ROSH Emergency Medicine Exam Questions
and Correct Answers latest 2025–
2026
A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between his
fingers after returning home from summer camp 1 week ago. He reports several other campers
had similar symptoms. On exam, you note excoriations in the inguinal region and axillae
surrounding scattered, erythematous papules. Which of the following is the most appropriate
treatment?
Ketoconazole
Lindane
Permethrin
Prednisone - -correct answer ( C ) Explanation:
This patient has scabies; a pruritic dermatitis caused by cutaneous infection with the mite
Sarcoptes scabei, var hominis. Scabies is spread by skin-to-skin contact and should be considered
in patients with generalized pruritus, especially when exposure to others with similar symptoms is
reported. The rash of scabies involves papules, which are often excoriated. Burrows are
pathognomonic but not uniformly present. Unless previously infected, pruritus generally takes 3-6
weeks to develop because symptoms are due to delayed (Type IV) sensitivity reaction. The
pruritus is classically worse at night and affects the web spaces of the fingers, flexor aspect of the
wrists, axillae, groin, nipples, and the periumbilical region. Except in cases involving an
immunocompromised host, the scalp and face are generally spared. Diagnosis is clinical but can
be confirmed by placing scrapings collected with a #15 blade scalpel in mineral oil for microscopic
examination. The treatment of choice for primary scabies infection is the application of topical
scabicidal agents, with repeat application in 7 days. The treatment of choice is permethrin 5%
lotion. Individuals affected by scabies should avoid skin-to-skin contact with others. Patients with
typical scabies may return to school or work 24 hours after the first treatment.
An 18-month-old boy presents to the emergency department with worsening shortness of breath.
The parents report he has had a cough, runny nose, and fussiness for the past five days. On exam,
the patient demonstrates subcostal retractions, tachypnea, and diffuse wheezing. The patient is
given an albuterol nebulizer treatment without any improvement of his wheezing. Chest X-ray
does not show any abnormality. Which of the following organisms is the most likely cause of his
symptoms?
Bordetella pertussis
Haemophilus influenzae
,Parainfluenza virus
Respiratory syncytial virus - -correct answer ( D )
Explanation:
The patient has bronchiolitis, which is the most common lower respiratory tract infection in
patients less than two years of age. It remains the leading cause for hospitalization in infants
under one year of age. Bronchiolitis is most commonly caused by respiratory syncytial virus (RSV),
but may be caused by other viral agents. Bronchiolitis is inflammation of the lower respiratory
tract, which involves edema, epithelial cell necrosis, bronchospasm, and increased mucus
production. The resultant lower airway obstruction causes increased work of breathing and
wheezing. Bronchiolitis is a clinical diagnosis based on age under two years old, rhinorrhea,
tachypnea, and wheezing. Unlike asthma or reactive airway disease, there is often no significant
improvement with albuterol. There is often a history of several days of upper respiratory
symptoms, such as rhinorrhea, mild cough, and mild fever. Rapid antigen tests, blood work, and
radiographs are not usually needed. Radiographs may demonstrate hyperinflation and atelectasis,
but do not show any focal infiltrates like with pneumonia. Bronchiolitis is usually self-limited, with
respiratory status typically improving over 2-5 days. Management involves supportive care.
Bronchiolitis - answer>>>
What months of the year contain the peak incidence of RSV in North America? -
answer>>>November to March.
A 76-year-old man presents to the emergency department with shortness of breath and
lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124 beats/minute,
respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended neck veins and
occasional dropped radial beats. His lungs are clear to auscultation, but his heart sounds are
distant. He has some fullness to palpation of the right upper quadrant of his abdomen. Which of
the following is the most appropriate diagnostic test? Bedside echocardiography
Chest radiograph
Computed tomography angiogram of the chest
Electrocardiogram - -correct answer ( A ) Explanation:
This patient presents with a clinical picture consistent with obstructive shock. His distended neck
veins, full right upper quadrant, muffled heart sounds, and hypotension are all consistent with
pericardial tamponade. A pericardial sac slowly accumulating fluid can stretch without obstructing
cardiac function. Tamponade occurs when rapid fluid accumulation results in elevated pressures
that inhibit venous return. This is a dynamic process over the course of the cardiac cycle,
therefore bedside echocardiography is the diagnostic test of choice. Fluid around the heart with
,evidence of right atrial compression and right ventricular diastolic collapse are diagnostic of
pericardial tamponade.
Pericardial Effusion - answer>>>
What is the emergent treatment of pericardial tamponade? - answer>>>Pericardiocentesis.
An 8-year-old African-American girl with a history of sickle cell anemia presents with diffuse pain
consistent with an acute sickle cell pain crisis. While in the emergency department, she develops
acute onset headache, right sided facial droop and right arm weakness. A CT scan confirms the
diagnosis. Which of the following is the next best step in management?
Alteplase
Exchange transfusion
MRI brain
Tranexamic acid - -correct answer ( B ) Explanation:
Cerebrovascular events are a potential complication of sickle cell disease. This patient developed
symptoms concerning for acute ischemic stroke. For pediatric patients with acute ischemic stroke
in the setting of sickle cell disease, exchange transfusion is the treatment of choice. Transfusion
goals include decreasing hemoglobin S levels to less than 30% and obtaining a total hemoglobin
level of 10 g/dL. For adults with acute ischemic stroke in the setting of sickle cell disease, consider
tissue plasminogen activator (tPA). tPA is not indicated or approved for use in pediatric patients
Tranexamic acid (D) is an antifibrinolytic agent used in the management of hemorrhage.
Indications include acute traumatic hemorrhage, intraoperative blood loss, and obstetric
hemorrhage. Tranexamic acid is not used for ischemic events
Manage Sickle Cell - answer>>>
What is the most common bacterial cause of acute chest syndrome in adults with sickle cell
disease? - answer>>>Atypical bacteria such as Chlamydia pneumoniae, Mycoplasma pneumoniae,
Mycoplasma hominis.
Correct Answer ( B ) Explanation:
The patient has atrial fibrillation with rapid ventricular response. Atrial fibrillation results when
multiple areas of the atrial myocardium simultaneously depolarize and contract. As a result, the
atrial walls do not contract in a coordinated fashion, but rather "quiver" or "fibrillate." The
electrocardiographic hallmarks of atrial fibrillation are a narrow, complex, irregularly irregular
rhythm and no discernible P waves. The rate may be slow, normal, or fast. Atrial fibrillation is
, usually associated with ischemic or valvular heart disease, and can also be seen in
cardiomyopathies, myocarditis, and thyrotoxicosis. Patients with atrial fibrillation may be
asymptomatic, or may complain of palpitations, dizziness, lightheadedness, chest pain, or
dyspnea. Patients in whom atrial fibrillation results in a rapid ventricular rate may develop clinical
heart failure due to inadequate ven - answer>>>A 52-year-old man with a history of diabetes
mellitus and hypertension presents to the ED with palpitations and dyspnea that have been
present intermittently over the past week. His vital signs include HR 135 beats/minute, blood
pressure 136/87 mm Hg, RR 15 breaths/minute, and oxygen saturation of 97% on room air. His
electrocardiogram is shown above. Which of the following is the most appropriate initial
management?
Administer intravenous adenosine
Administer intravenous diltiazem
Sedate the patient and perform synchronized cardioversion with 100 joules Transport
the patient to the cardiac catheterization suite
Afib Image - answer>>>
What are options for outpatient anticoagulation for atrial fibrillation? - answer>>>Warfarin or
new oral anticoagulant drugs (e.g., dabigatran, rivaroxaban, apixaban).
A 65-year-old man with a past medical history of hypertension presents to the Emergency
Department with "tearing" chest and abdominal pain radiating towards his back. His blood
pressure is 185/98 mm Hg. Which of the following medications should be administered first?
Aspirin
Esmolol
Heparin
Nitroprusside - -correct answer ( B ) Explanation:
Esmolol is the first line treatment for a hypertensive patient with an aortic dissection.
Ratecontrolling medication (e.g. esmolol) should be given before vasodilators to prevent reflex
tachycardia and subsequent increase in aortic shearing forces. An aortic dissection occurs when
the intima tears allowing blood to cause a false channel and intramural hematoma. If this extends
to the heart it can precipitate myocardial infarction, severe aortic regurgitation, or pericardial
tamponade leading to death. Risk factors include a history of hypertension, collagen vascular
disease or aortic aneurysm, as well as current pregnancy and cocaine use. Based on the Stanford
classification, a dissection is classified as type A if it involves the ascending aorta while a type B
dissection is limited to the descending aorta. Treatment of a type A dissection requires surgical
management while type B dissections are typically managed medically
and Correct Answers latest 2025–
2026
A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between his
fingers after returning home from summer camp 1 week ago. He reports several other campers
had similar symptoms. On exam, you note excoriations in the inguinal region and axillae
surrounding scattered, erythematous papules. Which of the following is the most appropriate
treatment?
Ketoconazole
Lindane
Permethrin
Prednisone - -correct answer ( C ) Explanation:
This patient has scabies; a pruritic dermatitis caused by cutaneous infection with the mite
Sarcoptes scabei, var hominis. Scabies is spread by skin-to-skin contact and should be considered
in patients with generalized pruritus, especially when exposure to others with similar symptoms is
reported. The rash of scabies involves papules, which are often excoriated. Burrows are
pathognomonic but not uniformly present. Unless previously infected, pruritus generally takes 3-6
weeks to develop because symptoms are due to delayed (Type IV) sensitivity reaction. The
pruritus is classically worse at night and affects the web spaces of the fingers, flexor aspect of the
wrists, axillae, groin, nipples, and the periumbilical region. Except in cases involving an
immunocompromised host, the scalp and face are generally spared. Diagnosis is clinical but can
be confirmed by placing scrapings collected with a #15 blade scalpel in mineral oil for microscopic
examination. The treatment of choice for primary scabies infection is the application of topical
scabicidal agents, with repeat application in 7 days. The treatment of choice is permethrin 5%
lotion. Individuals affected by scabies should avoid skin-to-skin contact with others. Patients with
typical scabies may return to school or work 24 hours after the first treatment.
An 18-month-old boy presents to the emergency department with worsening shortness of breath.
The parents report he has had a cough, runny nose, and fussiness for the past five days. On exam,
the patient demonstrates subcostal retractions, tachypnea, and diffuse wheezing. The patient is
given an albuterol nebulizer treatment without any improvement of his wheezing. Chest X-ray
does not show any abnormality. Which of the following organisms is the most likely cause of his
symptoms?
Bordetella pertussis
Haemophilus influenzae
,Parainfluenza virus
Respiratory syncytial virus - -correct answer ( D )
Explanation:
The patient has bronchiolitis, which is the most common lower respiratory tract infection in
patients less than two years of age. It remains the leading cause for hospitalization in infants
under one year of age. Bronchiolitis is most commonly caused by respiratory syncytial virus (RSV),
but may be caused by other viral agents. Bronchiolitis is inflammation of the lower respiratory
tract, which involves edema, epithelial cell necrosis, bronchospasm, and increased mucus
production. The resultant lower airway obstruction causes increased work of breathing and
wheezing. Bronchiolitis is a clinical diagnosis based on age under two years old, rhinorrhea,
tachypnea, and wheezing. Unlike asthma or reactive airway disease, there is often no significant
improvement with albuterol. There is often a history of several days of upper respiratory
symptoms, such as rhinorrhea, mild cough, and mild fever. Rapid antigen tests, blood work, and
radiographs are not usually needed. Radiographs may demonstrate hyperinflation and atelectasis,
but do not show any focal infiltrates like with pneumonia. Bronchiolitis is usually self-limited, with
respiratory status typically improving over 2-5 days. Management involves supportive care.
Bronchiolitis - answer>>>
What months of the year contain the peak incidence of RSV in North America? -
answer>>>November to March.
A 76-year-old man presents to the emergency department with shortness of breath and
lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124 beats/minute,
respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended neck veins and
occasional dropped radial beats. His lungs are clear to auscultation, but his heart sounds are
distant. He has some fullness to palpation of the right upper quadrant of his abdomen. Which of
the following is the most appropriate diagnostic test? Bedside echocardiography
Chest radiograph
Computed tomography angiogram of the chest
Electrocardiogram - -correct answer ( A ) Explanation:
This patient presents with a clinical picture consistent with obstructive shock. His distended neck
veins, full right upper quadrant, muffled heart sounds, and hypotension are all consistent with
pericardial tamponade. A pericardial sac slowly accumulating fluid can stretch without obstructing
cardiac function. Tamponade occurs when rapid fluid accumulation results in elevated pressures
that inhibit venous return. This is a dynamic process over the course of the cardiac cycle,
therefore bedside echocardiography is the diagnostic test of choice. Fluid around the heart with
,evidence of right atrial compression and right ventricular diastolic collapse are diagnostic of
pericardial tamponade.
Pericardial Effusion - answer>>>
What is the emergent treatment of pericardial tamponade? - answer>>>Pericardiocentesis.
An 8-year-old African-American girl with a history of sickle cell anemia presents with diffuse pain
consistent with an acute sickle cell pain crisis. While in the emergency department, she develops
acute onset headache, right sided facial droop and right arm weakness. A CT scan confirms the
diagnosis. Which of the following is the next best step in management?
Alteplase
Exchange transfusion
MRI brain
Tranexamic acid - -correct answer ( B ) Explanation:
Cerebrovascular events are a potential complication of sickle cell disease. This patient developed
symptoms concerning for acute ischemic stroke. For pediatric patients with acute ischemic stroke
in the setting of sickle cell disease, exchange transfusion is the treatment of choice. Transfusion
goals include decreasing hemoglobin S levels to less than 30% and obtaining a total hemoglobin
level of 10 g/dL. For adults with acute ischemic stroke in the setting of sickle cell disease, consider
tissue plasminogen activator (tPA). tPA is not indicated or approved for use in pediatric patients
Tranexamic acid (D) is an antifibrinolytic agent used in the management of hemorrhage.
Indications include acute traumatic hemorrhage, intraoperative blood loss, and obstetric
hemorrhage. Tranexamic acid is not used for ischemic events
Manage Sickle Cell - answer>>>
What is the most common bacterial cause of acute chest syndrome in adults with sickle cell
disease? - answer>>>Atypical bacteria such as Chlamydia pneumoniae, Mycoplasma pneumoniae,
Mycoplasma hominis.
Correct Answer ( B ) Explanation:
The patient has atrial fibrillation with rapid ventricular response. Atrial fibrillation results when
multiple areas of the atrial myocardium simultaneously depolarize and contract. As a result, the
atrial walls do not contract in a coordinated fashion, but rather "quiver" or "fibrillate." The
electrocardiographic hallmarks of atrial fibrillation are a narrow, complex, irregularly irregular
rhythm and no discernible P waves. The rate may be slow, normal, or fast. Atrial fibrillation is
, usually associated with ischemic or valvular heart disease, and can also be seen in
cardiomyopathies, myocarditis, and thyrotoxicosis. Patients with atrial fibrillation may be
asymptomatic, or may complain of palpitations, dizziness, lightheadedness, chest pain, or
dyspnea. Patients in whom atrial fibrillation results in a rapid ventricular rate may develop clinical
heart failure due to inadequate ven - answer>>>A 52-year-old man with a history of diabetes
mellitus and hypertension presents to the ED with palpitations and dyspnea that have been
present intermittently over the past week. His vital signs include HR 135 beats/minute, blood
pressure 136/87 mm Hg, RR 15 breaths/minute, and oxygen saturation of 97% on room air. His
electrocardiogram is shown above. Which of the following is the most appropriate initial
management?
Administer intravenous adenosine
Administer intravenous diltiazem
Sedate the patient and perform synchronized cardioversion with 100 joules Transport
the patient to the cardiac catheterization suite
Afib Image - answer>>>
What are options for outpatient anticoagulation for atrial fibrillation? - answer>>>Warfarin or
new oral anticoagulant drugs (e.g., dabigatran, rivaroxaban, apixaban).
A 65-year-old man with a past medical history of hypertension presents to the Emergency
Department with "tearing" chest and abdominal pain radiating towards his back. His blood
pressure is 185/98 mm Hg. Which of the following medications should be administered first?
Aspirin
Esmolol
Heparin
Nitroprusside - -correct answer ( B ) Explanation:
Esmolol is the first line treatment for a hypertensive patient with an aortic dissection.
Ratecontrolling medication (e.g. esmolol) should be given before vasodilators to prevent reflex
tachycardia and subsequent increase in aortic shearing forces. An aortic dissection occurs when
the intima tears allowing blood to cause a false channel and intramural hematoma. If this extends
to the heart it can precipitate myocardial infarction, severe aortic regurgitation, or pericardial
tamponade leading to death. Risk factors include a history of hypertension, collagen vascular
disease or aortic aneurysm, as well as current pregnancy and cocaine use. Based on the Stanford
classification, a dissection is classified as type A if it involves the ascending aorta while a type B
dissection is limited to the descending aorta. Treatment of a type A dissection requires surgical
management while type B dissections are typically managed medically
