SAEM UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS COMPREHENSIVE
STUDY GUIDE FULL SOLUTION
●● Which of the following is true about myasthenia gravis?
A. It typically presents as an ascending weakness of the peripheral
nervous system.
B. A myasthenic crisis involves an exacerbation of weakness, especially
of respiratory muscles, often necessitating intubation.
C. Weakness improves as the involved muscles are used repeatedly.
D. The "atropine test" is diagnostic when 0.5 mg of atropine is given
intravenously and the patient's symptoms improve within two minutes.
E. Cooling exacerbates the symptoms, and heat alleviates them.
Answer: B. A myasthenic crisis involves an exacerbation of weakness,
especially of respiratory muscles, often necessitating intubation.
The answer is B. Myasthenia gravis is an autoimmune disease that
results from antibodies directed against the acetylcholine receptor
(AChR) at the neuromuscular junction. Destruction of the AchR leads to
fewer receptors available to bind acetylcholine, with a resulting muscle
weakness. Ocular symptoms are usually the first to occur, with diplopia
and ptosis being common. The disease typically worsens as the day
progresses because of repeated use of the muscles involved. Diagnosis is
made with the tensilon test, where edrophonium is given and the
patient's symptoms are observed to transiently improve. The
,administration of atropine is not a diagnostic test. Cooling helps the
symptoms and heat exacerbates them. A myasthenic crisis is a feared
complication. Patients develop respiratory failure requiring intubation,
frequently for prolonged periods.
●● A 36 year old woman on chronic cyclosporine treatment for bilateral
lung transplantation visits the emergency department complaining of
extreme headache, nausea and vomiting. Her exam is notable for BP
239/165, normal cardiac exam, bibasilar pulmonary rales, and 1+ lower
extremity edema. EKG showed asymmetric inverted T-waves in I, aVL,
and V4-6. In an effort to acutely control her blood pressure, which of the
following is TRUE?
A. Hydralazine decreases myocardial oxygen demand by decreasing
afterload and would not be useful in this setting
B. Nitroprusside would be contraindicated in this patient due to its
relatively slow onset of action
C. Nitroglycerin decreases BP by decreasing venous return and cardiac
output
D. Prolonged nitroprusside therapy may potentially cause
methemoglobinemia
E. Esmolol works through both alpha-1 and selective beta-2 blockade
Answer: C. Nitroglycerin decreases BP by decreasing venous return and
cardiac output
The answer is C. Relative to other anti-hypertensive agents,
nitroprusside has an extremely rapid onset of action. Although rare,
,long-term nitroprusside treatment may lead to cyanide toxicity in renal
failure patients secondary to the presence of cyanide as an intermediate
metabolite. A history of long-term cyclosporine treatment suggests this
patient likely has some degree of renal insufficiency.
●● A 14 year-old child presents to the emergency department. His blood
pressure is 210/140. He complains of a headache, nausea, and recent
blurred vision. Of the following choices, the best goal for lowering his
mean arterial blood pressure is to have it drop by:
A. Until symptoms resolve
B. 5% in the first 5-6 hours
C. 25% in the first hour
D. 50% in the first hour
E. To normal for his age in the first hour
Answer: C. 25% in the first hour
The answer is C. A systolic BP of 210 or more, or a diastolic BP of 140
or greater, defines hypertensive urgency. With end-organs symptoms, as
above, the presumptive diagnosis is hypertensive emergency. In
hypertensive emergencies, the goal is to decrease mean arterial blood
pressure by 10-25% within the first hour, thereby alleviating symptoms
while not compromising cerebral perfusion.
●● A 2 year old male is brought to the ED in status epilepticus. He has
not responded to adequate doses of benzodiazepines. Which of the
, following possible causes of a seizure must be evaluated for in the
emergency department?
A. Hypoxia
B. Hypoglycemia
C. Toxic ingestion
D. Head trauma
E. All of the above possible causes must be evaluated for
Answer: E. All of the above possible causes must be evaluated for
The answer is E. Seizures have a number of secondary causes, which
must be identified and corrected before the seizure will end. Hypoxemia
and hypoglycemia are easily detected by pulse oximetry and bedside
measurement of glucose, respectively. Toddlers may ingest many toxins
accidentally, such as INH, tricyclic antidepressants, and camphor.
Trauma must be considered, too, including child abuse. Sickle cell
disease, SLE, and leukemia are some of the medical causes of seizures
and status epilepticus.
●● Shock is defined as:
A. tachycardia
B. hypotension
C. altered mental status
D. hypovolemia
E. inadequate tissue and organ perfusion
CORRECT ANSWERS COMPREHENSIVE
STUDY GUIDE FULL SOLUTION
●● Which of the following is true about myasthenia gravis?
A. It typically presents as an ascending weakness of the peripheral
nervous system.
B. A myasthenic crisis involves an exacerbation of weakness, especially
of respiratory muscles, often necessitating intubation.
C. Weakness improves as the involved muscles are used repeatedly.
D. The "atropine test" is diagnostic when 0.5 mg of atropine is given
intravenously and the patient's symptoms improve within two minutes.
E. Cooling exacerbates the symptoms, and heat alleviates them.
Answer: B. A myasthenic crisis involves an exacerbation of weakness,
especially of respiratory muscles, often necessitating intubation.
The answer is B. Myasthenia gravis is an autoimmune disease that
results from antibodies directed against the acetylcholine receptor
(AChR) at the neuromuscular junction. Destruction of the AchR leads to
fewer receptors available to bind acetylcholine, with a resulting muscle
weakness. Ocular symptoms are usually the first to occur, with diplopia
and ptosis being common. The disease typically worsens as the day
progresses because of repeated use of the muscles involved. Diagnosis is
made with the tensilon test, where edrophonium is given and the
patient's symptoms are observed to transiently improve. The
,administration of atropine is not a diagnostic test. Cooling helps the
symptoms and heat exacerbates them. A myasthenic crisis is a feared
complication. Patients develop respiratory failure requiring intubation,
frequently for prolonged periods.
●● A 36 year old woman on chronic cyclosporine treatment for bilateral
lung transplantation visits the emergency department complaining of
extreme headache, nausea and vomiting. Her exam is notable for BP
239/165, normal cardiac exam, bibasilar pulmonary rales, and 1+ lower
extremity edema. EKG showed asymmetric inverted T-waves in I, aVL,
and V4-6. In an effort to acutely control her blood pressure, which of the
following is TRUE?
A. Hydralazine decreases myocardial oxygen demand by decreasing
afterload and would not be useful in this setting
B. Nitroprusside would be contraindicated in this patient due to its
relatively slow onset of action
C. Nitroglycerin decreases BP by decreasing venous return and cardiac
output
D. Prolonged nitroprusside therapy may potentially cause
methemoglobinemia
E. Esmolol works through both alpha-1 and selective beta-2 blockade
Answer: C. Nitroglycerin decreases BP by decreasing venous return and
cardiac output
The answer is C. Relative to other anti-hypertensive agents,
nitroprusside has an extremely rapid onset of action. Although rare,
,long-term nitroprusside treatment may lead to cyanide toxicity in renal
failure patients secondary to the presence of cyanide as an intermediate
metabolite. A history of long-term cyclosporine treatment suggests this
patient likely has some degree of renal insufficiency.
●● A 14 year-old child presents to the emergency department. His blood
pressure is 210/140. He complains of a headache, nausea, and recent
blurred vision. Of the following choices, the best goal for lowering his
mean arterial blood pressure is to have it drop by:
A. Until symptoms resolve
B. 5% in the first 5-6 hours
C. 25% in the first hour
D. 50% in the first hour
E. To normal for his age in the first hour
Answer: C. 25% in the first hour
The answer is C. A systolic BP of 210 or more, or a diastolic BP of 140
or greater, defines hypertensive urgency. With end-organs symptoms, as
above, the presumptive diagnosis is hypertensive emergency. In
hypertensive emergencies, the goal is to decrease mean arterial blood
pressure by 10-25% within the first hour, thereby alleviating symptoms
while not compromising cerebral perfusion.
●● A 2 year old male is brought to the ED in status epilepticus. He has
not responded to adequate doses of benzodiazepines. Which of the
, following possible causes of a seizure must be evaluated for in the
emergency department?
A. Hypoxia
B. Hypoglycemia
C. Toxic ingestion
D. Head trauma
E. All of the above possible causes must be evaluated for
Answer: E. All of the above possible causes must be evaluated for
The answer is E. Seizures have a number of secondary causes, which
must be identified and corrected before the seizure will end. Hypoxemia
and hypoglycemia are easily detected by pulse oximetry and bedside
measurement of glucose, respectively. Toddlers may ingest many toxins
accidentally, such as INH, tricyclic antidepressants, and camphor.
Trauma must be considered, too, including child abuse. Sickle cell
disease, SLE, and leukemia are some of the medical causes of seizures
and status epilepticus.
●● Shock is defined as:
A. tachycardia
B. hypotension
C. altered mental status
D. hypovolemia
E. inadequate tissue and organ perfusion
