EMERGENCY EXAM 2025 QUESTIONS
AND ANSWERS
A 45-year-old man presents to the emergency room after tripping over a curb. He is unable to
put any weight on his right foot. On physical exam, there is bruising over the medial plantar
surface and tenderness over the tarsometatarsal joint. Radiographs reveal an avulsion fracture
of the second metatarsal and widening of the space between the medial cuneiform and base of
the second metatarsal. Which of the following is the most appropriate treatment? -
ANS Open reduction and internal fixation
Open reduction and internal fixation is indicated for Lisfranc injuries with any evidence of
instability or bony fracture. A Lisfranc injury is characterized by a disruption the tarsometatarsal
joints, which connect the forefoot to the midfoot. The injury can range from a mild sprain to
severe dislocations with fracture. Lisfranc injuries are more common in males and in the third
decade of life. The injury usually results from excessive indirect rotational forces and axial
loading through a hyper-plantar flexed foot. Common causes of Lisfranc injuries include motor
vehicle accidents, falls, or sports. Patients usually present with severe foot pain and an inability
to bear weight. Physical exam may reveal midfoot bruising of the plantar surface, generalized
swelling, and tenderness of the tarsometatarsal joint. Anteroposterior, lateral, and oblique
radiographs are first line imaging. Stress radiographs may be necessary if non-weight bearing
radiographs are unremarkable and there is high suspicion. Radiographic findings may include
disruption of second metatarsal, avulsion fragments, or malalignment of the fourth metatarsal
and the cuboid bone. Nonoperative management is indicated in patients with no displacement
on stress radiographs and no evidence of bony injury. Operative management is indicated in
patients with any evidence of instability or fracture. Posttraumatic arthritis is the most common
complication of Lisfranc injuries.
A five-year-old girl is brought by her father to the clinic because of a cat bite. Yesterday, she
was playing with a neighbor's cat that suddenly bit the girl's left hand. Her wound was
immediately cleaned. The following day, the father noted increased swelling and redness of the
girl's left hand. On physical examination, she has normal vital signs, and on the left hand are
two puncture wounds with a surrounding 1 cm diameter of erythema and swelling. Which of
the following is the best treatment for a suspected Pasteurella sp. soft tissue infection? -
ANS Amoxicillin-clavulanate
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 1
,The girl has a soft tissue infection from a cat bite. Clinical soft tissue infections with Pasteurella
multocida usually occur after cat bites, cat scratches, or dog bites but may also occur following
cat or dog licks of non-intact skin. P. multocida wound infections characteristically have a very
rapid development of an intense inflammatory response. Most patients develop symptoms
within 24 hours of the initial injury, and as early as three hours after a cat bite. Pain and
swelling are prominent. Purulent drainage is noted in about 40 pecent of patients, lymphangitis
in about 20 percent, and regional adenopathy in 10 percent. Cellulitis often occurs within 24 to
48 hours. Necrotizing fasciitis may occur. Pasteurella is the first organism to consider in any
patient who presents with a soft tissue infection following cat scratches or cat or dog bites or
licks. The diagnosis of P. multocida infection is made by isolation of the organism in culture.
Pasteurella sp., including P. multocida, are usually susceptible to a number of antibiotics,
including amoxicillin-clavulanate, piperacillin-tazobactam, doxycycline, fluoroquinolones,
advanced cephalosporins, and carbapenems.
Which of the following is most likely to be associated with a bilateral interfacetal dislocation? -
ANS complete cord transection
Bilateral facet dislocation is an unstable injury that occurs from forceful hyperflexion of the
neck. It occurs when the articular masses of one vertebra dislocate anteriorly and superiorly
from the articular surface of the vertebra below it causing anterior displacement of the spine.
This injury involves forceful disruption of multiple structures at the level of the injury, including
all ligamentous structures, the articular facet joints, and the intervertebral disc. This is
commonly associated with a complete spinal cord injury due to transection of the cord at the
level of the injury. Diagnosis is made by radiographic evidence of displacement of the superior
vertebral body anteriorly more than one half of its width.
A 19-year-old migrant worker presents to the ED with vomiting, diarrhea, diaphoresis,
wheezing, and excessive tearing. Vital signs are BP 150/100 mm Hg, HR 36 beats per minute, RR
28 breaths per minute, and T 98.6°F. Which of the following is the most appropriate initial step
in management? - ANS decontamination
This patient is exhibiting signs and symptoms consistent with cholinergic toxicity secondary to
organophosphate poisoning. Management of organophosphate poisoning should begin with
decontamination. Anyone coming into contact with the patient should wear a gown and gloves
to prevent transmission of the toxin. Clothing should be removed and discarded in a well-
ventilated area and the patient should be thoroughly washed including ocular irrigation. The
patient should then be resuscitated in a similar manner to any other ED patient. These patients
often require early intubation and aggressive IV fluid resuscitation. There are two keys to
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 2
,definitive treatment in patients with organophosphate poisoning. The first is to temporize the
life-threatening signs and symptoms of cholinergic toxicity. Atropine is a competitive inhibitor
of acetylcholine at muscarinic receptors. The goal of treatment with atropine is to titrate to the
drying of bronchial secretions. Pralidoxime (2-PAM) is the definitive antidote to
organophosphate poisoning. 2-PAM forms a complex with the bound acetylcholinesterase
enzyme to cause the release of the organophosphate from the enzyme. This results in
regeneration of its ability to metabolize acetylcholine. Organophosphates bind tightly to
acetylcholinesterase preventing the breakdown of acetylcholine. Signs and symptoms of
organophosphate poisoning relate to excess acetylcholine at the nicotinic and muscarinic
receptors. This produces the cholinergic toxidrome due to high postsynaptic parasympathetic
activity, resulting in the classic SLUDGE mnemonic: Salivation, Lacrimation, Urination, Diarrhea,
GI cramps and Emesis. Patients will also demonstrate diaphoresis, pupillary miosis, bradycardia,
muscular fasciculations, paralysis, agitation, seizures, or even coma.
A 22-year-old woman presents to the emergency department after developing a widespread
rash following a bee sting. The patient reports she has been stung once previously but never
had a reaction. She denies difficulty breathing but states she feels somewhat light-headed. She
is otherwise healthy, and has no significant past medical history. Vital signs are T 37, BP 85/60,
HR 100, RR 18, oxygen saturation is 98%. A diffuse urticarial rash is present on the patient's
extremities. Which of the following is the next best step in management? -
ANS intramuscular epinephrine
This woman's presentation is concerning for anaphylaxis. Anaphylaxis is characterized by upper
airway obstruction, rash, bronchospasm, and hypotension or cardiovascular collapse. Although
she does not yet have trouble breathing, epinephrine is indicated. Anaphylaxis occurs as a
result of IgE-mediated hypersensitivity that causes mast cell degranulation and histamine
release. Patients typically present with a combination of hives, facial edema, pruritus,
respiratory difficulty, and hypotension in the setting of an inciting factor such as bee sting,
peanuts, shellfish and other foods. Anaphylaxis generally does not occur during the patient's
first exposure to the allergen, instead presenting following the subsequent exposures.
Intramuscular epinephrine and the close monitoring of vital signs are the foundation of
anaphylaxis treatment. Patients with a history of reactive airway disease may benefit from
albuterol nebulizers as a supplement. Intramuscular epinephrine should be administered every
5-15 minutes until the symptoms resolve.
A 30-year-old man presents to the emergency department after being involved in a head-on
motor vehicle crash. He is complaining of severe pain in his right hip. On exam, his right leg
appears to be shortened and is held slightly flexed, internally rotated, and adducted. Range of
motion is severely limited due to pain. An anterior-posterior plain radiograph is negative for
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 3
, fractures, but the right femoral head appears smaller than the uninjured side. Which of the
following is the most likely diagnosis? - ANS Posterior hip dislocation
This man most likely has a posterior hip dislocation. Posterior hip dislocations are most
commonly associated with high-energy trauma such as motor vehicle collisions, falls from
significant height, and high impact sports. Artificial hips can dislocate with less force. Posterior
hip dislocations account for 90% of all hip dislocations. Posterior dislocations occur when a
large axial load is transmitted through a flexed knee, which may occur when the knee comes
into contact with the dashboard in a crash. Given the large amount of force needed to dislocate
the femoral head, the majority of dislocations are associated with other injuries. Patients
typically present with severe pain, an inability to bear weight, and deformity. Range of motion
will be severely limited. A detailed neurovascular exam should be conducted to rule out sciatic
nerve injury. In posterior dislocations, the affected leg tends to be held in slight flexion,
adduction, and internal rotation. Plain radiographs are first-line imaging for diagnosing hip
dislocations and associated fractures. A posteriorly dislocated femoral head will appear smaller
than the contralateral side on anteroposterior film. After ruling out life-threatening injuries, the
hip should be reduced within six hours. Concurrent femoral neck fracture is a contraindication
for reduction. After reduction, computed tomography scan should be performed on all
traumatic hip dislocation to evaluate for fractures. After reduction for simple dislocations, the
patient should be on protected weight bearing for four to six weeks. Complications of hip
dislocations include arthritis, femoral head osteonecrosis, sciatic nerve injury, and recurrent
dislocations.
A 45-year-old chemist presents to the emergency department after accidentally spilling
elemental aluminum on his left hand and forearm 30 minutes prior to arrival. What is the most
appropriate next step? - ANS cover the affected area with mineral oil
The first step in managing elemental metal burns is to covering the affected area in mineral oil,
sand, or foam from a Class D fire extinguisher. Chemical burns differ from thermal burns, in that
chemical burns can continue to cause damage at long as the active chemical is in contact with
the skin and can cause systemic toxicity if absorbed or inhaled. Chemical burns also heal more
slowly and require longer hospitalization periods. When encountering a chemical burn, it is
critical that treatment be started as soon as possible. General steps for management of topical
chemical burns includes securing the safety of rescuers and health care works, removing the
patient from the area of exposure, removing the patient's clothing and jewelry, and brushing
any dry chemicals off the patient. Unless use of water is contraindicated, copious irrigation with
moderately warm water at low pressures is essential for preventing further tissue damage.
Chemicals that should not be immediately irrigated with water include dry lime, elemental
metals (e.g. sodium, potassium, magnesium, and phosphorus), and phenols. Treatment for
elemental metal burns involves removal of the substance and the affected area covered in
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 4
AND ANSWERS
A 45-year-old man presents to the emergency room after tripping over a curb. He is unable to
put any weight on his right foot. On physical exam, there is bruising over the medial plantar
surface and tenderness over the tarsometatarsal joint. Radiographs reveal an avulsion fracture
of the second metatarsal and widening of the space between the medial cuneiform and base of
the second metatarsal. Which of the following is the most appropriate treatment? -
ANS Open reduction and internal fixation
Open reduction and internal fixation is indicated for Lisfranc injuries with any evidence of
instability or bony fracture. A Lisfranc injury is characterized by a disruption the tarsometatarsal
joints, which connect the forefoot to the midfoot. The injury can range from a mild sprain to
severe dislocations with fracture. Lisfranc injuries are more common in males and in the third
decade of life. The injury usually results from excessive indirect rotational forces and axial
loading through a hyper-plantar flexed foot. Common causes of Lisfranc injuries include motor
vehicle accidents, falls, or sports. Patients usually present with severe foot pain and an inability
to bear weight. Physical exam may reveal midfoot bruising of the plantar surface, generalized
swelling, and tenderness of the tarsometatarsal joint. Anteroposterior, lateral, and oblique
radiographs are first line imaging. Stress radiographs may be necessary if non-weight bearing
radiographs are unremarkable and there is high suspicion. Radiographic findings may include
disruption of second metatarsal, avulsion fragments, or malalignment of the fourth metatarsal
and the cuboid bone. Nonoperative management is indicated in patients with no displacement
on stress radiographs and no evidence of bony injury. Operative management is indicated in
patients with any evidence of instability or fracture. Posttraumatic arthritis is the most common
complication of Lisfranc injuries.
A five-year-old girl is brought by her father to the clinic because of a cat bite. Yesterday, she
was playing with a neighbor's cat that suddenly bit the girl's left hand. Her wound was
immediately cleaned. The following day, the father noted increased swelling and redness of the
girl's left hand. On physical examination, she has normal vital signs, and on the left hand are
two puncture wounds with a surrounding 1 cm diameter of erythema and swelling. Which of
the following is the best treatment for a suspected Pasteurella sp. soft tissue infection? -
ANS Amoxicillin-clavulanate
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 1
,The girl has a soft tissue infection from a cat bite. Clinical soft tissue infections with Pasteurella
multocida usually occur after cat bites, cat scratches, or dog bites but may also occur following
cat or dog licks of non-intact skin. P. multocida wound infections characteristically have a very
rapid development of an intense inflammatory response. Most patients develop symptoms
within 24 hours of the initial injury, and as early as three hours after a cat bite. Pain and
swelling are prominent. Purulent drainage is noted in about 40 pecent of patients, lymphangitis
in about 20 percent, and regional adenopathy in 10 percent. Cellulitis often occurs within 24 to
48 hours. Necrotizing fasciitis may occur. Pasteurella is the first organism to consider in any
patient who presents with a soft tissue infection following cat scratches or cat or dog bites or
licks. The diagnosis of P. multocida infection is made by isolation of the organism in culture.
Pasteurella sp., including P. multocida, are usually susceptible to a number of antibiotics,
including amoxicillin-clavulanate, piperacillin-tazobactam, doxycycline, fluoroquinolones,
advanced cephalosporins, and carbapenems.
Which of the following is most likely to be associated with a bilateral interfacetal dislocation? -
ANS complete cord transection
Bilateral facet dislocation is an unstable injury that occurs from forceful hyperflexion of the
neck. It occurs when the articular masses of one vertebra dislocate anteriorly and superiorly
from the articular surface of the vertebra below it causing anterior displacement of the spine.
This injury involves forceful disruption of multiple structures at the level of the injury, including
all ligamentous structures, the articular facet joints, and the intervertebral disc. This is
commonly associated with a complete spinal cord injury due to transection of the cord at the
level of the injury. Diagnosis is made by radiographic evidence of displacement of the superior
vertebral body anteriorly more than one half of its width.
A 19-year-old migrant worker presents to the ED with vomiting, diarrhea, diaphoresis,
wheezing, and excessive tearing. Vital signs are BP 150/100 mm Hg, HR 36 beats per minute, RR
28 breaths per minute, and T 98.6°F. Which of the following is the most appropriate initial step
in management? - ANS decontamination
This patient is exhibiting signs and symptoms consistent with cholinergic toxicity secondary to
organophosphate poisoning. Management of organophosphate poisoning should begin with
decontamination. Anyone coming into contact with the patient should wear a gown and gloves
to prevent transmission of the toxin. Clothing should be removed and discarded in a well-
ventilated area and the patient should be thoroughly washed including ocular irrigation. The
patient should then be resuscitated in a similar manner to any other ED patient. These patients
often require early intubation and aggressive IV fluid resuscitation. There are two keys to
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 2
,definitive treatment in patients with organophosphate poisoning. The first is to temporize the
life-threatening signs and symptoms of cholinergic toxicity. Atropine is a competitive inhibitor
of acetylcholine at muscarinic receptors. The goal of treatment with atropine is to titrate to the
drying of bronchial secretions. Pralidoxime (2-PAM) is the definitive antidote to
organophosphate poisoning. 2-PAM forms a complex with the bound acetylcholinesterase
enzyme to cause the release of the organophosphate from the enzyme. This results in
regeneration of its ability to metabolize acetylcholine. Organophosphates bind tightly to
acetylcholinesterase preventing the breakdown of acetylcholine. Signs and symptoms of
organophosphate poisoning relate to excess acetylcholine at the nicotinic and muscarinic
receptors. This produces the cholinergic toxidrome due to high postsynaptic parasympathetic
activity, resulting in the classic SLUDGE mnemonic: Salivation, Lacrimation, Urination, Diarrhea,
GI cramps and Emesis. Patients will also demonstrate diaphoresis, pupillary miosis, bradycardia,
muscular fasciculations, paralysis, agitation, seizures, or even coma.
A 22-year-old woman presents to the emergency department after developing a widespread
rash following a bee sting. The patient reports she has been stung once previously but never
had a reaction. She denies difficulty breathing but states she feels somewhat light-headed. She
is otherwise healthy, and has no significant past medical history. Vital signs are T 37, BP 85/60,
HR 100, RR 18, oxygen saturation is 98%. A diffuse urticarial rash is present on the patient's
extremities. Which of the following is the next best step in management? -
ANS intramuscular epinephrine
This woman's presentation is concerning for anaphylaxis. Anaphylaxis is characterized by upper
airway obstruction, rash, bronchospasm, and hypotension or cardiovascular collapse. Although
she does not yet have trouble breathing, epinephrine is indicated. Anaphylaxis occurs as a
result of IgE-mediated hypersensitivity that causes mast cell degranulation and histamine
release. Patients typically present with a combination of hives, facial edema, pruritus,
respiratory difficulty, and hypotension in the setting of an inciting factor such as bee sting,
peanuts, shellfish and other foods. Anaphylaxis generally does not occur during the patient's
first exposure to the allergen, instead presenting following the subsequent exposures.
Intramuscular epinephrine and the close monitoring of vital signs are the foundation of
anaphylaxis treatment. Patients with a history of reactive airway disease may benefit from
albuterol nebulizers as a supplement. Intramuscular epinephrine should be administered every
5-15 minutes until the symptoms resolve.
A 30-year-old man presents to the emergency department after being involved in a head-on
motor vehicle crash. He is complaining of severe pain in his right hip. On exam, his right leg
appears to be shortened and is held slightly flexed, internally rotated, and adducted. Range of
motion is severely limited due to pain. An anterior-posterior plain radiograph is negative for
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 3
, fractures, but the right femoral head appears smaller than the uninjured side. Which of the
following is the most likely diagnosis? - ANS Posterior hip dislocation
This man most likely has a posterior hip dislocation. Posterior hip dislocations are most
commonly associated with high-energy trauma such as motor vehicle collisions, falls from
significant height, and high impact sports. Artificial hips can dislocate with less force. Posterior
hip dislocations account for 90% of all hip dislocations. Posterior dislocations occur when a
large axial load is transmitted through a flexed knee, which may occur when the knee comes
into contact with the dashboard in a crash. Given the large amount of force needed to dislocate
the femoral head, the majority of dislocations are associated with other injuries. Patients
typically present with severe pain, an inability to bear weight, and deformity. Range of motion
will be severely limited. A detailed neurovascular exam should be conducted to rule out sciatic
nerve injury. In posterior dislocations, the affected leg tends to be held in slight flexion,
adduction, and internal rotation. Plain radiographs are first-line imaging for diagnosing hip
dislocations and associated fractures. A posteriorly dislocated femoral head will appear smaller
than the contralateral side on anteroposterior film. After ruling out life-threatening injuries, the
hip should be reduced within six hours. Concurrent femoral neck fracture is a contraindication
for reduction. After reduction, computed tomography scan should be performed on all
traumatic hip dislocation to evaluate for fractures. After reduction for simple dislocations, the
patient should be on protected weight bearing for four to six weeks. Complications of hip
dislocations include arthritis, femoral head osteonecrosis, sciatic nerve injury, and recurrent
dislocations.
A 45-year-old chemist presents to the emergency department after accidentally spilling
elemental aluminum on his left hand and forearm 30 minutes prior to arrival. What is the most
appropriate next step? - ANS cover the affected area with mineral oil
The first step in managing elemental metal burns is to covering the affected area in mineral oil,
sand, or foam from a Class D fire extinguisher. Chemical burns differ from thermal burns, in that
chemical burns can continue to cause damage at long as the active chemical is in contact with
the skin and can cause systemic toxicity if absorbed or inhaled. Chemical burns also heal more
slowly and require longer hospitalization periods. When encountering a chemical burn, it is
critical that treatment be started as soon as possible. General steps for management of topical
chemical burns includes securing the safety of rescuers and health care works, removing the
patient from the area of exposure, removing the patient's clothing and jewelry, and brushing
any dry chemicals off the patient. Unless use of water is contraindicated, copious irrigation with
moderately warm water at low pressures is essential for preventing further tissue damage.
Chemicals that should not be immediately irrigated with water include dry lime, elemental
metals (e.g. sodium, potassium, magnesium, and phosphorus), and phenols. Treatment for
elemental metal burns involves removal of the substance and the affected area covered in
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 4
