ROSH REVIEW EMERGENCY MEDICINE
ACTUAL EXAM PAPER 2026 QUESTIONS
WITH ANSWERS GRADED A+
◍ T/F: A primary spontaneous pneumothorax is associated with an underlying
lung disease..
Answer: f
◍ A 25-year-old man presents to the emergency department after a gunshot
wound to the chest. He is awake and following commands. His vital signs
are T 97.5°F, BP 89/50 mm Hg, HR 120 bpm, RR 35/min, and oxygen
saturation 87% on a nonrebreather face mask. Jugular venous distension is
present and he has diminished breath sounds on the left. Which of the
following is the next best step in management?
A. Focused assessment with sonography for trauma examination
B. Needle decompression of the chest
C. Pericardiocentesis
D. Upright chest x-ray.
Answer: Correct Answer: (B) Needle decompression of the
chestExplanation:Needle decompression of the chest in the second
intercostal space in the midclavicular line is recommended for emergent
management of a tension pneumothorax. A tension pneumothorax is caused
by a pleural defect that creates a one-way valve so that extrathoracic air
enters the thorax, but is not able to escape. This leads to a mass effect within
the chest and creates tension physiology by shifting mediastinal structures
away from the side of the defect. This can lead to hypotension and shock as
venous structures (e.g., superior vena cava) are compressed, which leads to
reduced preload and eventually obstructive shock. A tension pneumothorax
is a clinical diagnosis, and definitive management should not be delayed to
, obtain imaging. Clinical findings include diminished or absent breath
sounds on the side of the injury, tracheal deviation away from the side of the
injury, and evidence of mediastinal mass effect (e.g., hypotension, jugular
venous distension). As part of the primary survey of any trauma patient,
breathing should be assessed. When a tension pneumothorax is clinically
suspected, appropriate management is immediately indicated before
completing the survey. Management involves needle decompression with a
large bore (i.e., 14 gauge or greater) angiocatheter followed by chest tube
insertion.A focused assessment with sonography for trauma (FAST) exam
(A) is not indicated for diagnosis of a tension pneumothorax, as this is a
clinical diagnosis. A pericardiocentesis (C) is therapeutic for pericardial
effusions resulting in cardiac tamponade. However, breath sounds are
usually equal in cardiac tamponade. The classic triad of hypotension, jugular
venous distension, and muffled heart sounds is present in less than 10% of
cases. An upright chest X-ray (D) delays definitive management.
◍ A 45-year-old woman presents to the emergency department with dysuria
and right flank pain. Her symptoms started 6 days ago with urinary urgency
and dysuria. She developed the flank pain 2 days ago and has associated
chills and nausea. Vital signs are remarkable for a temperature of 37.8°C
(100.04°F), HR 80 bpm, RR 13/min, BP 130/60 mm Hg, and SpO₂ 99%.
What is the most appropriate management of this patient?
A. Ceftriaxone 1 g daily
B. Ciprofloxacin 500 mg twice daily
C. Fosfomycin 3 g once
D. Nitrofurantoin 100 mg twice daily.
Answer: Correct Answer: (B) Ciprofloxacin 500 mg twice
dailyExplanation:Pyelonephritis is an infection of the upper urinary tract,
typically of the renal parenchyma and pelvicalyceal system. Symptoms of
cystitis, such as dysuria and urinary urgency, may be seen on presentation or
may precede the pyelonephritis. Pyelonephritis is differentiated from cystitis
primarily by clinical findings of systemic illness (nausea, vomiting, chills,
fever) associated with flank pain or costovertebral angle tenderness. Patients
, that are otherwise well-appearing without features consistent with sepsis can
be safely discharged on oral antibiotics. Cefpodoxime, fluoroquinolones,
amoxicillin-clavulanate, or trimethoprim-sulfamethoxazole are all
appropriate options depending on local resistance patterns and
sensitivities.Ceftriaxone 1 g daily (A) is the treatment option for patients
with features concerning for sepsis. Prior to the administration of antibiotics,
blood cultures should be obtained. This patient is otherwise well-appearing
without fever or other features consistent with sepsis. Fosfomycin 3 g once
(C) and nitrofurantoin 100 mg twice daily (D) are both treatment options for
uncomplicated cystitis. However, this patient was diagnosed with
pyelonephritis.
◍ A 75-year-old man with a long-standing history of constipation presents to
the ED with abdominal pain for the last 2 days. He also has abdominal
distention, constipation, and inability to pass gas for the last 12 hours. On
examination, the abdomen is distended and tympanitic to percussion. An
upright abdominal X-ray is as shown above. What is the most likely
diagnosis?A) Cecal volvulusB) IntussusceptionC) Irritable bowel
syndromeD) Sigmoid volvulus.
Answer: d
◍ left sided infective endocarditis risk factor.
Answer: acquired valvular disease, congenital heart disease
◍ What patient population is at risk for developing fungal corneal ulcerations?.
Answer: Immunosuppressed individuals.
◍ A 67-year-old man with a history of hypertension and diabetes mellitus
presents to the emergency department with sudden onset left leg weakness.
His examination is notable for 3/5 strength in his left lower extremity as
well as diminished sensation over his left toes, foot, and leg. He has a flat
affect and appears slow in his speech. Which of the following vascular
territories is most likely affected in this patient?A) Left lenticulostriate
arteriesB) Left posterior cerebral arteryC) Right anterior cerebral arteryD)
Right middle cerebral artery.
, Answer: c
◍ Tension Pneumothorax.
Answer: History of chest traumaPE will show diminished or absent breath
sounds, tracheal deviation away from the side of the injury, hypotension,
jugular venous distensionDiagnosis is made clinicallyTreatment is needle
decompression of the chest in the second intercostal space in the
midclavicular line or fifth intercostal space in the midaxillary line followed
by chest tube insertion
◍ Work-UpCT without contrast reveals a biconvex/lens shaped hematoma.
Answer: epidural hematoma
◍ At what age is testicular torsion most likely to occur?.
Answer: There is a bimodal distribution, with peak incidence in the neonate
(within first few days of life) and preadolescence.
◍ Acute Hepatitis.
Answer: HAV: fecal-oral, shellfish, alone (no carrier), asymptomatic,
acuteHBV:HBsAg: active infectionAnti-HBs: recovered or
immunizedAnti-HBc IgM: early marker of infection, positive in window
periodAnti-HBc IgG: best marker for prior HBVHBeAg: high
infectivityAnti-HBeAb: low infectivityHCV: IVDU, chronic, cirrhosis,
carcinoma, carrierHDV: dependent on HBV coinfectionHEV: fecal-oral
(enteric), high mortality rate among pregnant (expectant) patients,
epidemicsHAV and HEV are fecal-oral: “The vowels hit your bowels”HAV
and HBV have preventative vaccine availableAutoimmune hepatitis: young
womenAlcoholic hepatitis: moderate transaminase elevation, AST > ALT
(2:1)Supportive Rx
◍ What is an alternative location for needle decompression?.
Answer: Fourth or fifth intercostal space in the mid-axillary line.
◍ What TBSA is the perineum?.
Answer: 1%
◍ A Ranson criteria score of >7 is associated with what mortality rate?.
ACTUAL EXAM PAPER 2026 QUESTIONS
WITH ANSWERS GRADED A+
◍ T/F: A primary spontaneous pneumothorax is associated with an underlying
lung disease..
Answer: f
◍ A 25-year-old man presents to the emergency department after a gunshot
wound to the chest. He is awake and following commands. His vital signs
are T 97.5°F, BP 89/50 mm Hg, HR 120 bpm, RR 35/min, and oxygen
saturation 87% on a nonrebreather face mask. Jugular venous distension is
present and he has diminished breath sounds on the left. Which of the
following is the next best step in management?
A. Focused assessment with sonography for trauma examination
B. Needle decompression of the chest
C. Pericardiocentesis
D. Upright chest x-ray.
Answer: Correct Answer: (B) Needle decompression of the
chestExplanation:Needle decompression of the chest in the second
intercostal space in the midclavicular line is recommended for emergent
management of a tension pneumothorax. A tension pneumothorax is caused
by a pleural defect that creates a one-way valve so that extrathoracic air
enters the thorax, but is not able to escape. This leads to a mass effect within
the chest and creates tension physiology by shifting mediastinal structures
away from the side of the defect. This can lead to hypotension and shock as
venous structures (e.g., superior vena cava) are compressed, which leads to
reduced preload and eventually obstructive shock. A tension pneumothorax
is a clinical diagnosis, and definitive management should not be delayed to
, obtain imaging. Clinical findings include diminished or absent breath
sounds on the side of the injury, tracheal deviation away from the side of the
injury, and evidence of mediastinal mass effect (e.g., hypotension, jugular
venous distension). As part of the primary survey of any trauma patient,
breathing should be assessed. When a tension pneumothorax is clinically
suspected, appropriate management is immediately indicated before
completing the survey. Management involves needle decompression with a
large bore (i.e., 14 gauge or greater) angiocatheter followed by chest tube
insertion.A focused assessment with sonography for trauma (FAST) exam
(A) is not indicated for diagnosis of a tension pneumothorax, as this is a
clinical diagnosis. A pericardiocentesis (C) is therapeutic for pericardial
effusions resulting in cardiac tamponade. However, breath sounds are
usually equal in cardiac tamponade. The classic triad of hypotension, jugular
venous distension, and muffled heart sounds is present in less than 10% of
cases. An upright chest X-ray (D) delays definitive management.
◍ A 45-year-old woman presents to the emergency department with dysuria
and right flank pain. Her symptoms started 6 days ago with urinary urgency
and dysuria. She developed the flank pain 2 days ago and has associated
chills and nausea. Vital signs are remarkable for a temperature of 37.8°C
(100.04°F), HR 80 bpm, RR 13/min, BP 130/60 mm Hg, and SpO₂ 99%.
What is the most appropriate management of this patient?
A. Ceftriaxone 1 g daily
B. Ciprofloxacin 500 mg twice daily
C. Fosfomycin 3 g once
D. Nitrofurantoin 100 mg twice daily.
Answer: Correct Answer: (B) Ciprofloxacin 500 mg twice
dailyExplanation:Pyelonephritis is an infection of the upper urinary tract,
typically of the renal parenchyma and pelvicalyceal system. Symptoms of
cystitis, such as dysuria and urinary urgency, may be seen on presentation or
may precede the pyelonephritis. Pyelonephritis is differentiated from cystitis
primarily by clinical findings of systemic illness (nausea, vomiting, chills,
fever) associated with flank pain or costovertebral angle tenderness. Patients
, that are otherwise well-appearing without features consistent with sepsis can
be safely discharged on oral antibiotics. Cefpodoxime, fluoroquinolones,
amoxicillin-clavulanate, or trimethoprim-sulfamethoxazole are all
appropriate options depending on local resistance patterns and
sensitivities.Ceftriaxone 1 g daily (A) is the treatment option for patients
with features concerning for sepsis. Prior to the administration of antibiotics,
blood cultures should be obtained. This patient is otherwise well-appearing
without fever or other features consistent with sepsis. Fosfomycin 3 g once
(C) and nitrofurantoin 100 mg twice daily (D) are both treatment options for
uncomplicated cystitis. However, this patient was diagnosed with
pyelonephritis.
◍ A 75-year-old man with a long-standing history of constipation presents to
the ED with abdominal pain for the last 2 days. He also has abdominal
distention, constipation, and inability to pass gas for the last 12 hours. On
examination, the abdomen is distended and tympanitic to percussion. An
upright abdominal X-ray is as shown above. What is the most likely
diagnosis?A) Cecal volvulusB) IntussusceptionC) Irritable bowel
syndromeD) Sigmoid volvulus.
Answer: d
◍ left sided infective endocarditis risk factor.
Answer: acquired valvular disease, congenital heart disease
◍ What patient population is at risk for developing fungal corneal ulcerations?.
Answer: Immunosuppressed individuals.
◍ A 67-year-old man with a history of hypertension and diabetes mellitus
presents to the emergency department with sudden onset left leg weakness.
His examination is notable for 3/5 strength in his left lower extremity as
well as diminished sensation over his left toes, foot, and leg. He has a flat
affect and appears slow in his speech. Which of the following vascular
territories is most likely affected in this patient?A) Left lenticulostriate
arteriesB) Left posterior cerebral arteryC) Right anterior cerebral arteryD)
Right middle cerebral artery.
, Answer: c
◍ Tension Pneumothorax.
Answer: History of chest traumaPE will show diminished or absent breath
sounds, tracheal deviation away from the side of the injury, hypotension,
jugular venous distensionDiagnosis is made clinicallyTreatment is needle
decompression of the chest in the second intercostal space in the
midclavicular line or fifth intercostal space in the midaxillary line followed
by chest tube insertion
◍ Work-UpCT without contrast reveals a biconvex/lens shaped hematoma.
Answer: epidural hematoma
◍ At what age is testicular torsion most likely to occur?.
Answer: There is a bimodal distribution, with peak incidence in the neonate
(within first few days of life) and preadolescence.
◍ Acute Hepatitis.
Answer: HAV: fecal-oral, shellfish, alone (no carrier), asymptomatic,
acuteHBV:HBsAg: active infectionAnti-HBs: recovered or
immunizedAnti-HBc IgM: early marker of infection, positive in window
periodAnti-HBc IgG: best marker for prior HBVHBeAg: high
infectivityAnti-HBeAb: low infectivityHCV: IVDU, chronic, cirrhosis,
carcinoma, carrierHDV: dependent on HBV coinfectionHEV: fecal-oral
(enteric), high mortality rate among pregnant (expectant) patients,
epidemicsHAV and HEV are fecal-oral: “The vowels hit your bowels”HAV
and HBV have preventative vaccine availableAutoimmune hepatitis: young
womenAlcoholic hepatitis: moderate transaminase elevation, AST > ALT
(2:1)Supportive Rx
◍ What is an alternative location for needle decompression?.
Answer: Fourth or fifth intercostal space in the mid-axillary line.
◍ What TBSA is the perineum?.
Answer: 1%
◍ A Ranson criteria score of >7 is associated with what mortality rate?.
