SAEM COMPREHENSIVE EXAM UPDATED QUESTIONS
AND ANSWERS GRADED A+
✔✔A 41 year old man is seen in the emergency department after a street fight where he
punched another man in the mouth. He has a small, jagged laceration over the dorsum
of the metacarpophalangeal joint of his right hand. The wound is irrigated copiously,
tetanus is given, and the wound is left open to heal by secondary intention because of
the infection risk. In addition to treating Streptococcus and Staphylococcus species,
antibiotics must also treat which other bacterial species?
A. Escherichia. coli
B. Actinomyces israelii
C. Eikenella corrodens
D. Pasteurella multocida - ✔✔C. Eikenella corrodens
The answer is C. There are many species of bacteria in the human mouth, and
Eikenella corrodens is an aggressive one, frequently causing infection in the first 24
hours after injury.
✔✔A young male patient presented to the emergency department with a history of
single gunshot wound from unknown source and caliber. He was hemodynamically
stable and had little pain in the right lower quadrant of the abdomen, which was the site
of two wounds about 6 inches apart (see Figure). No other wounds were identified
during physical examination. Which of the following statements regarding this case is
true?
[image]
A. The superior-medial wound (at the top right of the Figure) is likely the entrance
wound, and the inferior-lateral wound is likely the exit wound, of a single missile
B. If it is suspected that the two wounds are from the same missile, the emergency
department physician's documentation should note which wound is the entrance, and
which is the exit
C. Wound description is essential for the emergency medicine specialist. However,
description of a wound as to entrance or exit is best left to forens - ✔✔C. Wound
description is essential for the emergency medicine specialist. However, description of a
wound as to entrance or exit is best left to forensic examination.
The answer is C. The overall evidence points to a superior-medial to inferior-lateral
wound trajectory, with subcutaneous ecchymosis indicating the missile track and the
more ragged wound at the inferior-lateral (groin) region most likely an exit wound.
However, though wound description is very important for the emergency physician (both
as a guide to injury evaluation and also as an early characterization of wounds, before
interventions such as wound exploration obscure physical findings), speculation as to
whether wounds are entrance or exit wounds are best left off of the E.D. record.
Clinicians tend to oversimplify and/or misinterpret physical wound characteristics. Thus,
the best course is a meticulous description (or photograph) of the wound, noting items
such as tattooing (i.e. of gunpowder) or stellate tissue destruction (which can be due to
expansion of gun barrel gases in a contact wound) but leaving interpretation of the
,physical evidence to forensics experts. The wound characteristics are not consistent
with self-inflicted injury, though the ED physician should have a low index of suspicion
for psychiatric consultation when there is doubt on this subject.
✔✔A patient presents to the ED after a fall with chest pain. A chest xray shows a rib
fracture but no pneumothorax, and a chest CT is ordered. What is the most appropriate
treatment for a small pneumothorax, detected only on chest CT, in a hemodynamically
stable trauma patient?
A. 100% oxygen
B. Heliox by face mask
C. Immediate needle decompression
D. Chest tube placement - ✔✔A. 100% oxygen
The answer is A. An occult pneumothorax may resorb with only oxygen administration,
not requiring invasive management. Needle decompression is used for tension
pneumothorax, and heliox may be used for reactive airway disease to reduce resistance
to flow.
✔✔You are practicing in a trauma center a receive a call from an outlying facility that
they would like to transfer a male patient to you with a spinal cord injury after significant
flexion and compression of the vertebral body. What does this injury pattern tell you
about the patient's symptoms?
[image]
Figure used with permission from Hamilton et al, Emergency Medicine: An approach to
clinical problem-solving
A. The patient likely has symptoms on only one side of the his body
B. Patients with anterior cord syndromes have only sensory symptoms
C. The patient likely disproportionately greater weakness in the lower extremities (as
compared to the upper extremities)
D. The patient likely has paralysis and loss of sensation to pain and temperature
bilaterally below the lesion - ✔✔D. The patient likely has paralysis and loss of sensation
to pain and temperature bilaterally below the lesion
The answer is D. Answer A describes central cord syndrome, typically caused by
hyperextension. Answer C describes Brown-Sequard Syndrome, caused by
hemisection of the cord. Answer B is anterior cord, often caused by flexion and injury to
the anterior spinal artery; patient with this cord syndrome often have more than just
sensory symptoms.
✔✔A trauma patient resuscitated in the ED, has a post-tube thoracostomy computed
tomography (CT) scan as depicted in the figure. What finding is present?
[image]
A. Pericardial tamponade
B. Aortic rupture leading to a right hemothorax
,C. Chest tube not within the thoracic cavity
D. Persistent pneumothorax - ✔✔D. Persistent pneumothorax
The answer is D. The chest CT shows a chest tube in place on the right, with
incomplete reinflation of the lung. The left hemithorax is grossly normal, but there is a
large right pulmonary contusion, as well as pneumothorax and small hemothorax on the
right. The aorta appears intact (aortic injuries usually leak into the left hemithorax, not
the right).
✔✔In differentiating high voltage electrical injury from lightning injury, which of the
following is your best discriminator?
A. Deep burns
B. Fractures or dislocations
C. Loss of consciousness
D. Cardiac arrest - ✔✔A. Deep burns
The answer is A. Patients with high voltage injury commonly present with devastating
burns. The burns are most severe at the source and ground contact points. The most
common sites of contact with the source include the hands and the skull. The most
common areas of ground contact are the heels. Deep burns occur in less than 5% of
lightning injuries. Electrical injuries may cause four types of superficial burns or skin
changes: linear burns, punctate burns, feathering, or thermal burns. Loss of
consciousness, cardiac arrest and orthopedic injuries can be seen in both high voltage
electrical injury and lightning injury. Electrolyte abnormalities are not common in either
injury.
✔✔Using the rule of 9s, what is the approximate burn surface area of a victim who has
sustained second-degree burns to the anterior chest and anterior area of both arms?
A. 20%
B. 25%
C. 30%
D. 35% - ✔✔B. 25%
✔✔A right-handed patient sustains a circumferential burn (see figure) to the distal right
forearm and hand, which is cool despite warm ambient temperature. Regarding the
initial assessment and management of the patient, which of the following is correct?
[image]
A. As shown in the Figure, the burn represents about 10% of total body surface area
B. Pain medication should be withheld pending obtaining operative consent for
emergency burn debridement
C. Prophylactic penicillin should be given to any patient with a significant burn
D. The involved areas of this 3rd-degree burn would be expected to be mostly
insensate - ✔✔D. The involved areas of this 3rd-degree burn would be expected to be
mostly insensate
, The answer is D. The answer is D. 3rd-degree burns are often insensate; withholding
pain medication is not necessary; one hand is about 2-3% TBSA, and prophylactic
antibiotics are not recommended.
✔✔A 25 year old male is brought to the emergency department by his family, with a
complaint of feeling depressed for the past week. In obtaining the history, which of the
following statements regarding this patient would support a diagnosis of major
depression?
A. The screening mnemonic in SAD CAGES is negative
B. The patient has no history of medical illness
C. There is no family history of depression
D. The patient has a history of Crohn's disease - ✔✔D. The patient has a history of
Crohn's disease
The answer is D. In SAD CAGES is a screening mnemonic for symptoms, not causes,
of major depression. Depression is more common in patients with history of other
medical illnesses, some of which may actually cause depressive symptoms. As
compared with major depression, dysthymic disorder is a more chronic, and less
severe, form of depressive illness.
✔✔A 42 year old male with end stage liver disease due to chronic hepatitis C infection
arrives to the emergency department in stable condition after an unsuccessful suicide
attempt by bilateral wrist laceration. He reports no history of depression or psychiatric
disorder. Aside from his liver disease, for which he takes interferon alpha and ribavirin,
he reports that he is in good health and takes no other medications. Which of the
following factors increased this patient's risk of new-onset suicidal ideation?
A. end-stage liver disease
B. chronic hepatitis C infection
C. ribavirin therapy
D. interferon alfa therapy - ✔✔D. interferon alfa therapy
The answer is D. Interferon alfa, an important cytokine in the early immune response to
viral infection, has both antiproliferative and antiviral properties. It is the only therapy
approved by the Food and Drug Administration for hepatitis C infection. Interferon alfa
has been associated with high rates of central nervous system side effects, including
anhedonia, fatigue, anorexia, impaired concentration, sleep disturbance, and suicidal
ideation. Clinicians should always look up the side effects of their patients' medications,
especially unfamiliar drugs. This can both expedite diagnosis of drug-induced
complications and prevent them with appropriate pretreatment. Pretreatment with a
selective serotonin reuptake inhibitor appears to be an effective strategy to minimize
depression induced by interferon alfa. Chronic hepatitis C infection and end-stage liver
disease can both be difficult diseases to live with, however, these conditions are not
known to significantly increase a patients' risk for new suicidal ideation. Depression is
not a known side effect of ribavirin treatment. Although males have a higher percentage
of successful suicide attempt than females, females have a much higher incidence of
suicide attempt and ideation than males overall.
AND ANSWERS GRADED A+
✔✔A 41 year old man is seen in the emergency department after a street fight where he
punched another man in the mouth. He has a small, jagged laceration over the dorsum
of the metacarpophalangeal joint of his right hand. The wound is irrigated copiously,
tetanus is given, and the wound is left open to heal by secondary intention because of
the infection risk. In addition to treating Streptococcus and Staphylococcus species,
antibiotics must also treat which other bacterial species?
A. Escherichia. coli
B. Actinomyces israelii
C. Eikenella corrodens
D. Pasteurella multocida - ✔✔C. Eikenella corrodens
The answer is C. There are many species of bacteria in the human mouth, and
Eikenella corrodens is an aggressive one, frequently causing infection in the first 24
hours after injury.
✔✔A young male patient presented to the emergency department with a history of
single gunshot wound from unknown source and caliber. He was hemodynamically
stable and had little pain in the right lower quadrant of the abdomen, which was the site
of two wounds about 6 inches apart (see Figure). No other wounds were identified
during physical examination. Which of the following statements regarding this case is
true?
[image]
A. The superior-medial wound (at the top right of the Figure) is likely the entrance
wound, and the inferior-lateral wound is likely the exit wound, of a single missile
B. If it is suspected that the two wounds are from the same missile, the emergency
department physician's documentation should note which wound is the entrance, and
which is the exit
C. Wound description is essential for the emergency medicine specialist. However,
description of a wound as to entrance or exit is best left to forens - ✔✔C. Wound
description is essential for the emergency medicine specialist. However, description of a
wound as to entrance or exit is best left to forensic examination.
The answer is C. The overall evidence points to a superior-medial to inferior-lateral
wound trajectory, with subcutaneous ecchymosis indicating the missile track and the
more ragged wound at the inferior-lateral (groin) region most likely an exit wound.
However, though wound description is very important for the emergency physician (both
as a guide to injury evaluation and also as an early characterization of wounds, before
interventions such as wound exploration obscure physical findings), speculation as to
whether wounds are entrance or exit wounds are best left off of the E.D. record.
Clinicians tend to oversimplify and/or misinterpret physical wound characteristics. Thus,
the best course is a meticulous description (or photograph) of the wound, noting items
such as tattooing (i.e. of gunpowder) or stellate tissue destruction (which can be due to
expansion of gun barrel gases in a contact wound) but leaving interpretation of the
,physical evidence to forensics experts. The wound characteristics are not consistent
with self-inflicted injury, though the ED physician should have a low index of suspicion
for psychiatric consultation when there is doubt on this subject.
✔✔A patient presents to the ED after a fall with chest pain. A chest xray shows a rib
fracture but no pneumothorax, and a chest CT is ordered. What is the most appropriate
treatment for a small pneumothorax, detected only on chest CT, in a hemodynamically
stable trauma patient?
A. 100% oxygen
B. Heliox by face mask
C. Immediate needle decompression
D. Chest tube placement - ✔✔A. 100% oxygen
The answer is A. An occult pneumothorax may resorb with only oxygen administration,
not requiring invasive management. Needle decompression is used for tension
pneumothorax, and heliox may be used for reactive airway disease to reduce resistance
to flow.
✔✔You are practicing in a trauma center a receive a call from an outlying facility that
they would like to transfer a male patient to you with a spinal cord injury after significant
flexion and compression of the vertebral body. What does this injury pattern tell you
about the patient's symptoms?
[image]
Figure used with permission from Hamilton et al, Emergency Medicine: An approach to
clinical problem-solving
A. The patient likely has symptoms on only one side of the his body
B. Patients with anterior cord syndromes have only sensory symptoms
C. The patient likely disproportionately greater weakness in the lower extremities (as
compared to the upper extremities)
D. The patient likely has paralysis and loss of sensation to pain and temperature
bilaterally below the lesion - ✔✔D. The patient likely has paralysis and loss of sensation
to pain and temperature bilaterally below the lesion
The answer is D. Answer A describes central cord syndrome, typically caused by
hyperextension. Answer C describes Brown-Sequard Syndrome, caused by
hemisection of the cord. Answer B is anterior cord, often caused by flexion and injury to
the anterior spinal artery; patient with this cord syndrome often have more than just
sensory symptoms.
✔✔A trauma patient resuscitated in the ED, has a post-tube thoracostomy computed
tomography (CT) scan as depicted in the figure. What finding is present?
[image]
A. Pericardial tamponade
B. Aortic rupture leading to a right hemothorax
,C. Chest tube not within the thoracic cavity
D. Persistent pneumothorax - ✔✔D. Persistent pneumothorax
The answer is D. The chest CT shows a chest tube in place on the right, with
incomplete reinflation of the lung. The left hemithorax is grossly normal, but there is a
large right pulmonary contusion, as well as pneumothorax and small hemothorax on the
right. The aorta appears intact (aortic injuries usually leak into the left hemithorax, not
the right).
✔✔In differentiating high voltage electrical injury from lightning injury, which of the
following is your best discriminator?
A. Deep burns
B. Fractures or dislocations
C. Loss of consciousness
D. Cardiac arrest - ✔✔A. Deep burns
The answer is A. Patients with high voltage injury commonly present with devastating
burns. The burns are most severe at the source and ground contact points. The most
common sites of contact with the source include the hands and the skull. The most
common areas of ground contact are the heels. Deep burns occur in less than 5% of
lightning injuries. Electrical injuries may cause four types of superficial burns or skin
changes: linear burns, punctate burns, feathering, or thermal burns. Loss of
consciousness, cardiac arrest and orthopedic injuries can be seen in both high voltage
electrical injury and lightning injury. Electrolyte abnormalities are not common in either
injury.
✔✔Using the rule of 9s, what is the approximate burn surface area of a victim who has
sustained second-degree burns to the anterior chest and anterior area of both arms?
A. 20%
B. 25%
C. 30%
D. 35% - ✔✔B. 25%
✔✔A right-handed patient sustains a circumferential burn (see figure) to the distal right
forearm and hand, which is cool despite warm ambient temperature. Regarding the
initial assessment and management of the patient, which of the following is correct?
[image]
A. As shown in the Figure, the burn represents about 10% of total body surface area
B. Pain medication should be withheld pending obtaining operative consent for
emergency burn debridement
C. Prophylactic penicillin should be given to any patient with a significant burn
D. The involved areas of this 3rd-degree burn would be expected to be mostly
insensate - ✔✔D. The involved areas of this 3rd-degree burn would be expected to be
mostly insensate
, The answer is D. The answer is D. 3rd-degree burns are often insensate; withholding
pain medication is not necessary; one hand is about 2-3% TBSA, and prophylactic
antibiotics are not recommended.
✔✔A 25 year old male is brought to the emergency department by his family, with a
complaint of feeling depressed for the past week. In obtaining the history, which of the
following statements regarding this patient would support a diagnosis of major
depression?
A. The screening mnemonic in SAD CAGES is negative
B. The patient has no history of medical illness
C. There is no family history of depression
D. The patient has a history of Crohn's disease - ✔✔D. The patient has a history of
Crohn's disease
The answer is D. In SAD CAGES is a screening mnemonic for symptoms, not causes,
of major depression. Depression is more common in patients with history of other
medical illnesses, some of which may actually cause depressive symptoms. As
compared with major depression, dysthymic disorder is a more chronic, and less
severe, form of depressive illness.
✔✔A 42 year old male with end stage liver disease due to chronic hepatitis C infection
arrives to the emergency department in stable condition after an unsuccessful suicide
attempt by bilateral wrist laceration. He reports no history of depression or psychiatric
disorder. Aside from his liver disease, for which he takes interferon alpha and ribavirin,
he reports that he is in good health and takes no other medications. Which of the
following factors increased this patient's risk of new-onset suicidal ideation?
A. end-stage liver disease
B. chronic hepatitis C infection
C. ribavirin therapy
D. interferon alfa therapy - ✔✔D. interferon alfa therapy
The answer is D. Interferon alfa, an important cytokine in the early immune response to
viral infection, has both antiproliferative and antiviral properties. It is the only therapy
approved by the Food and Drug Administration for hepatitis C infection. Interferon alfa
has been associated with high rates of central nervous system side effects, including
anhedonia, fatigue, anorexia, impaired concentration, sleep disturbance, and suicidal
ideation. Clinicians should always look up the side effects of their patients' medications,
especially unfamiliar drugs. This can both expedite diagnosis of drug-induced
complications and prevent them with appropriate pretreatment. Pretreatment with a
selective serotonin reuptake inhibitor appears to be an effective strategy to minimize
depression induced by interferon alfa. Chronic hepatitis C infection and end-stage liver
disease can both be difficult diseases to live with, however, these conditions are not
known to significantly increase a patients' risk for new suicidal ideation. Depression is
not a known side effect of ribavirin treatment. Although males have a higher percentage
of successful suicide attempt than females, females have a much higher incidence of
suicide attempt and ideation than males overall.
