EMERGENCY MEDICINE SAEM EXAM T
PRACTICE AND STUDY GUIDE 2026 SCENARIO
BASED APPLICATION AND EMERGENCY
MEDICINE FRAMEWORK
◉ "A 51-year-old male with long-standing hypertension presents
with abrupt onset of severe chest pain radiating to the back. He
describes a tearing sensation. Vital signs are HR 110, BP 175/105,
RR 20, T 37.4. EKG shows LVH. CBC, electrolytes, BUN/Creatinine are
all normal. CXR is as shown below. What diagnostic test would be
most appropriate for making a definitive diagnosis at this time?
[image shows CXR w/ wide mediastinum]
A. MRI of the thoracic spine
B. Aortogram
C. CT of the chest with IV contrast
D. Esophagram using Gastrograffin".
Answer: "C. CT of the chest with IV contrast
"CT of the chest is the test most often used to confirm the diagnosis
of aortic dissection. CT is readily available in most Emergency
Departments, and has a sensitivity of 83-98% and specificity of 87-
100% for aortic dissection (highest accuracy with helical scans).
,Other benefits associated with the use of CT include the ability to
identify intramural thrombus, pericardial effusion, and potentially
reveal another etiology for the patient's pain. The major
disadvantage of CT is the need for iodinated contrast, which requires
normal renal function.""
◉ "A 60 year old male presented to the emergency department with
chest pain. He subsequently became unresponsive. The monitor
shows the rhythm below. The rhythm is:
[image monomorphic wide QRS tachycardia with no p waves]
A. sinus tachycardia
B. ventricular tachycardia
C. atrial fibrillation with rapid ventricular response
D. atrial flutter".
Answer: "B. ventricular tachycardia
The answer is B. Ventricular tachycardia is wide and complex. It is
distinguished from supraventricular tachycardia by width and
morphology of the QRS complexes. (Though there are numerous
exceptions, supraventricular tachycardias usually exhibit narrow
QRS complexes with morphology similar to that when the patient is
in sinus rhythm.)"
◉ "A 64 year old female presents to the emergency department with
chief complaints of occipital headache and chest pain. Physical
,examination reveals a blood pressure of 200/118 as well as edema
of the optic disk. Of the diagnoses below, the most likely is:
A. hypertensive crisis
B. acute hypertensive (non-emergency/non-urgency) episode
C. hypertensive urgency
D. moderate hypertension
E. white-coat hypertension".
Answer: "A. hypertensive crisis
The answer is A. Elevated blood pressure in the setting of optic disk
edema is a hallmark of malignant hypertension (also known as
hypertensive emergency or hypertensive crisis). While hypertensive
urgency is not consistently defined in the medical literature, this
patient's presentation indicates that there is some end-organ
damage and thus the diagnosis is malignant hypertension. The
white-coat"" syndrome, in which patients' blood pressures are
elevated only in the clinical setting and not at home, has been shown
to account for as many as a fifth of all cases of newly diagnosed
""hypertension."" Understanding of this phenomenom is important
for emergency physicians, since its frequency explains why patients
should not be given a diagnosis of new-onset hypertension based on
E.D. measurements."""
◉ "A 14 year old presents just after smoking crack cocaine and
complains of chest pain. He describes it as sharp and stabbing in the
middle of his chest. His EKG is normal. The intern reads the CXR as
, "negative" but your supervising resident asks you to have another
look (see Figure), after which you make the diagnosis of:
[image: big round heart, black in mediastinum, widened]
photo courtesy of eMedicine.com
A. Pneumonia
B. Aortic dissection
C. Congestive heart failure
D. Pneumomediastinum".
Answer: "D. Pneumomediastinum
The answer is D. Look closely along the right heart border and
mediastinum. There is a thin strip of air. Pneumomediastinum and
pneumopericardium result from Valsalva maneuvers, barotrauma,
asthma, and cocaine inhalation from positive pressure devices. On
physical exam there may be a Hamman's sign or mediastinal crunch
heard over the precordium. Westermark's sign is dilation of
pulmonary vessels proximal to a pulmonary embolism resulting in a
cut-off appearance of the vessel on CXR."
◉ "A 22 year old presents with chest pain and the following EKG:
[image: Septal ST elevations]
PRACTICE AND STUDY GUIDE 2026 SCENARIO
BASED APPLICATION AND EMERGENCY
MEDICINE FRAMEWORK
◉ "A 51-year-old male with long-standing hypertension presents
with abrupt onset of severe chest pain radiating to the back. He
describes a tearing sensation. Vital signs are HR 110, BP 175/105,
RR 20, T 37.4. EKG shows LVH. CBC, electrolytes, BUN/Creatinine are
all normal. CXR is as shown below. What diagnostic test would be
most appropriate for making a definitive diagnosis at this time?
[image shows CXR w/ wide mediastinum]
A. MRI of the thoracic spine
B. Aortogram
C. CT of the chest with IV contrast
D. Esophagram using Gastrograffin".
Answer: "C. CT of the chest with IV contrast
"CT of the chest is the test most often used to confirm the diagnosis
of aortic dissection. CT is readily available in most Emergency
Departments, and has a sensitivity of 83-98% and specificity of 87-
100% for aortic dissection (highest accuracy with helical scans).
,Other benefits associated with the use of CT include the ability to
identify intramural thrombus, pericardial effusion, and potentially
reveal another etiology for the patient's pain. The major
disadvantage of CT is the need for iodinated contrast, which requires
normal renal function.""
◉ "A 60 year old male presented to the emergency department with
chest pain. He subsequently became unresponsive. The monitor
shows the rhythm below. The rhythm is:
[image monomorphic wide QRS tachycardia with no p waves]
A. sinus tachycardia
B. ventricular tachycardia
C. atrial fibrillation with rapid ventricular response
D. atrial flutter".
Answer: "B. ventricular tachycardia
The answer is B. Ventricular tachycardia is wide and complex. It is
distinguished from supraventricular tachycardia by width and
morphology of the QRS complexes. (Though there are numerous
exceptions, supraventricular tachycardias usually exhibit narrow
QRS complexes with morphology similar to that when the patient is
in sinus rhythm.)"
◉ "A 64 year old female presents to the emergency department with
chief complaints of occipital headache and chest pain. Physical
,examination reveals a blood pressure of 200/118 as well as edema
of the optic disk. Of the diagnoses below, the most likely is:
A. hypertensive crisis
B. acute hypertensive (non-emergency/non-urgency) episode
C. hypertensive urgency
D. moderate hypertension
E. white-coat hypertension".
Answer: "A. hypertensive crisis
The answer is A. Elevated blood pressure in the setting of optic disk
edema is a hallmark of malignant hypertension (also known as
hypertensive emergency or hypertensive crisis). While hypertensive
urgency is not consistently defined in the medical literature, this
patient's presentation indicates that there is some end-organ
damage and thus the diagnosis is malignant hypertension. The
white-coat"" syndrome, in which patients' blood pressures are
elevated only in the clinical setting and not at home, has been shown
to account for as many as a fifth of all cases of newly diagnosed
""hypertension."" Understanding of this phenomenom is important
for emergency physicians, since its frequency explains why patients
should not be given a diagnosis of new-onset hypertension based on
E.D. measurements."""
◉ "A 14 year old presents just after smoking crack cocaine and
complains of chest pain. He describes it as sharp and stabbing in the
middle of his chest. His EKG is normal. The intern reads the CXR as
, "negative" but your supervising resident asks you to have another
look (see Figure), after which you make the diagnosis of:
[image: big round heart, black in mediastinum, widened]
photo courtesy of eMedicine.com
A. Pneumonia
B. Aortic dissection
C. Congestive heart failure
D. Pneumomediastinum".
Answer: "D. Pneumomediastinum
The answer is D. Look closely along the right heart border and
mediastinum. There is a thin strip of air. Pneumomediastinum and
pneumopericardium result from Valsalva maneuvers, barotrauma,
asthma, and cocaine inhalation from positive pressure devices. On
physical exam there may be a Hamman's sign or mediastinal crunch
heard over the precordium. Westermark's sign is dilation of
pulmonary vessels proximal to a pulmonary embolism resulting in a
cut-off appearance of the vessel on CXR."
◉ "A 22 year old presents with chest pain and the following EKG:
[image: Septal ST elevations]
