SAEM EXAM QUESTIONS 2023-2024 ACTUAL EXAM
400 REAL EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
A 19 year old woman is brought to the emergency department by her friends because
she has been saying that she is a superhero and trying to run into traffic to prove that
she is indestructible. The friends report that she has been using drugs but they do not
know which ones. Which of the following pairs of ocular finding and recreational drug is
commonly observed?
A. dilated pupils – heroin
B. internuclear ophthalmoplegia – marijuana
C. pinpoint pupils – amphetamines
D. vertical nystagmus – phencyclidine – …ANSWER…D. vertical nystagmus –
phencyclidine
Sympathomimetics (cocaine, amphetamines) cause dilated pupils. Opiates (heroin)
cause pinpoint pupils. Internuclear ophthalmoplegia is associated with multiple
sclerosis. CN VI palsy is not associated with any specific drugs.
A 42 year old former custodial worker presents stating, “I think that people can hear
what I am thinking.” In the emergency department, he becomes extremely agitated and
threatening, and his psychoses become more severe. In choosing an antipsychotic
medication, which of the following would be the most appropriate choice?
A. haloperidol
B. chlorpromazine
C. thioridazine
D. ketamine – …ANSWER…A. haloperidol
Haloperidol is the most studied high potency antipsychotic agent used in agitated
patients. Typical dosing is 5-10 mg IM every 10-30 minutes. Unlike thioridazine,
haloperidol does not cause respiratory depression, has negligible anticholinergic side effects, and rarely causes hypotension. Although benzodiazepines can be used in the
agitated patient, respiratory depression can occur, and close monitoring is essential.
A 20 year old college student is brought to the emergency department by campus police
after he was found by his roommate saying people in the TV were trying to kill him.
Which of the following criteria is not an indication for admission?
A. first-time psychiatric episode
B. demonstrates risk for suicide
C. inadequate psychosocial support
D. lacks capacity to cooperate with treatment – …ANSWER…A. first-time psychiatric
episode
For an acute psychiatric episode, the first goal is medically stabilizing the patient.
Subsequently, a patient who presents without previous history of a psychiatric episode
does not necessarily need to be admitted. This, of course, depends on the identity and
severity of the condition, and whether it can be treated in the emergency department.
A 55 year-old male presents with new onset agitation and confusion. Which of the
following medical histories would suggest a psychiatric (non-organic) cause?
A. History of diabetes mellitus only
B. History of alcohol abuse only
C. History of hypothyroidism only
D. History of chronic obstructive pulmonary disease only – …ANSWER…C. History of
hypothyroidism only
Although hyperthyroidism may result in an agitated state, hypothyroidism is not
generally associated with violent behavior. All other answers are potentially treatable
medical problems that could account for the presentation of an agitated or violent
patient. After assuring the safety of all parties involved, the emergency department
physician should rule out organic causes of agitation.
In dealing with the potential violent patient, the emergency physician should:
A. Approach the patient in a calm, controlled and professional manner
B. Assume that the strength of the doctor-patient relationship will ensure safety
C. Deal with the patient in a isolated room to protect the patient’s privacy
D. Use a loud voice and threaten to call security if the patient becomes agitated –
…ANSWER…A. Approach the patient in a calm, controlled and professional manner
Excessive eye contact may be interpreted as a sign of aggression (answer A).
Emergency physicians are encouraged to maintain intermittent eye contact with the
patient and to keep a professional and calm demeanor. Also a physician should never
deal with an agitated or violent patient alone in an isolated room (answer D). Doors
should always remain open and exits should never be blocked. Ample security should
be close at hand before interviewing the patient (answer E). Finally, involved parties are
encouraged to remove any personal effects (e.g. neckties, necklaces, earrings, etc.)
that could be used as a weapon by the violent patient.
A 35 year-old male is placed on his back on the gurney in physical restraints for violent
behavior. Which life-threatening complication can arise?
A. circulatory obstruction
B. Metabolic acidosis
C. Asphyxia
D. Rhabdomyolysis – …ANSWER…B. Metabolic acidosis
Bruises and abrasions are the most common complication of physical restraints. After
restraint application, patients need to be monitored frequently and positions changed to
prevent neurovascular complications such as circulatory obstruction, pressure sores,
and rhabdomyolysis. Positional asphyxia can arise when patients are placed into the
prone or hobbled position. Protracted struggle against restraints can promote a
significant metabolic acidosis that has been associated with cardiovascular collapse.
Patients who continue to struggle with physical restraints should be chemically
restrained as well
Which medication is ideal for the agitated or combative patient?
A. Nitrous oxide
B. Hydromorphone
C. Haloperidol
D. Propofol – …ANSWER…The answer is C. Drugs with a relatively short half-life allow
for more careful monitoring of chemically restrained patients. Patients may be given
multiple administrations of the restraining agent as needed. Antipsychotics (such as
haloperidol) and benzodiazepines (such as lorazepam) exhibit most of these
characteristics and are commonly used in combination in the emergency department.
The use of 5 mg of haloperidol IV/IM with 2 mg of lorazepam IV/IM, repeated every 30
minutes as needed, is recommended for the combative patient who does not have
contraindications to these medications. Half doses should be used in the elderly.
19 year old man is brought in to the emergency department by EMS after being found
obtunded in his apartment. No additional history is available. On arrival, the patient is
minimally responsive with sonorous respirations and a palpable rapid pulse. The most
appropriate initial diagnostic test would be
A. Arterial blood gas
B. Electrocardiogram
C. Fingerstick glucose
D. Urine drug screen – …ANSWER…C. Fingerstick glucose
Hypoglycemia is a common and readily treatable cause for altered mental status. An
ABG is unlikely to be diagnostic and more likely to reflect secondary abnormalities
caused by respiratory depression. While a urine drug screen may show positives, it
cannot quantitate the amount of a substance or the time period in which the exposure
occurred so a positive screen may not reflect cause and effect. An EKG, while a part of
a toxicology evaluation, is not an appropriate initiate screening test for an unstable
patient until airway and readily reversible causes have been addressed.
A 27 year old is found unresponsive in his car in the hospital parking lot and brought in
by security. During your initial evaluation you find him to be cyanotic with pulse oximetry
reading 82% on room air with a respiratory rate of 4 breaths per minute. Radial pulses
are present at 120 bpm. Pupils are 1mm bilaterally. Your team is having difficulty finding
a vein for an intravenous line due to extensive scarring of his arms. You are suspicious
of an overdose, which medication would you want to rapidly administer as a potential
antidote in this situation?
A. Glucose
B. Naloxone
C. Thiamine
D. Flumazenil – …ANSWER…B. Naloxone
The patient has stigmata of an opiate overdose with hypopnea, cyanosis, and miotic
pupils. In addition, intravenous drug users often use up their veins. While hypoglycemia
can definitely cause a depressed mental status and needs to be assessed, it should not
result in respiratory depression or miotic pupils. Thiamine is utilized to prevent
Wernicke’s encephalopathy particularly in malnourished patients who present with
hypoglycemia but is not an antidote per se. Flumazenil can be used to temporarily
reverse the respiratory depression caused by benzodiazepines but also carries with it
the risk of precipitating withdrawal and uncontrollable seizures in chronic
benzodiazepine users. As a result, it is not recommended for routine use in patients with
altered mental status.
A 53 year-old known alcoholic presents with agitation, vomiting and altered mental
status. His fingerstick glucose is 148. His serum ethanol level is undetectable and his
head CT is normal. An ABG shows a pH of 7.21, pCO2 of 34, pO2 of 98 on room air.
His basic chemistry panel includes a sodium of 136, potassium 4.1, chloride 108,
bicarbonate 14, BUN 12, creatinine 1.1. What substance are you concerned that he
may have ingested:
A. Ethylene glycol
B. Salicylates
C. Isopropyl alcohol
D. Methanoleeette – …ANSWER…C. Isopropyl alcohol
The patient is presenting with a non anion gap metabolic acidosis. Isopropyl alcohol is
metabolized via alcohol dehydrogenase to acetone which accumulates and causes
significant ketosis but not an anion gap. Other toxic alcohols such as methanol and
ethylene glycol are ultimately metabolized to formic and glycolic acids which cause toxic
effects and an anion gap metabolic acidosis. Salicylates result in an anion gap
metabolic acidosis with a superimposed respiratory alkalosis. The following mnemonic
can be used to recall the common causes of an increased anion gap metabolic acidosis:
CAT MUDPILES;
C – cyanide
A – alcoholic ketoacidosis
T – toluene
M – methanol
U – uremia
D – diabetic ketoacidosis
P – paraldehyde
I – isoniazid/iron
L – lactate
E – ethylene glycol