyperkalemia after ingesting a large quantity of sustained-release verapamil. Which antidote provides the most direct physiologic benefit?

Glucagon IV
Lipid emulsion therapy
High-dose insulin with dextrose (Correct answer)
Calcium gluconate IV

Correct answer: High-dose insulin with dextrose

High-dose insulin euglycemic therapy (HIET) improves myocardial carbohydrate metabolism and is the mainstay treatment for severe calcium channel blocker overdose.

Question 28: Which lab helps confirm infection?

Creatinine
WBC count (Correct answer)
Platelets
Glucose

Correct answer: WBC count

A White Blood Cell (WBC) count, also known as a leukocyte count, is a common laboratory test used to help identify and monitor infections. An elevated WBC count (leukocytosis) often indicates that the body's immune system is actively fighting an infection, as it produces more white blood cells to combat pathogens.

Question 29: A 28-year-old asthmatic presents with severe wheezing, cannot speak in full sentences, HR 128, and SpO2 88%. After initial bronchodilators, what adjunct treatment is MOST appropriate?

Systemic corticosteroids (Correct answer)
Immediate intubation
Ipratropium nebulization only
IV aminophylline

Correct answer: Systemic corticosteroids

Systemic corticosteroids (IV methylprednisolone or oral prednisone) reduce airway inflammation and decrease length of stay in severe asthma exacerbations.

Question 30: What documentation is MOST critical to maintain for safety compliance in the American Board of Emergency Medicine field?

Incident reports, training records, and inspection logs (Correct answer)
Annual revenue reports
Employee vacation schedules
Client marketing preferences

Correct answer: Incident reports, training records, and inspection logs

Incident reports, training records, and inspection logs are essential safety documentation. They demonstrate compliance with safety regulations, track training completion, and provide evidence of systematic hazard management.

Question 31: A patient presents with severe epigastric pain, fever, and jaundice. RUQ ultrasound shows CBD dilation and stones. What is the diagnosis?

Cholecystitis
Ascending cholangitis (Charcot's triad) (Correct answer)
Hepatitis
Biliary colic only

Correct answer: Ascending cholangitis (Charcot's triad)

Charcot's triad (fever, jaundice, RUQ pain) represents ascending cholangitis — a surgical emergency requiring antibiotics and biliary decompression.

Question 32: A patient with a history of kidney stones presents with colicky flank pain radiating to the groin, hematuria, and nausea. CT shows a 7 mm ureteral stone. What is the appropriate management?

Immediate urologic intervention
Foley catheter and observation
Extracorporeal shock wave lithotripsy in ED
Pain control, hydration, alpha-blocker, and urology follow-up (Correct answer)

Correct answer: Pain control, hydration, alpha-blocker, and urology follow-up

Stones 5–10 mm have a moderate chance of spontaneous passage; alpha-blockers (e.g., tamsulosin) plus analgesia and urology follow-up is appropriate.

Question 33: What PPE is essential in infection control?

Gloves and mask (Correct answer)
Thermometer
Shoes
Cap only

Correct answer: Gloves and mask

Gloves and masks are essential components of Personal Protective Equipment (PPE) for infection control. Gloves protect healthcare workers from direct contact with blood, body fluids, and contaminated surfaces, while masks prevent the inhalation of airborne pathogens and the spread of respiratory droplets. Together, they form a crucial barrier against transmission.

Question 34: A previously healthy 30-year-old male presents with sudden pleuritic chest pain and dyspnea after lifting weights. CXR shows a 25% pneumothorax on the right. He is hemodynamically stable. Management is:

Needle aspiration or small-bore chest tube (Correct answer)
Large-bore chest tube (28-32 Fr)
Observation only without oxygen
Supplemental O2 and discharge with follow-up

Correct answer: Needle aspiration or small-bore chest tube

A symptomatic primary spontaneous pneumothorax >15-20% in a stable patient is treated with needle aspiration or small-bore chest tube placement.

Question 35: A 30-year-old presents with acute onset of severe agitation, hyperthermia (40.5°C), diaphoresis, myoclonus, and hyperreflexia after starting a new medication. Which drug combination most likely caused this?

Clonazepam and alcohol
Haloperidol and benztropine
Amitriptyline alone
Tramadol and sertraline (Correct answer)

Correct answer: Tramadol and sertraline

Serotonin syndrome is caused by excess serotonergic activity, classically from combining opioids with serotonin activity (tramadol) and SSRIs.

Question 36: A 2-year-old presents with inspiratory stridor and a barking cough. Which intervention is first-line for moderate croup?

Racemic epinephrine only
Nebulized epinephrine
Heliox therapy
Dexamethasone 0.6 mg/kg IM/PO (Correct answer)

Correct answer: Dexamethasone 0.6 mg/kg IM/PO

Dexamethasone (0.6 mg/kg) is the first-line treatment for moderate croup, reducing airway edema and decreasing return visits.

Question 37: What is the first step in managing a cardiac arrest?

Initiate CPR (Correct answer)
Call family
Administer glucose
Apply cold packs

Correct answer: Initiate CPR

In managing a cardiac arrest, the immediate priority is to restore circulation and oxygenation to the brain and other vital organs. Initiating cardiopulmonary resuscitation (CPR) without delay is the critical first step, as it provides artificial circulation and breathing until advanced medical help arrives or a defibrillator can be used. Early CPR significantly improves the chances of survival and neurological outcomes.

Question 38: A patient with a gunshot wound through-and-through to the neck presents with subcutaneous emphysema and hemoptysis. Which structure is most likely injured?

Trachea or larynx (Correct answer)
Esophagus
Jugular vein
Carotid artery

Correct answer: Trachea or larynx

Subcutaneous emphysema and hemoptysis following penetrating neck trauma indicate airway (tracheal or laryngeal) injury.

Question 39: In American Board of Emergency Medicine practice, what is the FIRST step when a safety hazard is identified in the workplace?

Immediately secure the area and report the hazard (Correct answer)
Continue working and report at end of shift
Document it for the next safety audit
Wait for a supervisor to notice the issue

Correct answer: Immediately secure the area and report the hazard

When a safety hazard is identified, the immediate priority is to secure the area to prevent injury and report the hazard through proper channels. Delaying action increases the risk of incidents.

Question 40: A 4-year-old presents with moderate respiratory distress and wheezing. SpO2 is 91%. What is the immediate treatment for acute asthma exacerbation?

Heliox as first-line
IV corticosteroids only
Magnesium sulfate immediately
Albuterol via nebulizer and supplemental oxygen (Correct answer)

Correct answer: Albuterol via nebulizer and supplemental oxygen

Inhaled albuterol (bronchodilator) plus supplemental oxygen is the cornerstone initial treatment of acute pediatric asthma exacerbations.

Question 41: What is a sign of shock?

Rashes
Hypotension and tachycardia (Correct answer)
Hyperthermia
Bradycardia

Correct answer: Hypotension and tachycardia

Shock is a life-threatening condition characterized by inadequate tissue perfusion, meaning the body's cells aren't getting enough oxygen and nutrients. Hypotension (low blood pressure) occurs as the circulatory system fails to maintain adequate pressure, while tachycardia (rapid heart rate) is a compensatory mechanism as the heart tries to pump more blood to vital organs.

Question 42: A 25-year-old at 10 weeks gestation presents with vaginal bleeding and an empty uterus on ultrasound with no intrauterine pregnancy. β-hCG is 1,800 mIU/mL. What is the next step?

Dilation and curettage
Emergency laparotomy
Repeat β-hCG in 48 hours (Correct answer)
Immediate methotrexate

Correct answer: Repeat β-hCG in 48 hours

When β-hCG is below the discriminatory zone (~2,000 mIU/mL) and no IUP is seen, serial β-hCG in 48 hours is appropriate to differentiate ectopic from early IUP.

Question 43: A 7-year-old falls from the monkey bars and has distal radius pain. X-ray shows cortical buckling on one side without a complete fracture line. What is the most appropriate treatment?

Posterior long-arm splint for 3-4 weeks without reduction (Correct answer)
Short arm cast for 8 weeks
Open reduction and internal fixation
Closed reduction under sedation followed by casting

Correct answer: Posterior long-arm splint for 3-4 weeks without reduction

Torus (buckle) fractures are inherently stable due to the intact periosteum and cortex on one side; splinting for 3-4 weeks without reduction is sufficient.

Question 44: What is the most common cause of preventable death in penetrating extremity trauma?

Nerve injury
Infection
Compartment syndrome
Compressible hemorrhage (Correct answer)

Correct answer: Compressible hemorrhage

Compressible extremity hemorrhage is the leading preventable cause of death in combat and civilian penetrating trauma.

Question 45: How is heat stroke treated?

Antibiotics
Hot packs
Steroids
Cool and hydrate (Correct answer)

Correct answer: Cool and hydrate

Heat stroke is a severe, life-threatening condition caused by the body overheating, often due to prolonged exposure to high temperatures or physical exertion in the heat. The primary treatment involves rapid cooling of the body, such as with ice packs or cool water immersion, and rehydration to lower core body temperature and restore fluid balance.

Question 46: A 45-year-old with known alcoholism presents after a seizure. He last drank 48 hours ago. His blood alcohol level is 0. What is the MOST appropriate next step?

Order CT head with contrast
Load with phenytoin IV
Start propofol infusion
Administer lorazepam and thiamine (Correct answer)

Correct answer: Administer lorazepam and thiamine

Alcohol withdrawal seizures are best treated with benzodiazepines; thiamine must be given prior to or concurrently with glucose to prevent precipitating Wernicke encephalopathy.

Question 47: A 22-year-old college student presents with fever, severe headache, photophobia, and a non-blanching petechial rash. Which action is most critical and time-sensitive?

Obtain blood cultures before any treatment
Give dexamethasone and await CT results
Administer IV ceftriaxone immediately without waiting for LP (Correct answer)
Perform LP to identify organism before antibiotics

Correct answer: Administer IV ceftriaxone immediately without waiting for LP

Bacterial meningitis with petechial rash (suggesting meningococcemia) requires immediate IV antibiotics; any delay for cultures or CT is unacceptable given mortality risk.

Question 48: Which trauma score assesses severity?

ABG
BMI
GCS (Correct answer)
APGAR

Correct answer: GCS

The Glasgow Coma Scale (GCS) is a widely used neurological scale that provides an objective and reliable way to assess a patient's conscious state, particularly after a head injury or in other trauma. It evaluates eye opening, verbal response, and motor response, with a lower score indicating greater severity of brain injury and overall trauma.

Question 49: A 55-year-old man with hypertension presents with acute pulmonary edema. His BP is 220/130 mmHg. Which vasodilator acts primarily as a venodilator to rapidly reduce preload?

Labetalol
Hydralazine
Nitroglycerin (Correct answer)
Nicardipine

Correct answer: Nitroglycerin

Nitroglycerin at low doses acts primarily as a venodilator, rapidly reducing preload and relieving acute pulmonary congestion.

Question 50: What is a seizure?

Heart spasm
Brain activity (Correct answer)
Low oxygen
Muscle fatigue

Correct answer: Brain activity

A seizure is fundamentally a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. It is caused by uncontrolled electrical discharges in the brain, which can manifest in various ways, including altered consciousness, involuntary movements, or sensory disturbances.

Question 51: Which scenario represents a violation of the American Board of Emergency Medicine code of professional conduct?

Misrepresenting qualifications or certification status (Correct answer)
Seeking continuing education beyond minimum requirements
Declining work outside one's area of competence
Reporting safety concerns to regulatory authorities

Correct answer: Misrepresenting qualifications or certification status

Misrepresenting qualifications or certification status is a serious violation of professional conduct. It undermines public trust and can lead to harm when unqualified individuals perform specialized work.

Question 52: A trauma patient develops paradoxical chest wall movement involving multiple ribs bilaterally after a crush injury. What is the primary concern?

Aortic dissection
Pneumothorax
Diaphragmatic rupture
Flail chest with underlying pulmonary contusion (Correct answer)

Correct answer: Flail chest with underlying pulmonary contusion

Paradoxical chest wall movement indicates flail chest, and the underlying pulmonary contusion is the primary driver of respiratory failure.

Question 53: A patient presents with fever, neck stiffness, and photophobia. CSF shows glucose 30 mg/dL, protein 180 mg/dL, and 800 WBC/µL (90% neutrophils). Which empiric antibiotic regimen is most appropriate for an immunocompetent adult?

Vancomycin + ceftriaxone + ampicillin
Ceftriaxone alone
Vancomycin + ceftriaxone + dexamethasone (Correct answer)
Meropenem + vancomycin

Correct answer: Vancomycin + ceftriaxone + dexamethasone

Bacterial meningitis in an immunocompetent adult is treated with vancomycin plus a third-generation cephalosporin; dexamethasone reduces inflammation and improves outcomes, particularly in S. pneumoniae meningitis.

Question 54: A 7-year-old presents with a 3-day history of periorbital swelling, fever, and proptosis with painful eye movement. What is the most concerning diagnosis?

Orbital cellulitis (Correct answer)
Dacryocystitis
Allergic reaction
Periorbital (preseptal) cellulitis

Correct answer: Orbital cellulitis

Proptosis and painful eye movement in a febrile child indicate orbital (postseptal) cellulitis, which can spread intracranially and requires urgent CT and IV antibiotics.

Question 55: Which of the following presentations is MOST consistent with black widow spider envenomation rather than brown recluse envenomation?

Painless local erythema with central eschar formation
Diffuse muscle cramping, diaphoresis, and severe abdominal rigidity (Correct answer)
Local urticaria and angioedema within 30 minutes of the bite
Expanding necrotic wound with blue-gray halo at the bite site

Correct answer: Diffuse muscle cramping, diaphoresis, and severe abdominal rigidity

Latrodectus (black widow) venom causes alpha-latrotoxin-induced neurotransmitter release, producing the classic latrodectism: painful muscle cramping, diaphoresis, and autonomic instability.

Question 56: A 16-year-old female presents with lower abdominal pain, fever, and cervical motion tenderness. What is the most likely diagnosis?

Ovarian torsion
Pelvic inflammatory disease (Correct answer)
Ruptured ectopic pregnancy
Appendicitis

Correct answer: Pelvic inflammatory disease

The classic triad of lower abdominal pain, adnexal tenderness, and cervical motion tenderness in a sexually active female indicates PID.

Question 57: A patient is found in pulseless electrical activity (PEA). Which of the H's and T's should be considered FIRST given a history of massive hemorrhage?

Thrombosis (PE)
Hypovolemia (Correct answer)
Hydrogen ion excess
Hypothermia

Correct answer: Hypovolemia

Hypovolemia from hemorrhage is the most immediately reversible cause of PEA and should be addressed with rapid volume resuscitation.

Question 58: What is stroke sign?

High fever
Facial droop (Correct answer)
Itchy eyes
Arm rash

Correct answer: Facial droop

Facial droop is a classic and easily recognizable sign of a stroke, often affecting one side of the face. It occurs due to damage to the brain areas that control facial muscles. This symptom is part of the FAST mnemonic (Face, Arm, Speech, Time) and indicates a need for urgent medical evaluation for potential stroke.

Question 59: When conducting a risk assessment for ABEM operations, which factor should receive the HIGHEST priority?

Probability and severity of potential harm (Correct answer)
Time required for safety training
Cost of implementing safety measures
Convenience for daily operations

Correct answer: Probability and severity of potential harm

The probability and severity of potential harm are the primary factors in risk assessment. While cost and convenience are considerations, they should never override the assessment of how likely an incident is and how severe its consequences could be.

Question 60: A 55-year-old presents with severe low back pain radiating bilaterally to both legs, new urinary retention, and decreased rectal sphincter tone. What is the most appropriate next step?

Epidural steroid injection for nerve root decompression
Lumbar X-ray and discharge with muscle relaxants and follow-up
Urgent MRI of the lumbar spine and neurosurgical consultation (Correct answer)
NSAIDs, physical therapy referral, and reassurance

Correct answer: Urgent MRI of the lumbar spine and neurosurgical consultation

Cauda equina syndrome is a surgical emergency; urgent MRI is required to identify the compressive lesion and emergent neurosurgical decompression must not be delayed.

Question 61: A restrained driver sustains a lap-belt abdominal bruise pattern. Which injury triad is classically associated with this mechanism?

Chance fracture, hollow viscus injury, mesenteric tear (Correct answer)
Liver laceration, spleen rupture, bladder injury
Aortic transection, hemothorax, rib fractures
Sternal fracture, cardiac contusion, aortic injury

Correct answer: Chance fracture, hollow viscus injury, mesenteric tear

The lap-belt complex includes Chance fracture (flexion-distraction lumbar), bowel/mesenteric injury from compression against the spine.

Question 62: A patient on lithium presents with coarse tremor, ataxia, and confusion with a lithium level of 2.8 mEq/L. Which intervention is most critical?

Give activated charcoal
Begin hemodialysis (Correct answer)
Administer thiamine 100 mg IV
Administer sodium bicarbonate IV

Correct answer: Begin hemodialysis

Severe lithium toxicity (level >2.5 mEq/L with neurological symptoms) requires hemodialysis, as lithium is not protein-bound and is dialyzable.

Question 63: A patient presents with calcium of 14.2 mg/dL, confusion, polyuria, and constipation. What is the first-line treatment for hypercalcemic crisis?

Furosemide as first step
IV normal saline hydration (Correct answer)
Bisphosphonates IV immediately
Calcitonin before fluids

Correct answer: IV normal saline hydration

Aggressive IV normal saline rehydration is the cornerstone first step in treating hypercalcemic crisis, increasing renal calcium excretion.

Question 64: A 50-year-old male develops acute onset dyspnea and hypoxia 3 days after an MI. Echocardiogram shows a new VSD. Which finding would you expect on physical exam?

Continuous machine-like murmur
Diastolic murmur at the apex
Pericardial friction rub
Loud systolic murmur at the left sternal border (Correct answer)

Correct answer: Loud systolic murmur at the left sternal border

Post-MI ventricular septal defect causes a harsh holosystolic murmur heard best at the left lower sternal border due to left-to-right shunting.

Question 65: An 18-month-old presents with a femur fracture with a history inconsistent with the injury. What is the most appropriate next step?

Genetic workup for osteogenesis imperfecta
Non-accidental trauma workup and child protective services notification (Correct answer)
Bone density scan
Discharge with orthopedics follow-up

Correct answer: Non-accidental trauma workup and child protective services notification

A femur fracture in a pre-ambulatory child with an inconsistent history is highly concerning for non-accidental trauma and mandates a full workup and CPS notification.

Question 66: Which statement BEST describes the relationship between American Board of Emergency Medicine certification requirements and industry evolution?

Changes only occur when government mandates new requirements
Requirements become less stringent over time
Certification requirements never change once established
Requirements evolve periodically to reflect advances in knowledge, technology, and practice standards (Correct answer)

Correct answer: Requirements evolve periodically to reflect advances in knowledge, technology, and practice standards

Certification requirements evolve to keep pace with advances in professional knowledge, technological developments, and changes in practice standards. This ensures that certified professionals remain current and competent in a changing professional landscape.

Question 67: What helps de-escalate agitated patient?

Verbal de-escalation (Correct answer)
Sedation first
Restraints only
Yelling

Correct answer: Verbal de-escalation

Verbal de-escalation techniques are the preferred first-line approach for managing agitated patients, aiming to reduce their distress and prevent escalation to physical aggression. This involves using calm, respectful communication, active listening, empathy, and offering choices to help the patient regain control and cooperate with care. It prioritizes patient safety and autonomy over immediate physical restraint or sedation.

Question 68: Which rhythm requires defibrillation?

Bradycardia
Ventricular fibrillation (Correct answer)
Sinus rhythm
Asystole

Correct answer: Ventricular fibrillation

Ventricular fibrillation (VF) is a chaotic electrical activity in the ventricles that prevents the heart from pumping blood effectively, leading to cardiac arrest. Defibrillation, which delivers an electrical shock, is the definitive treatment for VF because it aims to reset the heart's electrical activity, allowing a normal rhythm to resume. Asystole, a flatline rhythm, indicates no electrical activity and does not respond to defibrillation.

Question 69: A construction worker collapses on a hot summer day with core temperature of 41.5°C, anhidrosis, and delirium. What is the MOST effective cooling method to reduce core temperature rapidly?

Misting fans and evaporative cooling
Ice packs to axillae, groin, and neck
Ice water immersion (Correct answer)
Cooling blanket set at 20°C

Correct answer: Ice water immersion

Ice water immersion provides the fastest rate of core cooling (0.2°C/min) for exertional heat stroke and is the gold standard cooling method.

Question 70: What is the first step in trauma assessment?

Measure glucose
Obtain history
Primary survey (Correct answer)
Check temperature

Correct answer: Primary survey

In trauma assessment, the primary survey is the crucial first step, focusing on identifying and immediately treating life-threatening injuries. It follows the ABCDE mnemonic (Airway, Breathing, Circulation, Disability, Exposure) to systematically assess and manage critical issues, ensuring the patient's immediate survival before proceeding to a more detailed secondary assessment.

Question 71: A 40-year-old male with HIV presents with progressive dyspnea and dry cough. CXR shows bilateral interstitial infiltrates. LDH is markedly elevated. The most likely diagnosis is:

Pneumocystis jirovecii pneumonia (PCP) (Correct answer)
Tuberculosis
Community-acquired pneumonia
Pulmonary Kaposi's sarcoma

Correct answer: Pneumocystis jirovecii pneumonia (PCP)

PCP is the most common opportunistic lung infection in HIV patients with low CD4 counts and classically presents with bilateral interstitial infiltrates and elevated LDH.

Question 72: Which personal protective equipment (PPE) principle applies to ALL ABEM certified professionals regardless of their specific role?

PPE is optional if experienced in the field
Any PPE will provide adequate protection
PPE must be properly fitted, maintained, and replaced as needed (Correct answer)
PPE is only necessary during formal inspections

Correct answer: PPE must be properly fitted, maintained, and replaced as needed

Regardless of experience level or specific role, PPE must be properly fitted to the individual, regularly maintained in good condition, and replaced when worn or damaged. Improperly fitted or degraded PPE can provide a false sense of security.

Question 73: A 25-year-old jams her finger and cannot actively extend the distal interphalangeal (DIP) joint; there is a slight flexion deformity. X-ray shows no bony avulsion. What is the correct diagnosis and treatment?

Boutonniere deformity; PIP extension splinting
Mallet finger; continuous DIP extension splinting for 6-8 weeks (Correct answer)
Swan neck deformity; hand therapy referral
Jersey finger; urgent surgical tendon repair

Correct answer: Mallet finger; continuous DIP extension splinting for 6-8 weeks

Mallet finger results from disruption of the terminal extensor tendon at the DIP joint and is treated with uninterrupted DIP extension splinting for 6-8 weeks.

Question 74: How does the ABEM body of knowledge relate to daily professional practice?

It provides the foundational framework that guides decision-making and standard practices (Correct answer)
It is relevant only for academic research
It only applies during certification exams
It is theoretical and has limited practical application

Correct answer: It provides the foundational framework that guides decision-making and standard practices

The body of knowledge provides the foundational framework of principles, standards, and best practices that professionals use to guide their daily decision-making, ensure consistent quality, and maintain alignment with industry standards.

Question 75: What is the MOST important reason for American Board of Emergency Medicine professionals to maintain continuing education?

To increase billing rates
To satisfy employer preferences
To stay current with evolving standards, practices, and regulations (Correct answer)
To accumulate credentials for personal prestige

Correct answer: To stay current with evolving standards, practices, and regulations

Continuing education ensures professionals remain current with evolving industry standards, best practices, and regulatory requirements. This directly impacts the quality of service provided and maintains public trust in the profession.

Question 76: What is the purpose of chest decompression?

Drain abscess
Control heart rate
Remove clot
Relieve pneumothorax (Correct answer)

Correct answer: Relieve pneumothorax

Chest decompression, often performed via needle decompression or chest tube insertion, is an emergency procedure to relieve a tension pneumothorax. In this life-threatening condition, air accumulates in the pleural space, collapsing the lung and putting pressure on the heart and great vessels. Decompression releases this trapped air, restoring lung function and cardiovascular stability.

Question 77: What is used for insecticide poisoning?

Atropine (Correct answer)
Lidocaine
Naloxone
Insulin

Correct answer: Atropine

Organophosphate insecticide poisoning causes overstimulation of the parasympathetic nervous system due to inhibition of acetylcholinesterase. Atropine is the primary antidote, acting as a competitive antagonist at muscarinic acetylcholine receptors. It helps reverse life-threatening symptoms like bradycardia, bronchospasm, and excessive secretions.

Question 78: What is the first action in suspected sepsis?

Oxygen only
Painkillers
Steroids
Antibiotics (Correct answer)

Correct answer: Antibiotics

Sepsis is a life-threatening condition caused by the body's overwhelming response to an infection, leading to organ dysfunction. Administering broad-spectrum antibiotics as quickly as possible is critical in suspected sepsis to target the underlying infection and prevent its progression. Early antibiotic therapy significantly improves patient outcomes and survival rates.

Question 79: What is a common asthma treatment?

Aspirin
Atropine
Albuterol (Correct answer)
Insulin

Correct answer: Albuterol

Albuterol is a short-acting beta-agonist (SABA) bronchodilator commonly used to treat asthma symptoms. It works by relaxing the smooth muscles in the airways, opening them up and making it easier to breathe. This medication provides rapid relief for acute asthma attacks and is a cornerstone of asthma management.

Question 80: When a ABEM professional faces pressure to compromise professional standards, the BEST response is to:

Document the pressure and uphold professional standards (Correct answer)
Ignore the pressure and continue without reporting
Immediately resign from the position
Comply to maintain workplace relationships

Correct answer: Document the pressure and uphold professional standards

Professionals should document any pressure to compromise standards and continue upholding their professional obligations. Documentation creates a record of the situation while maintaining ethical integrity.

Question 81: Which foundational principle is MOST important for success in the American Board of Emergency Medicine profession?

Maximizing financial returns on every engagement
Specializing in only one narrow area of practice
Maintaining the minimum requirements for certification
Commitment to continuous learning, ethical practice, and quality outcomes (Correct answer)

Correct answer: Commitment to continuous learning, ethical practice, and quality outcomes

Question 82: A patient is bitten by a copperhead snake and develops local swelling to the forearm. Which of the following is the STRONGEST indication for antivenom (Crotalidae polyvalent immune Fab)?

Isolated thrombocytopenia without bleeding
Nausea and vomiting without systemic bleeding
Swelling progressing across one joint boundary (Correct answer)
Bite site pain and erythema only

Correct answer: Swelling progressing across one joint boundary

Rapidly progressive edema crossing joint boundaries indicates significant envenomation and warrants antivenom (CroFab) to prevent compartment syndrome and tissue necrosis.

Question 83: A patient presents with sudden severe 'tearing' back pain, pulsatile abdominal mass, and hypotension. What is the immediate priority?

IV fluids to normalize BP
Emergent vascular surgery consultation and operative repair (Correct answer)
CT angiography to confirm
Aortic ultrasound only

Correct answer: Emergent vascular surgery consultation and operative repair

A ruptured AAA with hemodynamic instability requires immediate operative intervention; delaying for imaging is associated with mortality.

Question 84: A 19-year-old presents with sudden-onset psychosis, orofacial dyskinesias, autonomic instability, and decreased consciousness following a viral illness. Which antibody is most likely responsible?

Anti-MOG antibody
Anti-voltage-gated calcium channel antibody
Anti-Hu antibody
Anti-NMDA receptor antibody (Correct answer)

Correct answer: Anti-NMDA receptor antibody

Anti-NMDA receptor encephalitis presents with psychiatric symptoms, movement disorders, autonomic dysfunction, and decreased consciousness, often following herpes encephalitis or in young women with ovarian teratoma.

Question 85: Which of the following correctly characterizes the Rumack-Matthew nomogram used in acetaminophen toxicity?

It predicts hepatotoxicity risk based on serum level plotted against time post-ingestion (Correct answer)
It is valid for extended-release acetaminophen formulations
It applies to all acetaminophen exposures regardless of time of ingestion
It is used to determine NAC dosing duration

Correct answer: It predicts hepatotoxicity risk based on serum level plotted against time post-ingestion

The Rumack-Matthew nomogram plots serum acetaminophen concentration against hours post-acute ingestion to predict risk of hepatotoxicity and guide NAC treatment.

Question 86: Which medication is first-line for controlling severe hypertension in eclampsia?

Labetalol IV (Correct answer)
Hydralazine
Nifedipine
ACE inhibitors

Correct answer: Labetalol IV

IV labetalol is a first-line agent for acute severe hypertension in pregnancy due to its safety profile and rapid onset.

Question 87: What needle size is typically used for trauma IV access?

30 gauge
10 gauge
22 gauge
14-16 gauge (Correct answer)

Correct answer: 14-16 gauge

In trauma, rapid fluid resuscitation and blood product administration are often critical. Larger bore IV catheters, specifically 14-16 gauge, are preferred because their wider lumen allows for a much faster flow rate of fluids and blood compared to smaller gauges. This enables efficient volume replacement to combat hypovolemic shock.

Question 88: What is priority in head trauma?

Draw labs
Spine and GCS (Correct answer)
Feed patient
Check pulse

Correct answer: Spine and GCS

In head trauma, ensuring cervical spine immobilization is paramount to prevent further neurological injury, as concurrent spinal cord injury is common. Assessing the Glasgow Coma Scale (GCS) is crucial for evaluating the patient's level of consciousness and neurological status, which guides immediate management and helps monitor changes over time. These are critical components of the primary survey in trauma.

Question 89: A 32-year-old presents with visual disturbances, bilateral internuclear ophthalmoplegia, and an episode of transverse myelitis 6 months ago. MRI shows periventricular white matter lesions. What is the most likely diagnosis?

CNS vasculitis
Multiple sclerosis (Correct answer)
Neurosarcoidosis
Anti-NMDA receptor encephalitis

Correct answer: Multiple sclerosis

Multiple sclerosis presents with relapsing-remitting neurological episodes, periventricular demyelinating lesions, and internuclear ophthalmoplegia due to MLF involvement.

Question 90: A patient arrives in hemorrhagic shock after a high-speed MVA. Pelvis is unstable on examination with an 'open book' pattern on X-ray. Despite 2L of IV crystalloid, BP remains 70/40. What is the most immediate intervention?

Bilateral femoral arterial angioembolization
Apply a pelvic binder and activate massive transfusion protocol (Correct answer)
Immediate exploratory laparotomy
Emergent CT angiography of the pelvis

Correct answer: Apply a pelvic binder and activate massive transfusion protocol

A pelvic binder reduces pelvic volume and tamponades venous hemorrhage from the pelvic plexus while MTP addresses the lethal triad of coagulopathy.

Question 91: A pregnant patient at 36 weeks presents with painless vaginal bleeding. Ultrasound shows placenta covering the cervical os. What is the diagnosis?

Placental abruption
Placenta previa (Correct answer)
Uterine rupture
Vasa previa

Correct answer: Placenta previa

Placenta previa is characterized by painless vaginal bleeding with the placenta overlying the cervical os on ultrasound.

Question 92: A ABEM professional discovers a conflict of interest in a current assignment. What is the MOST ethical course of action?

Disclose the conflict immediately and recuse if necessary (Correct answer)
Continue the assignment but document the conflict later
Handle it privately without informing stakeholders
Ignore it if no one else has noticed

Correct answer: Disclose the conflict immediately and recuse if necessary

Ethical standards require immediate disclosure of conflicts of interest. Transparency protects both the professional's integrity and the stakeholders' interests. Recusal may be necessary to maintain objectivity.

Question 93: A patient with end-stage renal disease presents with peaked T-waves, widening QRS, and a sine-wave pattern on ECG. The MOST immediately life-saving treatment is:

Insulin + glucose IV
Kayexalate PO
Calcium gluconate IV (Correct answer)
Sodium bicarbonate IV

Correct answer: Calcium gluconate IV

Calcium gluconate immediately stabilizes the cardiac membrane in severe hyperkalemia, buying time while other measures to lower potassium are implemented.

Question 94: Which ECG finding during SVT suggests the rhythm is atrial flutter rather than AVNRT?

Retrograde P waves immediately after QRS
No visible P waves
Sawtooth flutter waves at 300 bpm in leads II, III, aVF (Correct answer)
Regular narrow QRS complexes

Correct answer: Sawtooth flutter waves at 300 bpm in leads II, III, aVF

Atrial flutter characteristically shows sawtooth flutter waves at approximately 300 bpm (atrial rate) in inferior leads, often with 2:1 AV conduction giving a ventricular rate of 150 bpm.

Question 95: A patient presents with fever, hepatosplenomegaly, and pancytopenia after returning from a tropical trip; a bone marrow biopsy shows macrophages engulfing red blood cells and platelets. What is the diagnosis?

Malignant tertian malaria
Disseminated histoplasmosis
Hemophagocytic lymphohistiocytosis
Visceral leishmaniasis (kala-azar) (Correct answer)

Correct answer: Visceral leishmaniasis (kala-azar)

Visceral leishmaniasis (kala-azar) causes macrophage invasion of the reticuloendothelial system, presenting with fever, massive splenomegaly, and pancytopenia in a returning traveler.

Question 96: An 8-month-old presents with high fever, bulging anterior fontanelle, and irritability. What is the most appropriate next step?

IV antibiotics then lumbar puncture (Correct answer)
Lumbar puncture immediately
Blood cultures only
CT head before lumbar puncture

Correct answer: IV antibiotics then lumbar puncture

IV antibiotics should be administered promptly in suspected bacterial meningitis before LP if signs of elevated ICP are present.

Question 97: A patient presents with tetanus following a puncture wound. Which medication directly addresses the pathophysiology of muscle spasms in tetanus?

Tetanus immune globulin (TIG)
Penicillin G
Benzodiazepines (Correct answer)
Metronidazole

Correct answer: Benzodiazepines

Tetanus toxin blocks inhibitory neurotransmitter release (glycine and GABA), causing muscle spasms best managed with benzodiazepines that enhance GABA activity.

Question 98: A patient has a shotgun wound to the right chest with sucking chest wound. After occlusive dressing placement the patient acutely deteriorates. What is the most likely cause?

Air embolism
Hemothorax
Tension pneumothorax from occluded dressing (Correct answer)
Pulmonary contusion

Correct answer: Tension pneumothorax from occluded dressing

A fully occlusive dressing on an open pneumothorax can convert it to a tension pneumothorax if air cannot escape.

Question 99: A patient falls on a flexed, pronated wrist and presents with dorsal wrist pain. X-ray shows a distal radius fracture with volar angulation and dorsal displacement of the carpus. This fracture pattern is called:

Barton's fracture
Smith's fracture (Correct answer)
Colles' fracture
Chauffeur's fracture

Correct answer: Smith's fracture

Smith's fracture (reverse Colles') involves volar angulation of the distal radius, occurring from a fall on a flexed wrist, in contrast to the dorsal angulation of a Colles' fracture.

Question 100: A patient with a stab wound to zone II of the neck is hemodynamically stable with an expanding hematoma. What is the correct management?

Observation and serial exams
CT angiography of the neck
MRI neck
Immediate surgical exploration (Correct answer)

Correct answer: Immediate surgical exploration

An expanding hematoma in zone II neck trauma indicates vascular injury requiring immediate surgical exploration.

Question 101: A 35-year-old with HIV presents with headache, fever, and altered mental status. CSF shows lymphocytic pleocytosis and India ink staining is positive. What is the treatment?

IV acyclovir
Trimethoprim-sulfamethoxazole
Dexamethasone plus ceftriaxone
Amphotericin B plus flucytosine (Correct answer)

Correct answer: Amphotericin B plus flucytosine

Cryptococcal meningitis in HIV patients is treated with amphotericin B plus flucytosine for induction therapy.

Question 102: What is used to assess stroke?

ABCDE
BLS
APGAR
FAST exam (Correct answer)

Correct answer: FAST exam

The FAST exam (Face drooping, Arm weakness, Speech difficulty, Time to call emergency services) is a widely recognized and simple mnemonic used to quickly assess for common signs of a stroke. This rapid assessment helps identify potential stroke victims, enabling prompt medical attention and improving outcomes. Early recognition and treatment are critical for stroke management.

Question 103: A 70-year-old diabetic male presents with 2 hours of vague epigastric discomfort and diaphoresis. ECG shows new ST elevation in leads II, III, and aVF. The culprit artery is most likely:

Left circumflex
Left main coronary
Left anterior descending
Right coronary artery (Correct answer)

Correct answer: Right coronary artery

ST elevation in inferior leads II, III, and aVF indicates inferior STEMI, most commonly caused by right coronary artery (RCA) occlusion.

Question 104: A patient is found unconscious with empty bottles of amitriptyline and alcohol. ECG shows a QRS of 140 ms and right axis deviation of the terminal 40 ms. What is the most appropriate initial treatment?

Physostigmine 2 mg IV
Sodium bicarbonate 1–2 mEq/kg IV bolus (Correct answer)
Overdrive pacing
Magnesium sulfate 2 g IV

Correct answer: Sodium bicarbonate 1–2 mEq/kg IV bolus

Sodium bicarbonate narrows the QRS in tricyclic antidepressant overdose by increasing serum sodium and alkalinizing the blood, reversing sodium channel blockade.

Question 105: A trauma patient with a suspected diaphragmatic rupture is intubated. Which finding on chest X-ray is most specific?

Left lower lobe atelectasis
Nasogastric tube coiled in left chest (Correct answer)
Elevated hemidiaphragm
Mediastinal shift

Correct answer: Nasogastric tube coiled in left chest

A nasogastric tube visible in the left chest cavity is pathognomonic for left-sided diaphragmatic rupture with gastric herniation.

Question 106: A 35-year-old found after lying on a hard surface for 10 hours presents with diffuse muscle pain, dark urine, and creatinine of 3.1 mg/dL. Urine dipstick is 3+ blood with no RBCs on microscopy. What is the most critical initial treatment?

Sodium bicarbonate IV bolus to alkalinize urine
Aggressive IV fluid resuscitation with isotonic normal saline (Correct answer)
Furosemide 40 mg IV to promote forced diuresis
Urgent hemodialysis initiation

Correct answer: Aggressive IV fluid resuscitation with isotonic normal saline

Aggressive isotonic saline resuscitation targeting urine output of 200-300 mL/hr is the cornerstone of rhabdomyolysis management to prevent myoglobin-induced acute tubular necrosis.

Question 107: A 62-year-old female presents with acute dyspnea, pleuritic chest pain, and leg swelling after a 10-hour flight. D-dimer is elevated. The MOST appropriate next step is:

Empiric anticoagulation and discharge
Lower extremity venous duplex only
CT pulmonary angiography (Correct answer)
V/Q scan

Correct answer: CT pulmonary angiography

CT pulmonary angiography (CTPA) is the gold standard imaging study for diagnosing pulmonary embolism in patients with intermediate-to-high clinical probability.

Question 108: What confirms pneumothorax?

EKG
Blood sugar
Chest x-ray (Correct answer)
Ultrasound

Correct answer: Chest x-ray

A pneumothorax, or collapsed lung, occurs when air leaks into the space between the lung and chest wall, causing the lung to partially or fully collapse. A chest x-ray is the primary diagnostic imaging tool used to confirm a pneumothorax, as it clearly visualizes the presence of air in the pleural space and the collapsed lung tissue.

Question 109: A patient presents with septic shock from suspected gram-negative bacteremia. Which of the following represents the BEST evidence-based initial fluid resuscitation target in the first 3 hours per surviving sepsis guidelines?

1 L boluses until MAP > 65 mmHg, maximum 4 L
Colloid 20 mL/kg to minimize fluid overload
Vasopressors first without fluid bolus
30 mL/kg of crystalloid IV, then reassess (Correct answer)

Correct answer: 30 mL/kg of crystalloid IV, then reassess

The Surviving Sepsis Campaign recommends at least 30 mL/kg of IV crystalloid within the first 3 hours of sepsis-induced hypoperfusion recognition.

Question 110: A child presents with fever, refusal to bear weight, and a painful hip held in flexion and external rotation. Which finding best distinguishes septic arthritis from transient synovitis?

ESR > 40 mm/hr alone
Age of the patient
Duration of symptoms
WBC > 12,000 and fever > 38.5°C (Correct answer)

Correct answer: WBC > 12,000 and fever > 38.5°C

The Kocher criteria (fever >38.5°C, WBC >12,000, ESR >40, non-weight-bearing) help differentiate septic arthritis from transient synovitis.

Question 111: A 50-year-old presents with acute onset severe headache after intercourse. CT and LP are negative for subarachnoid hemorrhage. What is the most likely diagnosis?

Cluster headache
Primary thunderclap headache / coital cephalgia (Correct answer)
Basilar migraine
Cerebral venous sinus thrombosis

Correct answer: Primary thunderclap headache / coital cephalgia

Primary thunderclap headache (coital or exertional cephalgia) can mimic SAH and must be a diagnosis of exclusion after negative workup.

Question 112: A 68-year-old woman presents with acute decompensated heart failure and severe dyspnea. Despite diuretics and nitroglycerin, she remains hypoxic with SpO2 86%. The BEST next step is:

Start dobutamine infusion
Administer IV morphine 4mg
Increase the dose of furosemide
Apply CPAP via non-invasive ventilation (Correct answer)

Correct answer: Apply CPAP via non-invasive ventilation

CPAP reduces work of breathing, improves oxygenation, and decreases preload in acute cardiogenic pulmonary edema, reducing intubation rates.

Question 113: A patient with blunt chest trauma has absent breath sounds on the left and tracheal deviation to the right. BP is 70/40 mmHg. What is the immediate next step?

Intubation
Chest X-ray
Chest tube insertion
Needle decompression at left 2nd ICS MCL (Correct answer)

Correct answer: Needle decompression at left 2nd ICS MCL

Tension pneumothorax causing hemodynamic instability requires immediate needle decompression before imaging.

Question 114: A patient with a known seizure disorder is brought in seizing. He received 4 mg of lorazepam IV and continues to seize at 10 minutes. What is the next intervention?

Load with fosphenytoin or levetiracetam IV (Correct answer)
Proceed directly to intubation and propofol
Administer a second dose of lorazepam 4 mg IV
Administer phenobarbital 20 mg/kg IV

Correct answer: Load with fosphenytoin or levetiracetam IV

After benzodiazepine failure, the next step in status epilepticus management per guidelines is a second-line antiepileptic such as fosphenytoin, valproate, or levetiracetam.

Question 115: A comatose patient has pinpoint pupils, bradycardia, and respiratory depression after being found with empty prescription bottles. What is the antidote?

Flumazenil 0.2 mg IV
Physostigmine 1–2 mg IV slow push
Naloxone 0.4–2 mg IV (Correct answer)
N-acetylcysteine IV

Correct answer: Naloxone 0.4–2 mg IV

The opioid toxidrome (CNS depression, miosis, respiratory depression) is reversed with naloxone, an opioid receptor antagonist.

Question 116: Which foundational principle is MOST important for success in the American Board of Emergency Medicine profession?

Specializing in only one narrow area of practice
Maximizing financial returns on every engagement
Maintaining the minimum requirements for certification
Commitment to continuous learning, ethical practice, and quality outcomes (Correct answer)

Correct answer: Commitment to continuous learning, ethical practice, and quality outcomes

Question 117: A patient presents with ascending flaccid paralysis, areflexia, and respiratory insufficiency 10 days after a gastroenteritis illness. CSF shows elevated protein with normal glucose and no pleocytosis. What is the most appropriate emergency intervention?

Thiamine 100 mg IV and glucose
Intubation and mechanical ventilation if FVC < 20 mL/kg (Correct answer)
High-dose methylprednisolone IV
Plasmapheresis or IVIG

Correct answer: Intubation and mechanical ventilation if FVC < 20 mL/kg

In Guillain-Barré syndrome, the most critical emergency intervention is airway management; intubation is indicated when FVC falls below 20 mL/kg or the patient cannot complete a sentence.

Question 118: Which clinical sign differentiates obstructive shock from distributive shock?

Tachycardia
Cool, clamped extremities with elevated JVP (Correct answer)
Hypotension
Widened pulse pressure

Correct answer: Cool, clamped extremities with elevated JVP

Obstructive shock (e.g., PE, tamponade, tension pneumothorax) presents with elevated JVP and cool extremities due to mechanical obstruction impeding cardiac output.

Question 119: How to treat status epilepticus?

Digoxin
Insulin
Epinephrine
Lorazepam (Correct answer)

Correct answer: Lorazepam

Status epilepticus is a medical emergency characterized by prolonged or recurrent seizures without full recovery of consciousness between episodes. Benzodiazepines, such as lorazepam, are the first-line treatment because they act rapidly to suppress seizure activity by enhancing the effect of GABA, an inhibitory neurotransmitter in the brain.

Question 120: What is the mechanism by which PEEP (positive end-expiratory pressure) improves oxygenation in ARDS?

Increases cardiac output
Recruits collapsed alveoli and prevents derecruitment (Correct answer)
Reduces pulmonary vascular resistance
Increases FiO2 delivery

Correct answer: Recruits collapsed alveoli and prevents derecruitment

PEEP keeps alveoli open at end-expiration, recruits previously collapsed lung units, and improves ventilation-perfusion matching in ARDS.

Question 121: Which statement BEST describes the relationship between American Board of Emergency Medicine certification requirements and industry evolution?

Requirements become less stringent over time
Changes only occur when government mandates new requirements
Requirements evolve periodically to reflect advances in knowledge, technology, and practice standards (Correct answer)
Certification requirements never change once established

Correct answer: Requirements evolve periodically to reflect advances in knowledge, technology, and practice standards

Question 122: A patient on warfarin presents with an INR of 9.8 and active intracranial hemorrhage. Which is the FASTEST and most appropriate reversal strategy?

Fresh frozen plasma 4 units
4-factor prothrombin complex concentrate (4F-PCC) (Correct answer)
Vitamin K 10 mg IV alone
Recombinant factor VIIa

Correct answer: 4-factor prothrombin complex concentrate (4F-PCC)

4-factor PCC reverses warfarin-related INR within minutes, contains all vitamin K-dependent factors, requires small volume, and is superior to FFP for emergent reversal.

Question 123: A patient presents with altered mental status, tachycardia, fever, and a thyroid-stimulating hormone near zero with T4 markedly elevated. What is the diagnosis?

Myxedema coma
Subacute thyroiditis
Thyroid storm (Correct answer)
Sick euthyroid syndrome

Correct answer: Thyroid storm

Thyroid storm is a life-threatening hypermetabolic emergency characterized by hyperthermia, tachycardia, altered mental status, and extremely low TSH.

Question 124: A 28-year-old presents with acute psychosis, severe agitation, hyperthermia, rigidity, and elevated CK after starting haloperidol 3 days ago. What is the most likely diagnosis?

Malignant hyperthermia
Neuroleptic malignant syndrome (Correct answer)
Anticholinergic toxicity
Serotonin syndrome

Correct answer: Neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) presents with hyperthermia, lead-pipe rigidity, altered mental status, and autonomic instability following antipsychotic use.

Question 125: A 35-year-old is restrained in a head-on collision. He presents with his right hip in flexion, adduction, and internal rotation with severe pain. What is the most likely diagnosis?

Anterior hip dislocation
Posterior hip dislocation (Correct answer)
Intertrochanteric hip fracture
Central acetabular fracture-dislocation

Correct answer: Posterior hip dislocation

Posterior hip dislocation, the most common type, presents with the hip flexed, adducted, and internally rotated — the classic 'dashboard injury' pattern.

Question 126: Why reassess after interventions?

Monitor effectiveness (Correct answer)
Check policy
Avoid documentation
Increase workload

Correct answer: Monitor effectiveness

Reassessment after medical interventions is a fundamental principle of patient care. It allows healthcare providers to determine if the treatment administered is having the desired effect and if the patient's condition is improving, worsening, or remaining stable. This continuous monitoring guides further management decisions and ensures optimal patient outcomes.

Question 127: A patient with end-stage renal disease on dialysis presents with shortness of breath, JVD, crackles, and BP 200/110. What is the most appropriate ED treatment?

Beta-blockers only
Nitroglycerin and emergent dialysis (Correct answer)
Furosemide 40 mg IV
Morphine and observation

Correct answer: Nitroglycerin and emergent dialysis

ESRD patients are anuric and unresponsive to diuretics; nitroglycerin for afterload reduction and emergent dialysis is definitive treatment for flash pulmonary edema.

Question 128: How are airborne diseases prevented?

N95 and isolation (Correct answer)
Open windows
Wash hands only
Drink fluids

Correct answer: N95 and isolation

Airborne diseases, such as tuberculosis or measles, are spread through tiny particles that remain suspended in the air. Prevention requires specialized measures like placing infected patients in airborne isolation rooms with negative pressure and healthcare workers wearing N95 respirators. These respirators filter out at least 95% of airborne particles, providing superior protection.

Question 129: A 45-year-old presents with sudden facial drooping involving the forehead, inability to close the eye, and loss of taste on the anterior two-thirds of the tongue. What is the most likely diagnosis?

Central (cortical) stroke affecting CN VII
Bell's palsy (idiopathic peripheral CN VII palsy) (Correct answer)
Acoustic neuroma
Ramsay Hunt syndrome

Correct answer: Bell's palsy (idiopathic peripheral CN VII palsy)

Peripheral CN VII palsy (Bell's palsy) involves upper and lower face including forehead, distinguishing it from central lesions which spare the forehead due to bilateral cortical representation.

Question 130: What distinguishes a American Board of Emergency Medicine certified professional from a non-certified practitioner?

Certification validates competency through standardized assessment against established benchmarks (Correct answer)
There is no meaningful difference in competency
Certified professionals exclusively work in larger organizations
Certified professionals always have more years of experience

Correct answer: Certification validates competency through standardized assessment against established benchmarks

Question 131: A 30-year-old female presents with acute knee injury after pivoting. To test anterior cruciate ligament integrity, which maneuver is performed with the knee at 20-30 degrees of flexion while translating the tibia anteriorly on the femur?

Valgus stress test
Patellar apprehension test
McMurray test
Lachman test (Correct answer)

Correct answer: Lachman test

The Lachman test is the most sensitive clinical test for ACL rupture, performed at 20-30 degrees of flexion to relax the posterior capsule and isolate ACL function.

Question 132: Which of the following is the MOST common cause of massive hemoptysis requiring emergency intervention?

Goodpasture syndrome
Pulmonary embolism
Bronchogenic carcinoma
Bronchiectasis (Correct answer)

Correct answer: Bronchiectasis

Bronchiectasis is the most common cause of massive hemoptysis due to hypertrophied bronchial arteries and recurrent infections.

Question 133: Which of the following is the preferred initial airway management in a patient with suspected C-spine injury and a GCS of 6?

Awake fiberoptic intubation
Surgical cricothyrotomy
Nasotracheal intubation
Orotracheal RSI with inline stabilization (Correct answer)

Correct answer: Orotracheal RSI with inline stabilization

RSI with manual inline cervical stabilization is the standard approach for airway management in trauma patients with suspected C-spine injury.

Question 134: A trauma patient requiring emergent intubation has a full stomach. Which RSI modification reduces aspiration risk?

Rapid sequence with minimal bag-mask ventilation (Correct answer)
Sellick maneuver (cricoid pressure) during bag-mask ventilation
Positioning the patient in reverse Trendelenburg
Pre-oxygenation with BVM at high flow

Correct answer: Rapid sequence with minimal bag-mask ventilation

RSI with succinylcholine or rocuronium minimizes the interval of apnea without bag-mask ventilation to reduce aspiration risk in full stomach.

Question 135: What is the MOST effective way for new ABEM professionals to build competency in their field?

Studying certification materials exclusively
Combining formal education, mentored practice, and ongoing professional development (Correct answer)
Learning entirely through trial and error
Focusing solely on the most advanced topics

Correct answer: Combining formal education, mentored practice, and ongoing professional development

Building professional competency requires a multi-faceted approach: formal education provides foundational knowledge, mentored practice develops applied skills under guidance, and ongoing professional development ensures continuous growth and currency in the field.

Question 136: A patient presents with midepigastric pain radiating to the back, nausea, and elevated lipase 3× the upper limit of normal. What is the cornerstone of initial management?

Nasogastric tube decompression
Urgent cholecystectomy
Immediate ERCP
IV fluid resuscitation and NPO (Correct answer)

Correct answer: IV fluid resuscitation and NPO

Aggressive IV fluid resuscitation and bowel rest are the mainstays of initial acute pancreatitis management.

Question 137: A patient presents with a serum glucose of 40 mg/dL and confusion. The patient is unable to swallow safely. What is the correct treatment?

Subcutaneous insulin
Orange juice PO
Dextrose 50% (D50) IV push (Correct answer)
IM glucagon only if no IV access

Correct answer: Dextrose 50% (D50) IV push

IV D50 is the fastest and most reliable treatment for symptomatic hypoglycemia when the patient cannot safely swallow.

Question 138: What is the PRIMARY ethical obligation of a certified American Board of Emergency Medicine professional regarding confidential information?

Discuss it informally during professional networking
Use it to advance career opportunities
Protect it from unauthorized disclosure at all times (Correct answer)
Share it with colleagues who might benefit

Correct answer: Protect it from unauthorized disclosure at all times

Question 139: A patient presents with locked-in syndrome after a pontine stroke. Which finding would you expect on examination?

Bilateral miosis and pinpoint pupils only
Absence of all brainstem reflexes
Preserved vertical gaze and blinking with quadriplegia (Correct answer)
Decerebrate posturing with intact consciousness

Correct answer: Preserved vertical gaze and blinking with quadriplegia

Locked-in syndrome from ventral pontine lesions spares the midbrain, preserving vertical eye movements and blinking (controlled by CN III/IV and superior colliculus) while causing quadriplegia.

Question 140: A 30-year-old with fever, painless ulcer on the penis, and bilateral inguinal lymphadenopathy is diagnosed with primary syphilis. He has a documented penicillin allergy with anaphylaxis. What is the recommended alternative?

Doxycycline 100 mg BID for 14 days
Ceftriaxone 1 g IM daily for 10 days
Azithromycin 1 g single dose
Desensitization followed by penicillin G benzathine (Correct answer)

Correct answer: Desensitization followed by penicillin G benzathine

Penicillin G benzathine is the only proven treatment for all stages of syphilis; in penicillin-allergic patients with primary syphilis, doxycycline is acceptable but desensitization is preferred in non-pregnant patients with neurosyphilis or pregnancy.

Question 141: A child ingests iron tablets and presents 6 hours later with vomiting, abdominal pain, and bloody diarrhea. Which laboratory finding best indicates systemic iron toxicity?

Leukocytosis > 15,000/µL
Anion gap metabolic acidosis (Correct answer)
Serum iron level > 350 µg/dL
Hyperglycemia

Correct answer: Anion gap metabolic acidosis

An anion gap metabolic acidosis reflects mitochondrial dysfunction from free radical damage and is a marker of systemic iron toxicity requiring deferoxamine.

Question 142: A patient presents with altered mental status, hyperthermia, lead-pipe rigidity, and markedly elevated CPK after starting haloperidol two weeks ago. What distinguishes neuroleptic malignant syndrome (NMS) from serotonin syndrome?

NMS has slower onset and lead-pipe rigidity; SS has rapid onset and clonus/hyperreflexia (Correct answer)
NMS is caused by serotonin excess; SS is caused by dopamine blockade
NMS presents with diarrhea; SS presents with constipation
NMS always has a higher temperature than SS

Correct answer: NMS has slower onset and lead-pipe rigidity; SS has rapid onset and clonus/hyperreflexia

NMS develops over days-weeks with lead-pipe rigidity and lacks the clonus/hyperreflexia of serotonin syndrome, which has rapid onset (hours) after serotonergic drug exposure.

Question 143: When performing a diagnostic peritoneal lavage (DPL), a positive result for blunt abdominal trauma includes which finding?

WBC > 100 cells/µL on lavage return
Amylase > 20 IU/L
RBC > 100,000 cells/µL on lavage return (Correct answer)
Bile on gross inspection only

Correct answer: RBC > 100,000 cells/µL on lavage return

DPL is positive for hemoperitoneum when lavage fluid contains >100,000 RBC/µL in blunt trauma.

Question 144: What is the PRIMARY purpose of obtaining ABEM certification in American Board of Emergency Medicine?

To demonstrate verified competency and adherence to professional standards (Correct answer)
To satisfy a personal achievement goal
To bypass educational requirements
To guarantee employment in the field

Correct answer: To demonstrate verified competency and adherence to professional standards

Question 145: Which type of shock is expected in a patient with blunt cardiac injury causing right ventricular failure after sternal fracture?

Obstructive
Cardiogenic (Correct answer)
Hemorrhagic
Distributive

Correct answer: Cardiogenic

Blunt cardiac injury causing RV dysfunction produces cardiogenic shock due to impaired myocardial pump function.

Question 146: An 80-year-old woman presents with groin pain and inability to bear weight after a fall. Her leg is slightly shortened and externally rotated but plain X-rays are negative. What is the best next imaging step?

Discharge with analgesics and follow-up in 1 week
Technetium bone scan
CT scan of the pelvis
MRI of the hip (Correct answer)

Correct answer: MRI of the hip

MRI is the preferred modality for occult hip fractures when plain radiographs are negative but clinical suspicion is high, offering high sensitivity and no radiation.

Question 147: Which personal protective equipment (PPE) principle applies to ALL ABEM certified professionals regardless of their specific role?

PPE must be properly fitted, maintained, and replaced as needed (Correct answer)
Any PPE will provide adequate protection
PPE is optional if experienced in the field
PPE is only necessary during formal inspections

Correct answer: PPE must be properly fitted, maintained, and replaced as needed

Question 148: What distinguishes a American Board of Emergency Medicine certified professional from a non-certified practitioner?

Certified professionals exclusively work in larger organizations
There is no meaningful difference in competency
Certification validates competency through standardized assessment against established benchmarks (Correct answer)
Certified professionals always have more years of experience

Correct answer: Certification validates competency through standardized assessment against established benchmarks

Question 149: Which of the following ECG findings is MOST specific for right heart strain in pulmonary embolism?

ST depression in V1-V4
Diffuse ST elevation
Left bundle branch block
S1Q3T3 pattern (Correct answer)

Correct answer: S1Q3T3 pattern

The S1Q3T3 pattern (S wave in lead I, Q wave and T-wave inversion in lead III) is the classic but not sensitive ECG finding in PE suggesting right heart strain.

Question 150: A motorcyclist is brought in after a high-speed crash with a GCS of 8, bilateral femur fractures, and BP 80/50. After two large-bore IVs and 2L crystalloid, BP remains 85/55. What is the priority?

Foley catheter insertion
Pelvic binder application only
CT scan of head and abdomen
Activate massive transfusion protocol and FAST exam (Correct answer)

Correct answer: Activate massive transfusion protocol and FAST exam

Persistent hypotension after initial resuscitation warrants MTP activation and bedside FAST to identify hemorrhage source.

Question 151: A 75-year-old female on digoxin presents with nausea, yellow-green visual halos, and bradycardia with a junctional rhythm on ECG. Digoxin toxicity is suspected. The MOST important electrolyte to check and correct is:

Sodium
Phosphate
Calcium
Potassium (Correct answer)

Correct answer: Potassium

Hypokalemia potentiates digoxin toxicity by competing with digoxin for the same Na+/K+ ATPase binding site; correcting potassium is essential.

Question 152: A 30-year-old falls on an outstretched hand and has anatomical snuffbox tenderness. Initial X-rays are negative. What is the most appropriate management?

Thumb spica splint with MRI or repeat X-ray in 1-2 weeks (Correct answer)
Apply cast for 6 weeks without further imaging
CT scan of the wrist immediately
Discharge with wrist splint and routine follow-up in 2 weeks

Correct answer: Thumb spica splint with MRI or repeat X-ray in 1-2 weeks

Anatomical snuffbox tenderness after a FOOSH injury warrants presumptive treatment for occult scaphoid fracture with thumb spica splinting and early MRI or repeat X-ray due to avascular necrosis risk.

Question 153: A patient presents with oliguria, BUN 80, creatinine 6.2 (baseline 1.0), and no urine output for 12 hours. Bladder scan shows 600 mL. What is the next step?

Nephrology consult first
Start hemodialysis
IV furosemide
Foley catheter placement (Correct answer)

Correct answer: Foley catheter placement

Post-renal AKI from bladder outlet obstruction requires immediate Foley catheterization to relieve the obstruction.

Question 154: What indicates respiratory distress?

Cyanosis and effort (Correct answer)
Dry mouth
Itching
Sneezing

Correct answer: Cyanosis and effort

Respiratory distress is characterized by visible signs that indicate difficulty breathing and inadequate oxygenation. Cyanosis, a bluish discoloration of the skin or mucous membranes, signifies low oxygen levels, while increased effort (e.g., nasal flaring, retractions, accessory muscle use) shows the body struggling to breathe. These are critical indicators requiring immediate medical attention.

Question 155: A 22-year-old sustains an anterior shoulder dislocation during a tackle. Which neurovascular structure is most commonly injured in this dislocation?

Axillary nerve (Correct answer)
Brachial artery
Musculocutaneous nerve
Radial nerve

Correct answer: Axillary nerve

The axillary nerve wraps around the surgical neck of the humerus and is the most commonly injured nerve in anterior shoulder dislocations, causing deltoid weakness and lateral shoulder numbness.

Question 156: A 25-year-old develops severe forearm pain after a closed forearm fracture. The pain is disproportionate to injury and worsens with passive finger extension. Compartment pressure measures 35 mmHg with a diastolic BP of 60 mmHg. What is the next step?

IV antibiotics and repeat pressure measurement
Ice, analgesics, and close monitoring
Emergency fasciotomy (Correct answer)
Elevate the extremity and reassess in 2 hours

Correct answer: Emergency fasciotomy

Compartment syndrome is confirmed when pressures are within 30 mmHg of diastolic BP; emergency fasciotomy is the definitive and only treatment.

Question 157: A patient presents after a tonic-clonic seizure. Which finding on history or exam would most urgently warrant a CT head before lumbar puncture?

Post-ictal drowsiness resolving over 20 minutes
Known seizure disorder with breakthrough seizure
New focal neurological deficit with GCS 12 (Correct answer)
Single provoked seizure after alcohol binge

Correct answer: New focal neurological deficit with GCS 12

New focal neurological deficits after seizure may indicate an intracranial mass or hemorrhage; CT must precede LP to rule out herniation risk.

Question 158: What is a FAST exam used for?

Infection
Internal bleeding (Correct answer)
Head trauma
Liver enzymes

Correct answer: Internal bleeding

A FAST (Focused Assessment with Sonography for Trauma) exam is a rapid ultrasound scan performed in emergency settings. Its primary purpose is to quickly identify free fluid, typically blood, in specific body cavities like the pericardium, perihepatic, perisplenic, and pelvic regions. This helps detect significant internal bleeding in trauma patients, guiding immediate management decisions.

Question 159: What distinguishes a American Board of Emergency Medicine certified professional from a non-certified practitioner?

Certification validates competency through standardized assessment against established benchmarks (Correct answer)
Certified professionals always have more years of experience
There is no meaningful difference in competency
Certified professionals exclusively work in larger organizations

Correct answer: Certification validates competency through standardized assessment against established benchmarks

Question 160: In American Board of Emergency Medicine, what is the PRIMARY purpose of conducting regular safety drills and exercises?

To evaluate employee performance reviews
To reduce daily workload
To satisfy insurance requirements only
To ensure personnel can respond effectively in emergencies (Correct answer)

Correct answer: To ensure personnel can respond effectively in emergencies

Regular safety drills ensure that all personnel are prepared to respond effectively during actual emergencies. Practice builds muscle memory, identifies gaps in emergency procedures, and improves overall response times.

Question 161: A 40-year-old squash player hears a 'pop' and feels as if he was kicked in the back of his leg. He cannot plantar flex against resistance. Which test confirms the diagnosis?

Thompson test (calf squeeze test) (Correct answer)
Peroneal provocation test
Tinel sign at the heel
Anterior drawer test of the ankle

Correct answer: Thompson test (calf squeeze test)

A positive Thompson test — absence of plantar flexion when the calf is squeezed with the patient prone — confirms complete Achilles tendon rupture.

Question 162: A 45-year-old new mother presents with radial-sided wrist pain at the base of the thumb that worsens with gripping and pinching. Finkelstein test reproduces her pain. What is the diagnosis?

Carpal tunnel syndrome
Occult scaphoid fracture
De Quervain's tenosynovitis (Correct answer)
First carpometacarpal joint osteoarthritis

Correct answer: De Quervain's tenosynovitis

De Quervain's tenosynovitis is inflammation of the APL and EPB tendons in the first dorsal compartment; Finkelstein's test (thumb in fist with ulnar deviation) is the diagnostic maneuver.

Question 163: Which statement BEST describes the relationship between American Board of Emergency Medicine certification requirements and industry evolution?

Certification requirements never change once established
Requirements evolve periodically to reflect advances in knowledge, technology, and practice standards (Correct answer)
Requirements become less stringent over time
Changes only occur when government mandates new requirements

Correct answer: Requirements evolve periodically to reflect advances in knowledge, technology, and practice standards

Question 164: How does the ABEM body of knowledge relate to daily professional practice?

It is theoretical and has limited practical application
It is relevant only for academic research
It only applies during certification exams
It provides the foundational framework that guides decision-making and standard practices (Correct answer)

Correct answer: It provides the foundational framework that guides decision-making and standard practices

Question 165: A patient with known cirrhosis presents with confusion and asterixis. Ammonia level is elevated. What is the first-line treatment for hepatic encephalopathy?

Hemodialysis
IV neomycin
Protein restriction only
Lactulose and rifaximin (Correct answer)

Correct answer: Lactulose and rifaximin

Lactulose reduces ammonia absorption from the gut, and rifaximin reduces ammonia-producing gut bacteria; both are first-line for hepatic encephalopathy.

Question 166: A 3-year-old presents with refusal to use his right arm after being lifted by his hands. The arm hangs with the elbow slightly flexed and forearm pronated. X-rays are normal. What is the most appropriate management?

Orthopedic consultation for casting
Hyperpronation or supination-flexion reduction technique (Correct answer)
IV sedation with closed reduction under fluoroscopy
Splint in posterior long-arm splint and obtain MRI

Correct answer: Hyperpronation or supination-flexion reduction technique

Nursemaid's elbow (radial head subluxation) is successfully reduced at the bedside using hyperpronation or supination-flexion without anesthesia.

Question 167: A patient presents with right lower quadrant pain, fever, and elevated WBC. CT confirms acute appendicitis without perforation. What is the standard management?

Appendectomy with IV antibiotics (Correct answer)
Colonoscopy to confirm
Antibiotics alone and discharge
Observation only

Correct answer: Appendectomy with IV antibiotics

Acute uncomplicated appendicitis is treated with surgical appendectomy; IV antibiotics are given perioperatively.

Question 168: A 45-year-old woman presents with sudden syncope. ECG shows a prolonged QTc of 520ms and polymorphic VT. The first-line treatment is:

Lidocaine IV
Magnesium sulfate IV (Correct answer)
Synchronized cardioversion
Amiodarone IV

Correct answer: Magnesium sulfate IV

Torsades de pointes (polymorphic VT with prolonged QT) is treated first with IV magnesium sulfate 1-2g regardless of serum magnesium level.

Question 169: During central venous line placement in a trauma patient, which complication is identified by worsening hypoxia, hypotension, and distended neck veins after line insertion?

Catheter-associated DVT
Line sepsis
Air embolism
Iatrogenic tension pneumothorax (Correct answer)

Correct answer: Iatrogenic tension pneumothorax

Pneumothorax complicating subclavian or internal jugular CVC placement can tension if the patient is on positive pressure ventilation.

Question 170: In American Board of Emergency Medicine, what is the PRIMARY purpose of conducting regular safety drills and exercises?

To ensure personnel can respond effectively in emergencies (Correct answer)
To satisfy insurance requirements only
To reduce daily workload
To evaluate employee performance reviews

Correct answer: To ensure personnel can respond effectively in emergencies

Question 171: A 25-year-old with a stab wound to the left chest develops JVD, hypotension, and muffled heart sounds. What procedure is indicated?

Intubation
Needle pericardiocentesis or ED thoracotomy (Correct answer)
Bilateral needle decompression
Chest tube insertion

Correct answer: Needle pericardiocentesis or ED thoracotomy

Beck's triad (JVD, hypotension, muffled heart sounds) indicates cardiac tamponade requiring pericardiocentesis or ED thoracotomy.

Question 172: Why give aspirin in MI?

Lowers temperature
Decreases sugar
Reduces clotting (Correct answer)
For pain only

Correct answer: Reduces clotting

Aspirin is given in cases of myocardial infarction (MI) because it is an antiplatelet agent. It works by inhibiting platelet aggregation, which helps to prevent the formation of new blood clots and reduces the growth of existing clots in the coronary arteries. This action is crucial in limiting heart muscle damage during a heart attack.

Question 173: A 32-year-old sustains a foot injury in a motor vehicle accident. Weight-bearing X-ray reveals a fracture at the base of the second metatarsal with widening between the first and second metatarsals. What injury does this represent?

Dancer's fracture (spiral fifth metatarsal)
Lisfranc tarsometatarsal fracture-dislocation (Correct answer)
Jones fracture of the fifth metatarsal
Navicular stress fracture

Correct answer: Lisfranc tarsometatarsal fracture-dislocation

A fracture at the second metatarsal base is pathognomonic for Lisfranc injury; the second metatarsal base is the keystone of the tarsometatarsal joint complex.

Question 174: In American Board of Emergency Medicine practice, what is the FIRST step when a safety hazard is identified in the workplace?

Immediately secure the area and report the hazard (Correct answer)
Continue working and report at end of shift
Document it for the next safety audit
Wait for a supervisor to notice the issue

Correct answer: Immediately secure the area and report the hazard

When a safety hazard is identified, the immediate priority is to secure the area to prevent injury and report the hazard through proper channels. Delaying action increases the risk of incidents.

Question 175: A 3-year-old presents with sudden-onset choking and unilateral decreased breath sounds. What is the most likely diagnosis?

Asthma exacerbation
Bronchiolitis
Pneumothorax
Foreign body aspiration (Correct answer)

Correct answer: Foreign body aspiration

Sudden choking with unilateral decreased breath sounds in a toddler is foreign body aspiration until proven otherwise.

Question 176: During a difficult airway attempt, the patient becomes apneic and you cannot intubate or ventilate. What is the definitive rescue procedure?

LMA insertion
Nasopharyngeal airway
Transtracheal jet ventilation
Surgical cricothyrotomy (Correct answer)

Correct answer: Surgical cricothyrotomy

Surgical cricothyrotomy is the definitive rescue airway in the cannot-intubate-cannot-oxygenate scenario.

Question 177: A patient with fever and rigors after returning from sub-Saharan Africa has a peripheral blood smear showing ring-form parasites in >5% of RBCs with multiple parasites per RBC. Which malaria species is most likely?

Plasmodium ovale
Plasmodium falciparum (Correct answer)
Plasmodium vivax
Plasmodium malariae

Correct answer: Plasmodium falciparum

Plasmodium falciparum causes high-density parasitemia (>5% RBCs infected), multiple ring forms per cell, and is responsible for cerebral malaria and life-threatening complications.

Question 178: A patient sustains a closed mid-shaft femur fracture after a motor vehicle collision. Approximately how much blood can accumulate in the thigh from this injury?

2500-3000 mL
500-750 mL
250-500 mL
1000-1500 mL (Correct answer)

Correct answer: 1000-1500 mL

A closed femur fracture can cause 1,000-1,500 mL of blood loss into the thigh, enough to precipitate hemorrhagic shock even without external bleeding.

Question 179: What to check before intubation?

Start IV
Check tools (Correct answer)
Call nurse
Give pain meds

Correct answer: Check tools

Before intubation, it is critical to perform a thorough 'check tools' or 'check equipment' step to ensure all necessary equipment is present, functional, and correctly sized. This includes verifying the laryngoscope blade and light, endotracheal tube, stylet, suction, and ventilation device. This preparation prevents delays and complications during the procedure, which can be life-threatening.

Question 180: Which maneuver is used to confirm proper endotracheal tube placement in a trauma patient immediately after intubation?

Chest X-ray alone
Bilateral breath sounds alone
Waveform capnography combined with clinical assessment (Correct answer)
Pulse oximetry

Correct answer: Waveform capnography combined with clinical assessment

Continuous waveform capnography is the gold standard for confirming ETT placement, especially during trauma resuscitation.

Question 181: A scuba diver surfaces too quickly and develops joint pain, dyspnea, and marbling of the skin. Which chamber pressure is used in hyperbaric oxygen therapy for decompression sickness?

2.0 ATA
1.5 ATA
3.5 ATA
2.8 ATA (Correct answer)

Correct answer: 2.8 ATA

US Navy Treatment Table 6 uses 2.8 ATA with 100% oxygen to maximize bubble reabsorption and treat decompression illness.

Question 182: A 65-year-old smoker with known COPD presents in respiratory failure. ABG shows pH 7.22, PaCO2 78, PaO2 52. The MOST appropriate initial ventilatory support is:

Immediate orotracheal intubation
Simple face mask at 10 L/min
Non-invasive positive pressure ventilation (BiPAP) (Correct answer)
High-flow nasal cannula at 60 L/min

Correct answer: Non-invasive positive pressure ventilation (BiPAP)

BiPAP is the preferred initial ventilatory support for COPD exacerbation with hypercapnic respiratory failure as it reduces intubation rates and mortality.

Question 183: Which feature most reliably distinguishes hypertensive encephalopathy from hypertensive urgency without end-organ damage?

Blood pressure level above 220/120 mmHg
Presence of papilledema, encephalopathy, or focal neurological deficits (Correct answer)
Presence of severe headache
Elevated serum creatinine

Correct answer: Presence of papilledema, encephalopathy, or focal neurological deficits

Hypertensive emergency is defined by end-organ damage (encephalopathy, papilledema, focal deficits, AKI, heart failure) rather than a specific blood pressure threshold.

Question 184: What is a symptom of carbon monoxide poisoning?

Fever
Cough
Rash
Headache and confusion (Correct answer)

Correct answer: Headache and confusion

Carbon monoxide (CO) is a colorless, odorless gas that binds to hemoglobin more readily than oxygen, leading to cellular hypoxia. Common symptoms of CO poisoning, often mistaken for flu, include headache, dizziness, nausea, and confusion. Severe poisoning can lead to loss of consciousness, seizures, and death due to oxygen deprivation to vital organs.

Question 185: What documentation is MOST critical to maintain for safety compliance in the American Board of Emergency Medicine field?

Incident reports, training records, and inspection logs (Correct answer)
Client marketing preferences
Employee vacation schedules
Annual revenue reports

Correct answer: Incident reports, training records, and inspection logs

Question 186: What is pulmonary embolism symptom?

Sore throat
Nausea
Rash
Sudden dyspnea (Correct answer)

Correct answer: Sudden dyspnea

Pulmonary embolism (PE) occurs when a blood clot blocks an artery in the lungs, leading to impaired blood flow and oxygen exchange. Sudden onset of dyspnea (shortness of breath) is a classic and often the most prominent symptom of PE, as the body struggles to get enough oxygen. This symptom, especially when acute and unexplained, warrants immediate investigation for PE.

Question 187: In a trauma patient with a suspected thoracic aortic injury after deceleration, which initial imaging study is most appropriate?

Pulmonary arteriography
Transthoracic echocardiogram
MRI thorax
Plain chest X-ray followed by CT angiography of the chest (Correct answer)

Correct answer: Plain chest X-ray followed by CT angiography of the chest

CXR serves as the initial screen; CT angiography is the definitive study for blunt thoracic aortic injury.

Question 188: When conducting a risk assessment for ABEM operations, which factor should receive the HIGHEST priority?

Convenience for daily operations
Time required for safety training
Probability and severity of potential harm (Correct answer)
Cost of implementing safety measures

Correct answer: Probability and severity of potential harm

Question 189: What is the recommended initial fluid bolus for hypotensive trauma patients according to damage control resuscitation principles?

2L lactated Ringer's followed by 2L NS
3L normal saline
1–2L crystalloid then reassess
Immediate blood product transfusion with limited crystalloid (Correct answer)

Correct answer: Immediate blood product transfusion with limited crystalloid

Damage control resuscitation prioritizes early blood products over crystalloid to prevent dilutional coagulopathy and hypothermia.

Question 190: During a resuscitative thoracotomy for penetrating cardiac trauma, you find a laceration to the right ventricle. Which maneuver is most appropriate to control bleeding?

Pulmonary artery clamping
Finger occlusion followed by stapling or suture repair (Correct answer)
Pericardial patch
Aortic cross-clamp only

Correct answer: Finger occlusion followed by stapling or suture repair

Finger occlusion of the ventricular laceration followed by suture or staple repair is the standard initial control technique.

Question 191: An 18-year-old male presents with his third episode of sudden bilateral leg weakness with preserved consciousness, triggered by emotional laughter. EEG is normal during an episode. What is the most likely diagnosis?

Conversion disorder
Absence seizure disorder
Cataplexy associated with narcolepsy (Correct answer)
Transient ischemic attack

Correct answer: Cataplexy associated with narcolepsy

Cataplexy is characterized by sudden bilateral muscle weakness triggered by strong emotions (especially laughter), associated with narcolepsy, with preserved consciousness and normal EEG.

Question 192: A ABEM certified professional is asked to provide services outside their scope of competence. The CORRECT ethical response is to:

Accept and learn as they go
Decline and refer to a qualified professional (Correct answer)
Accept but charge a lower rate
Accept the work to gain new experience

Correct answer: Decline and refer to a qualified professional

Ethical practice requires professionals to work within their scope of competence. Accepting work beyond one's qualifications can lead to substandard results and potential harm. Referring to qualified professionals ensures proper service delivery.

Question 193: During thoracentesis for a large hemothorax, you immediately drain 1,500 mL of blood. What does this finding indicate?

Chylothorax
Normal post-traumatic finding
Massive hemothorax requiring immediate thoracotomy (Correct answer)
Lung laceration only

Correct answer: Massive hemothorax requiring immediate thoracotomy

Immediate drainage of ≥1,500 mL blood (or >200 mL/hr) indicates massive hemothorax requiring operative intervention.

Question 194: A ABEM professional discovers a conflict of interest in a current assignment. What is the MOST ethical course of action?

Ignore it if no one else has noticed
Disclose the conflict immediately and recuse if necessary (Correct answer)
Handle it privately without informing stakeholders
Continue the assignment but document the conflict later

Correct answer: Disclose the conflict immediately and recuse if necessary

Question 195: A patient with history of alcohol use presents with hematemesis. EGD shows actively bleeding esophageal varices. Which medication should be administered immediately?

PPI infusion only
Beta-blockers
IV vasopressin alone
Octreotide IV infusion (Correct answer)

Correct answer: Octreotide IV infusion

Octreotide reduces portal hypertension by inhibiting vasodilatory peptides, and is given as a continuous infusion in acute variceal bleeding.

Question 196: What is the MOST effective way for new ABEM professionals to build competency in their field?

Studying certification materials exclusively
Combining formal education, mentored practice, and ongoing professional development (Correct answer)
Learning entirely through trial and error
Focusing solely on the most advanced topics

Correct answer: Combining formal education, mentored practice, and ongoing professional development

Question 197: What is the MOST important reason for American Board of Emergency Medicine professionals to maintain continuing education?

To increase billing rates
To stay current with evolving standards, practices, and regulations (Correct answer)
To satisfy employer preferences
To accumulate credentials for personal prestige

Correct answer: To stay current with evolving standards, practices, and regulations

Question 198: A patient sustains a crush injury to the left thigh. Six hours later he develops severe calf pain with passive stretch, tense compartments, and paresthesias. Compartment pressure is 38 mmHg and diastolic BP is 65 mmHg. What is the threshold for fasciotomy?

Compartment pressure > 40 mmHg absolute
Compartment pressure > 30 mmHg absolute
Delta pressure (diastolic BP - compartment pressure) < 30 mmHg (Correct answer)
Clinical signs alone regardless of pressure

Correct answer: Delta pressure (diastolic BP - compartment pressure) < 30 mmHg

Fasciotomy is indicated when the delta pressure (diastolic BP minus compartment pressure) falls below 30 mmHg.

Question 199: A patient with known myasthenia gravis presents with worsening dyspnea and inability to swallow after starting ciprofloxacin for a UTI. What is the most likely explanation?

Cholinergic crisis from pyridostigmine overdose
Aspiration pneumonia
Fluoroquinolone-induced myasthenic crisis (Correct answer)
Autonomic neuropathy

Correct answer: Fluoroquinolone-induced myasthenic crisis

Fluoroquinolones, aminoglycosides, and other antibiotics can worsen neuromuscular junction blockade and precipitate myasthenic crisis.

Question 200: Which feature best differentiates Todd's paralysis from an acute ischemic stroke in a patient with post-ictal focal weakness?

Abnormal CT head
Gradual resolution of weakness over minutes to hours (Correct answer)
Elevated blood pressure
Presence of headache

Correct answer: Gradual resolution of weakness over minutes to hours

Todd's paralysis (post-ictal paresis) typically resolves within minutes to hours after a seizure, whereas stroke deficits are persistent.

Question 201: A patient develops diffuse muscle pain, dark urine, and AKI after a severe rattlesnake envenomation. Which complication is most directly responsible for the renal injury?

Direct nephrotoxin in venom
Myoglobinuria from venom-induced rhabdomyolysis (Correct answer)
Hypotension-related ischemia
Disseminated intravascular coagulation

Correct answer: Myoglobinuria from venom-induced rhabdomyolysis

Crotalid venom causes myonecrosis and rhabdomyolysis; the resulting myoglobinuria precipitates in renal tubules and causes acute tubular necrosis.

Question 202: In a patient with suspected tension pneumothorax, what is the IMMEDIATE management?

Chest CT scan
Intubate and ventilate
Obtain chest X-ray first
Needle decompression at 2nd ICS midclavicular line (Correct answer)

Correct answer: Needle decompression at 2nd ICS midclavicular line

Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression without waiting for imaging to prevent cardiac arrest.

Question 203: Which of the following is a reliable clinical feature distinguishing heat stroke from severe heat exhaustion?

Hypotension
Core temperature > 40°C
Diaphoresis
Central nervous system dysfunction (Correct answer)

Correct answer: Central nervous system dysfunction

CNS dysfunction (altered mentation, seizures, coma) is the defining feature of heat stroke and differentiates it from heat exhaustion, where cognition remains intact.

Question 204: A 68-year-old man presents with sudden-onset vertigo, ipsilateral facial numbness, contralateral body numbness, hoarseness, and dysphagia. What is the most likely diagnosis?

Central pontine myelinolysis
Cerebellar hemorrhage
Wallenberg syndrome (lateral medullary syndrome) (Correct answer)
Basilar artery occlusion

Correct answer: Wallenberg syndrome (lateral medullary syndrome)

Wallenberg syndrome results from posterior inferior cerebellar artery (PICA) occlusion causing lateral medullary infarction with crossed sensory deficits and cranial nerve findings.

Question 205: A patient presents with fever, cough, and bilateral hilar lymphadenopathy after disturbing bat guano in an Ohio cave. Bronchoalveolar lavage reveals intracellular yeast within macrophages. What is the treatment for severe pulmonary disease?

Fluconazole 400 mg daily PO
Itraconazole 200 mg TID for 3 days then BID
Amphotericin B lipid complex (Correct answer)
Voriconazole IV loading dose

Correct answer: Amphotericin B lipid complex

Severe or disseminated histoplasmosis requires amphotericin B lipid formulation as initial therapy, followed by step-down to itraconazole after clinical improvement.

Question 206: A 22-year-old is brought in with hyperthermia of 41.2°C, muscle rigidity, diaphoresis, and clonus after starting linezolid while taking sertraline. Which intervention is MOST important to reduce mortality?

Dantrolene 2.5 mg/kg IV
Bromocriptine 2.5 mg PO
Cyproheptadine 12 mg PO
Lorazepam 2 mg IV and active cooling (Correct answer)

Correct answer: Lorazepam 2 mg IV and active cooling

Serotonin syndrome treatment prioritizes benzodiazepines for neuromuscular agitation plus aggressive cooling; cyproheptadine is adjunctive but oral delivery is slower.

Question 207: A 72-year-old nursing home patient presents with gradual cognitive decline, urinary incontinence, and a wide-based magnetic gait. CT shows enlarged ventricles disproportionate to cortical atrophy. What condition should be ruled out?

Multi-infarct dementia
Creutzfeldt-Jakob disease
Alzheimer dementia
Normal pressure hydrocephalus (Correct answer)

Correct answer: Normal pressure hydrocephalus

Normal pressure hydrocephalus presents with the classic triad of gait apraxia, urinary incontinence, and dementia, and is potentially reversible with VP shunting.

Question 208: A newborn delivered in the ED has no spontaneous respirations. After drying and stimulation, the heart rate is 80 bpm. What is the next step?

Intubation only
Chest compressions
IV epinephrine
Positive pressure ventilation (Correct answer)

Correct answer: Positive pressure ventilation

Positive pressure ventilation is indicated when HR is below 100 bpm or respirations are absent after initial newborn stabilization steps.

Question 209: A patient with a gunshot wound to the right upper quadrant has a BP of 90/60 despite 2L NS. FAST shows free fluid in Morison's pouch. What is the next step?

CT abdomen with contrast
IR embolization
Emergent operative laparotomy (Correct answer)
Repeat FAST in 15 minutes

Correct answer: Emergent operative laparotomy

Hemodynamically unstable penetrating abdominal trauma with positive FAST requires emergent surgical intervention.

Question 210: A patient presents in wide-complex tachycardia at 180 bpm, is hemodynamically stable. The rhythm is regular and the QRS morphology is LBBB pattern. The SAFEST initial pharmacologic treatment is:

Verapamil
Adenosine
Metoprolol
Procainamide (Correct answer)

Correct answer: Procainamide

Procainamide is the preferred agent for stable wide-complex tachycardia of uncertain origin; verapamil and other AV nodal blockers can cause deterioration in VT.

Question 211: What is the PRIMARY purpose of obtaining ABEM certification in American Board of Emergency Medicine?

To bypass educational requirements
To guarantee employment in the field
To demonstrate verified competency and adherence to professional standards (Correct answer)
To satisfy a personal achievement goal

Correct answer: To demonstrate verified competency and adherence to professional standards

Question 212: In damage control resuscitation, what ratio of packed red blood cells to fresh frozen plasma to platelets is recommended?

6:4:1
1:1:1 (Correct answer)
2:1:0
4:1:1

Correct answer: 1:1:1

A 1:1:1 ratio of pRBC:FFP:platelets approximates whole blood and is the standard for damage control resuscitation.

Question 213: A neonate is born with a heart rate of 50 bpm and no spontaneous respirations after 30 seconds of PPV. What is the next step?

Start chest compressions and continue PPV (Correct answer)
Intubate only
Continue PPV alone
IV epinephrine immediately

Correct answer: Start chest compressions and continue PPV

Chest compressions are initiated when HR remains below 60 bpm despite 30 seconds of adequate PPV in neonatal resuscitation.

Question 214: A patient with diabetes presents with nausea, vomiting, blood glucose 520 mg/dL, pH 7.20, bicarbonate 10, and ketones positive. What is the most critical initial intervention?

IV fluid resuscitation with normal saline (Correct answer)
Sodium bicarbonate infusion
Dextrose 50% IV
Insulin infusion immediately

Correct answer: IV fluid resuscitation with normal saline

IV fluid resuscitation is the most critical first step in DKA to restore intravascular volume before initiating insulin therapy.

Question 215: What is the MOST effective way for new ABEM professionals to build competency in their field?

Studying certification materials exclusively
Learning entirely through trial and error
Focusing solely on the most advanced topics
Combining formal education, mentored practice, and ongoing professional development (Correct answer)

Correct answer: Combining formal education, mentored practice, and ongoing professional development

Question 216: A pregnant patient at 32 weeks presents with severe headache, BP 168/110, and 3+ proteinuria. What is the diagnosis?

Gestational hypertension
Severe preeclampsia (Correct answer)
HELLP syndrome
Chronic hypertension

Correct answer: Severe preeclampsia

Severe preeclampsia is defined by BP ≥160/110 with proteinuria or other severe features after 20 weeks gestation.

Question 217: Which finding during FAST examination suggests cardiac tamponade?

Right ventricular dilation
Aortic root dilation
Pericardial effusion with diastolic right heart collapse (Correct answer)
Hypokinetic left ventricle

Correct answer: Pericardial effusion with diastolic right heart collapse

Pericardial effusion with diastolic collapse of the right ventricle on FAST indicates tamponade physiology.

Question 218: A patient with known Addison's disease presents with hypotension, weakness, and hyponatremia with hyperkalemia. What is the immediate treatment?

Fludrocortisone alone
IV hydrocortisone and normal saline (Correct answer)
Oral prednisone
Vasopressors first

Correct answer: IV hydrocortisone and normal saline

Adrenal crisis requires immediate IV hydrocortisone (stress-dose) and aggressive IV normal saline to restore volume and cortisol deficiency.

Question 219: A patient with known COPD presents with acute exacerbation. SpO2 is 82%. What is the target oxygen saturation range for this patient?

98-100%
94-98%
88-92% (Correct answer)
80-85%

Correct answer: 88-92%

In COPD patients with chronic hypercapnia, target SpO2 is 88-92% to avoid suppressing the hypoxic drive and worsening hypercapnia.

Question 220: A 25-year-old woman presents with ascending weakness starting in the legs over 3 days, areflexia, and mild autonomic instability. CSF shows albuminocytologic dissociation. What is the priority concern?

Cardiac arrhythmia
Urinary retention
Imminent respiratory failure (Correct answer)
Aspiration pneumonia

Correct answer: Imminent respiratory failure

In Guillain-Barré syndrome, respiratory muscle involvement causing respiratory failure is the most immediately life-threatening complication requiring serial FVC monitoring.

Question 221: A 10-year-old presents with acute onset severe scrotal pain for 2 hours. What is the priority management?

Doppler ultrasound only
Ultrasound then urology consult
Immediate surgical exploration (Correct answer)
Analgesics and observation

Correct answer: Immediate surgical exploration

Testicular torsion requires immediate surgical exploration; time to detorsion directly determines testicular salvage rates.

Question 222: What is the purpose of cervical spine immobilization?

Prevent spine injury (Correct answer)
Lower stress
Monitor BP
Reduce pain

Correct answer: Prevent spine injury

Cervical spine immobilization is crucial in trauma to stabilize the neck and prevent movement of potentially fractured or damaged vertebrae. This stabilization minimizes the risk of further injury to the spinal cord, which could lead to permanent neurological deficits. It's a prophylactic measure to protect the delicate spinal cord from secondary damage.

Question 223: Which foundational principle is MOST important for success in the American Board of Emergency Medicine profession?

Maintaining the minimum requirements for certification
Commitment to continuous learning, ethical practice, and quality outcomes (Correct answer)
Specializing in only one narrow area of practice
Maximizing financial returns on every engagement

Correct answer: Commitment to continuous learning, ethical practice, and quality outcomes

Question 224: A 38-year-old female presents with episodic severe unilateral headache with nausea, photophobia, and a preceding visual aura of a scintillating scotoma. Which medication is most appropriate for acute treatment of a moderate-to-severe attack?

Verapamil 80 mg PO
Acetaminophen 1000 mg PO
Sumatriptan 6 mg SC (Correct answer)
Metoprolol 50 mg PO

Correct answer: Sumatriptan 6 mg SC

Triptans (serotonin 5-HT1B/1D agonists) are first-line for moderate-to-severe migraine attacks; sumatriptan SC has the fastest onset.

Question 225: Which of the following is the MOST appropriate management of severe hypothermia (core temp 25°C) with ventricular fibrillation refractory to three defibrillation attempts?

Administer amiodarone 300 mg IV and shock every 2 minutes
Continue CPR and withhold further shocks until rewarmed to ≥30°C (Correct answer)
Perform urgent cardiopulmonary bypass in the ED
Initiate extracorporeal membrane oxygenation (ECMO) rewarming

Correct answer: Continue CPR and withhold further shocks until rewarmed to ≥30°C

In severe hypothermia, pharmacologic and electrical therapies are largely ineffective below 30°C; CPR should be maintained and rewarming prioritized before repeating defibrillation.

Question 226: Which of the following is the MOST reliable antidote for methanol poisoning in the emergency setting when fomepizole is unavailable?

Sodium bicarbonate bolus
N-acetylcysteine
Pyridoxine IV
Ethanol IV infusion (Correct answer)

Correct answer: Ethanol IV infusion

Ethanol competitively inhibits alcohol dehydrogenase and prevents conversion of methanol to its toxic metabolite formic acid when fomepizole is unavailable.

Question 227: What is suicide risk factor?

Good grades
No insurance
History of attempt (Correct answer)
Sibling illness

Correct answer: History of attempt

A history of previous suicide attempts is one of the strongest predictors and highest risk factors for future suicide. Individuals who have attempted suicide before are at a significantly increased risk of making another attempt, underscoring the importance of recognizing this history and providing ongoing support and intervention.

Question 228: Which risk management approach is MOST effective for ABEM professionals when evaluating potential workplace hazards?

Proactive hazard identification and assessment (Correct answer)
Delegating all safety decisions to management
Relying solely on historical accident data
Reactive analysis after incidents occur

Correct answer: Proactive hazard identification and assessment

Proactive hazard identification and assessment allows professionals to identify and mitigate risks before incidents occur, which is far more effective than reactive approaches that only address problems after they happen.

Question 229: What is the MOST effective way for new ABEM professionals to build competency in their field?

Learning entirely through trial and error
Combining formal education, mentored practice, and ongoing professional development (Correct answer)
Studying certification materials exclusively
Focusing solely on the most advanced topics

Correct answer: Combining formal education, mentored practice, and ongoing professional development

Question 230: Which risk management approach is MOST effective for ABEM professionals when evaluating potential workplace hazards?

Relying solely on historical accident data
Reactive analysis after incidents occur
Proactive hazard identification and assessment (Correct answer)
Delegating all safety decisions to management

Correct answer: Proactive hazard identification and assessment

Question 231: A patient taking metformin presents with lactic acidosis, pH 7.05, lactate 12, and acute renal failure. What is the most effective treatment?

Sodium bicarbonate infusion
IV saline and observation
Hemodialysis (Correct answer)
Activated charcoal

Correct answer: Hemodialysis

Hemodialysis is the definitive treatment for severe metformin-associated lactic acidosis as it removes metformin and corrects acidosis.

Question 232: A ABEM certified professional is asked to provide services outside their scope of competence. The CORRECT ethical response is to:

Decline and refer to a qualified professional (Correct answer)
Accept the work to gain new experience
Accept and learn as they go
Accept but charge a lower rate

Correct answer: Decline and refer to a qualified professional

Question 233: How does the ABEM body of knowledge relate to daily professional practice?

It provides the foundational framework that guides decision-making and standard practices (Correct answer)
It is relevant only for academic research
It is theoretical and has limited practical application
It only applies during certification exams

Correct answer: It provides the foundational framework that guides decision-making and standard practices

Question 234: Which statement BEST describes the relationship between American Board of Emergency Medicine certification requirements and industry evolution?

Requirements evolve periodically to reflect advances in knowledge, technology, and practice standards (Correct answer)
Certification requirements never change once established
Requirements become less stringent over time
Changes only occur when government mandates new requirements

Correct answer: Requirements evolve periodically to reflect advances in knowledge, technology, and practice standards

Question 235: A patient presents with descending flaccid paralysis, dry mouth, diplopia, and ptosis after eating home-canned green beans. Autonomic function is preserved. Which toxin mechanism is responsible?

Blockade of presynaptic acetylcholine release at the neuromuscular junction (Correct answer)
Irreversible inhibition of acetylcholinesterase at the neuromuscular junction
Competitive antagonism of nicotinic receptors
Inhibition of glycine release in the spinal cord

Correct answer: Blockade of presynaptic acetylcholine release at the neuromuscular junction

Botulinum toxin cleaves SNARE proteins, blocking presynaptic acetylcholine vesicle release at the neuromuscular junction, causing flaccid paralysis.

Question 236: A patient with HIV and CD4 count of 60/µL presents with headache, fever, and altered mentation. India ink stain of the CSF is positive. What is the first-line induction therapy?

Fluconazole 400 mg PO daily
Micafungin IV
Amphotericin B deoxycholate + flucytosine (Correct answer)
Voriconazole IV

Correct answer: Amphotericin B deoxycholate + flucytosine

Cryptococcal meningitis induction therapy requires amphotericin B plus flucytosine for at least 2 weeks to achieve fungal clearance before consolidation with fluconazole.

Question 237: A patient with acute STEMI develops cardiogenic shock. After PCI, which medication should be AVOIDED as it may worsen outcomes in this setting?

Heparin
Intra-aortic balloon pump support
High-dose vasopressors as primary treatment without PCI (Correct answer)
Aspirin

Correct answer: High-dose vasopressors as primary treatment without PCI

High-dose vasopressors increase afterload and myocardial oxygen demand; early revascularization with PCI is the priority in cardiogenic shock from STEMI.

Question 238: Which type of aortic dissection (Stanford classification) requires immediate surgical intervention?

Neither; all dissections are managed medically first
Type B dissections only
Both Type A and B equally
Type A dissections involving the ascending aorta (Correct answer)

Correct answer: Type A dissections involving the ascending aorta

Stanford Type A dissections involve the ascending aorta and require emergent surgery due to risk of cardiac tamponade, coronary occlusion, and stroke.

Question 239: A patient presents with a Gustilo type IIIB open tibia fracture with significant soft tissue loss. After hemorrhage control and wound assessment, what is the highest priority in the ED?

Wound irrigation with saline followed by primary closure in the ED
Immediate IV antibiotics and urgent surgical debridement in the OR (Correct answer)
Splinting and outpatient orthopedic follow-up within 24 hours
ORIF in the ED procedure room

Correct answer: Immediate IV antibiotics and urgent surgical debridement in the OR

Open fractures require immediate IV antibiotics (cephalosporin plus aminoglycoside for type III) and urgent operative debridement to prevent osteomyelitis and sepsis.

Question 240: When a ABEM professional faces pressure to compromise professional standards, the BEST response is to:

Document the pressure and uphold professional standards (Correct answer)
Comply to maintain workplace relationships
Immediately resign from the position
Ignore the pressure and continue without reporting

Correct answer: Document the pressure and uphold professional standards

Question 241: A patient on ACE inhibitor presents with serum potassium of 6.8 mEq/L and peaked T-waves on ECG. What is the FIRST treatment to administer?

Sodium bicarbonate IV
Kayexalate
Insulin plus dextrose
Calcium gluconate IV (Correct answer)

Correct answer: Calcium gluconate IV

Calcium gluconate is the first-line treatment in hyperkalemia with ECG changes because it stabilizes the cardiac membrane immediately.

Question 242: A patient presents with narrow-complex tachycardia at 160 bpm, regular rhythm, and hemodynamic stability. Vagal maneuvers fail. What is the FIRST-LINE pharmacologic treatment?

Metoprolol 5mg IV
Diltiazem 0.25 mg/kg IV
Amiodarone 150mg IV
Adenosine 6mg rapid IV push (Correct answer)

Correct answer: Adenosine 6mg rapid IV push

Adenosine 6mg rapid IV push is first-line for stable SVT because it transiently blocks AV nodal conduction and terminates re-entry circuits.

Question 243: A 7-year-old presents with 3 days of fever, hip pain, and refusal to bear weight. WBC is 18,500, ESR 60, CRP 4.8 mg/dL, and temperature 38.9°C — meeting all 4 Kocher criteria. Ultrasound shows an effusion. What is the definitive treatment?

Joint aspiration alone with IV antibiotics
Emergent surgical joint irrigation and debridement (Correct answer)
IV antibiotics alone for 6 weeks
NSAIDs and bed rest with repeat labs in 48 hours

Correct answer: Emergent surgical joint irrigation and debridement

Septic arthritis of the hip requires emergent surgical irrigation and debridement plus antibiotics to prevent articular cartilage destruction and avascular necrosis.

Question 244: A 55-year-old presents with thunderclap headache of maximal intensity at onset. CT head is negative. What is the next most appropriate step?

Discharge with analgesics and neurology follow-up
Perform lumbar puncture to evaluate for xanthochromia (Correct answer)
Order MRI brain without contrast
Start IV dexamethasone

Correct answer: Perform lumbar puncture to evaluate for xanthochromia

A negative CT does not rule out subarachnoid hemorrhage; lumbar puncture to detect xanthochromia is required when CT is negative in the setting of thunderclap headache.

Question 245: A patient with ulcerative colitis presents with >10 bloody stools per day, fever, tachycardia, and Hgb of 8. What is the first management step in the ED?

Oral prednisone and discharge
IV corticosteroids and GI consultation (Correct answer)
Colonoscopy immediately
Oral mesalamine

Correct answer: IV corticosteroids and GI consultation

Severe ulcerative colitis requires hospitalization, IV corticosteroids, and urgent GI consultation to prevent toxic megacolon.

Question 246: A patient with pelvic fracture and hemodynamic instability has a negative FAST. What is the next most appropriate intervention?

CT pelvis with contrast
Pelvic binder application and angioembolization or operative packing (Correct answer)
DPL
Repeat FAST

Correct answer: Pelvic binder application and angioembolization or operative packing

Pelvic binder reduces pelvic volume and hemorrhage; angioembolization or preperitoneal packing addresses arterial and venous bleeding.

Question 247: What is psychosis?

Nausea
Low BP
Muscle cramps
Delusions or hallucinations (Correct answer)

Correct answer: Delusions or hallucinations

Psychosis is a severe mental disorder characterized by a loss of contact with reality. Its hallmark symptoms include delusions (fixed, false beliefs not amenable to change in light of conflicting evidence) and hallucinations (perceiving things that are not actually present, such as hearing voices or seeing things). These symptoms indicate a significant disruption in thought processes and perception.

Question 248: Which scenario represents a violation of the American Board of Emergency Medicine code of professional conduct?

Reporting safety concerns to regulatory authorities
Seeking continuing education beyond minimum requirements
Declining work outside one's area of competence
Misrepresenting qualifications or certification status (Correct answer)

Correct answer: Misrepresenting qualifications or certification status

Question 249: What is the PRIMARY purpose of obtaining ABEM certification in American Board of Emergency Medicine?

To demonstrate verified competency and adherence to professional standards (Correct answer)
To guarantee employment in the field
To bypass educational requirements
To satisfy a personal achievement goal

Correct answer: To demonstrate verified competency and adherence to professional standards

Question 250: A 20-year-old football player receives a direct blow to his shoulder and develops a visible step deformity with elevation of the distal clavicle. Which structures are disrupted in a grade III acromioclavicular separation?

The sternoclavicular ligament complex
Both the acromioclavicular and coracoclavicular ligaments (Correct answer)
Glenohumeral joint capsule and rotator cuff
The supraspinatus and infraspinatus tendons

Correct answer: Both the acromioclavicular and coracoclavicular ligaments

Grade III AC separation involves complete disruption of both the AC and coracoclavicular (conoid and trapezoid) ligaments, allowing complete clavicular elevation.

Question 251: What is the antidote for opioid overdose?

Epinephrine
Digoxin
Naloxone (Correct answer)
Atropine

Correct answer: Naloxone

Naloxone is a specific opioid antagonist that rapidly reverses the effects of opioid overdose. It works by binding to opioid receptors in the brain, displacing opioids and blocking their effects, particularly respiratory depression. This can quickly restore normal breathing and consciousness in someone experiencing an opioid overdose.

Question 252: Which tool is used to stop external bleeding?

Tourniquet (Correct answer)
Bandage
Stethoscope
IV catheter

Correct answer: Tourniquet

A tourniquet is a life-saving device specifically designed to apply circumferential pressure to a limb, thereby occluding arterial blood flow. This extreme pressure is highly effective in stopping severe, life-threatening external bleeding that cannot be controlled by direct pressure alone. While bandages cover wounds, a tourniquet actively stops the hemorrhage.

Question 253: How does the ABEM body of knowledge relate to daily professional practice?

It is relevant only for academic research
It is theoretical and has limited practical application
It only applies during certification exams
It provides the foundational framework that guides decision-making and standard practices (Correct answer)

Correct answer: It provides the foundational framework that guides decision-making and standard practices

ABEM Qualifying Examination (QE)

This exam is the initial certification examination for physicians seeking board certification in Emergency Medicine, assessing broad knowledge of the specialty.

300

Questions

480 min

Time Limit

70%

To Pass

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