ABEM Qualifying Examination: Emergency Medicine Decision Guide Study Guide

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An older patient with suspected infection becomes confused and oliguric while blood pressure falls. Treat this as threatened organ perfusion, begin resuscitation, and repeatedly assess the response while identifying the infectious source and alternative causes.

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A hypotensive trauma patient has severe respiratory distress and absent breath sounds on one side. Recognize a possible obstructive mechanism and decompress the chest promptly instead of repeatedly administering fluid while the obstruction remains untreated.

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A well-appearing 24-day-old with documented fever needs blood and urine testing despite being afebrile now. Even if all PECARN low-risk criteria are met, hospital observation is required; neonatal cultures are generally observed for 36 hours, with a 24-hour option when a respiratory virus other than rhinovirus is confirmed. A previous brief hospitalization also limits routine risk-rule application; the hospitalization does not have to have been prolonged.

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A healthy term 45-day-old has fever, negative urinalysis, ANC 2,800/µL, and procalcitonin 0.12 ng/mL. After baseline cultures, conditional outpatient care is reasonable if feeding and follow-up arrangements are reliable. This disposition would differ for an otherwise similar 24-day-old.

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Two household members develop headache and confusion after using an indoor generator. Their conventional oxygen saturations are normal. Treat the exposure as potentially serious and obtain blood CO-oximetry while providing oxygen and assessing other causes.

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A patient taking an SGLT2 inhibitor has vomiting, deep rapid breathing, clear lungs, and glucose of 182 mg/dL. Measure ketones and acid-base status rather than excluding ketoacidosis or treating the breathing pattern as asthma alone.

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A patient has characteristic epigastric pain radiating to the back and lipase six times the upper limit of normal. Establish pancreatitis clinically and biochemically, then assess severity and cause without ordering immediate CT solely for confirmation.

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A patient with repeated hematemesis has systolic pressure of 78 mm Hg and ongoing bleeding. Begin hemorrhage resuscitation and coordinate urgent gastroenterology care; do not send the unstable patient directly to an endoscopy suite without stabilization.

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After initial treatment, a patient with mild pancreatitis has improving pain, no vomiting, and an appetite, although lipase remains elevated. Offer tolerated oral nutrition instead of prolonging fasting until the laboratory value returns to normal.

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A 9-month-old has repeated brief episodes of crying and pallor, vomiting, and unusual sleepiness between episodes without blood in the stool. Obtain ultrasound and involve pediatric surgery rather than diagnosing gastroenteritis from vomiting alone.

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A patient with a regular narrow-complex rhythm at 190/min, confusion, and blood pressure of 72/40 mm Hg needs synchronized cardioversion. A patient with sustained polymorphic ventricular tachycardia needs immediate unsynchronized defibrillation regardless of whether a pulse is briefly detectable.

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An older adult with diabetes develops exertional upper-abdominal pressure, dyspnea, and nausea. Evaluate for acute coronary syndrome with ECG and the appropriate troponin pathway rather than assuming gastrointestinal disease because the patient denies chest pain.

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CT identifies an acute descending dissection without rupture or malperfusion in a hypertensive patient. Begin monitored anti-impulse therapy and specialist management. New renal ischemia or persistent pain would change the case from uncomplicated disease to one requiring intervention.

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A stable patient with known Wolff-Parkinson-White pattern develops an irregular wide-complex tachycardia with varying QRS shapes. Avoid diltiazem and other AV nodal blockers; select an accessory-pathway-appropriate treatment with expert support and immediate cardioversion capability.

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A monitored patient becomes unresponsive and pulseless with ventricular fibrillation. Begin compressions, deliver an available defibrillation shock promptly, and resume compressions immediately rather than pausing to see whether an organized tracing has produced a pulse.

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After major blood loss, a patient has organized narrow complexes but no palpable pulse. Continue CPR and treat the hemorrhagic cause while following the nonshockable arrest pathway instead of delivering a shock to the organized rhythm.

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A patient has a tender fluctuant thigh lesion with localized erythema and no systemic illness. Identify the drainable collection and perform appropriate drainage, then assess whether host factors or infection severity warrant additional antimicrobial treatment.

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A patient with diabetes has rapidly worsening leg pain, fever, and hypotension, although the erythematous area initially looks modest. Escalate urgently for possible necrotizing infection rather than managing the appearance as uncomplicated cellulitis.

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A patient with diabetes has glucose of 260 mg/dL, beta-hydroxybutyrate of 4.8 mmol/L, and bicarbonate of 14 mmol/L. Recognize DKA from the combined criteria rather than treating the glucose value as uncomplicated hyperglycemia.

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An adult with DKA has potassium of 3.1 mmol/L and preserved urine output. Begin monitored potassium replacement and appropriate fluids, delaying insulin until potassium is above 3.5 mmol/L rather than immediately starting the usual insulin infusion.

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A patient taking empagliflozin develops abdominal discomfort and vomiting during a fasting illness. Glucose is 168 mg/dL, beta-hydroxybutyrate is 5.2 mmol/L, and pH is 7.22. Recognize euglycemic DKA and treat the ketotic acidosis.

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A runner collapses during hot weather, is confused, and has a core temperature of 40.6°C while still sweating. Initiate rapid active cooling and emergency support instead of classifying the episode as heat exhaustion because the skin is wet.

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An older patient presents with unilateral severe eye pain, redness, blurred vision, and vomiting. Recognize a vision-threatening glaucoma presentation and arrange immediate evaluation instead of treating the nausea and scheduling a routine outpatient eye examination.

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A child splashes an alkaline cleaning product into one eye and cannot tolerate opening it. Begin irrigation with topical analgesia and appropriate assistance immediately, including examination beneath the lids for retained material.

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During a red-cell transfusion, a patient develops chills, flank pain, hypotension, and dark urine. Stop the transfusion, maintain appropriate access and support, and initiate the transfusion-reaction evaluation with the blood bank while monitoring renal and coagulation consequences.

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A patient with renal failure becomes hypertensive and hypoxemic after several transfused units, with elevated venous pressure and pulmonary edema that improves after diuresis. These findings favor TACO over an isolated permeability lung injury.

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Minutes after an antibiotic infusion begins, a patient develops wheezing and blood pressure of 76/42 mm Hg without hives. Stop the exposure and administer intramuscular epinephrine promptly while supporting breathing and circulation and preparing for escalation.

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A patient with suspected bacterial septic shock has antibiotics ready 40 minutes after recognition, but another culture attempt would add substantial delay. Obtain feasible specimens and administer antibiotics now rather than completing the collection at the expense of timely treatment.

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Despite initial resuscitation, a patient with septic shock remains profoundly hypotensive. A reliable proximal peripheral IV is available, but central access will take time. Start monitored norepinephrine through the peripheral line while arranging appropriate continuing access.

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A patient with septic shock has an obstructed infected collecting system. Start antimicrobials immediately and arrange urgent stenting or nephrostomy alongside resuscitation, aiming for early drainage rather than waiting for antibiotics alone to improve the obstruction.

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After initial crystalloid, a septic patient remains hypotensive and develops increasing oxygen requirements. Reassess fluid responsiveness and congestion, and consider vasopressor support rather than assuming that every low pressure requires another empiric fluid bolus.

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A patient with fever and an acutely swollen knee has urate crystals in aspirated fluid. Continue the infection evaluation with synovial culture and appropriate specialist involvement instead of ending the assessment with a diagnosis of gout alone.

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An immunosuppressed patient has fever, a painful effusion, and synovial white cells of 18,000/µL. Maintain concern for infection, send cultures, and arrange appropriate treatment rather than using the relatively low count as a rule-out test.

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A patient develops aphasia and right arm weakness. Check glucose, determine when the patient was last normal, obtain anticoagulant history, and expedite brain imaging and stroke-team evaluation rather than assuming ischemia before hemorrhage is excluded.

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A 72-kg adult convulsing for six minutes without IV access should receive 10 mg IM midazolam promptly. A 20-kg child with IV access receives 2 mg IV lorazepam, with one full-dose repeat permitted if needed.

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A 70-kg adult continues convulsing after two appropriately administered 4-mg IV lorazepam doses. Severe hepatic disease excludes valproate. Calculate levetiracetam: 60 mg/kg × 70 kg = 4,200 mg, below the 4,500-mg maximum. Infuse over 10 minutes, equivalent to 420 mg/min, while supporting ventilation and monitoring circulation. Reassess continuously and explicitly at infusion completion: verify delivery of the full dose, determine whether convulsions have stopped, and reassess breathing, blood pressure, and responsiveness. Continuing convulsions warrant prompt refractory-status escalation. If movements stop but consciousness does not recover, obtain urgent EEG to assess for continuing electrographic seizures.

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After convulsions stop, a patient remains unexpectedly unresponsive despite adequate oxygenation and corrected glucose. Reassess medication effects and other causes, and pursue evaluation for ongoing nonconvulsive seizure activity instead of assuming that motor cessation proves complete seizure control.

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A patient with a positive pregnancy test develops severe abdominal pain, syncope, and hypotension. Initiate hemorrhage resuscitation and urgent gynecologic surgical involvement rather than waiting for serial hormone measurements to establish the pregnancy's location.

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A stable patient has a positive pregnancy test and nondiagnostic early transvaginal ultrasound. Explain the unresolved location, arrange dependable follow-up, and provide emergency return precautions rather than declaring either a normal intrauterine pregnancy or a confirmed ectopic pregnancy.

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A patient denies current intent after an impulsive overdose, but collateral history reveals a recent detailed plan and access to a firearm. Incorporate that information into safety planning and disposition rather than relying solely on the latest denial.

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A patient with fever, hypotension, and hydronephrosis above a ureteral stone needs urgent urologic drainage alongside antibiotics and resuscitation. Do not schedule routine stone follow-up or wait for antibiotics alone to sterilize the obstructed system.

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An afebrile patient has a small distal ureteral stone, preserved renal function, controlled pain, and reliable follow-up. Conservative management may be appropriate, with clear instructions to return for fever, uncontrolled symptoms, or reduced urine output.

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A 3-year-old has barking cough, persistent stridor at rest, marked retractions, and increasing agitation. Keep the child with a caregiver, administer nebulized epinephrine and dexamethasone, and obtain senior airway assessment. After improvement, continue observation for at least three hours after epinephrine. Recurrent stridor, repeated epinephrine requirements, or persistent respiratory distress warrants further monitored care rather than discharge.

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A patient with severe asthma becomes less wheezy but also drowsy, with minimal air entry and weakening respiratory effort. Treat this as deterioration requiring immediate escalation rather than interpreting reduced wheeze as evidence that bronchodilators have succeeded.

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A patient has a severe exacerbation with difficulty speaking and marked airflow limitation. Begin repeated inhaled bronchodilation, systemic corticosteroid treatment, and appropriate oxygen, adding severity-directed therapies while repeatedly assessing response and preparing escalation if clinical improvement is inadequate.

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A 32-year-old with pleuritic pain is independently assessed as low probability. Pulse is 82/min, room-air saturation is 98%, and the remaining PERC findings are negative except appendectomy requiring hospitalization three weeks earlier. That qualifying operation prevents PERC exclusion. Proceed through the D-dimer pathway; this criterion alone neither establishes PE nor mandates CT.

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A patient recovers from an exacerbation but has been using only a reliever inhaler. Establish an appropriate corticosteroid-containing regimen, demonstrate technique, confirm access, and provide an action plan and follow-up rather than simply renewing the reliever.

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Several residents develop headache after a heater malfunction, and one becomes confused despite a pulse oximeter reading of 99%. Provide oxygen and obtain blood CO-oximetry rather than excluding poisoning on the basis of the displayed saturation.

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A patient improves with oxygen after a combustion exposure but had syncope and persistent difficulty concentrating. Seek expert advice about hyperbaric treatment and arrange neurologic follow-up while explaining that delayed cognitive or behavioral symptoms require reassessment.

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After chest trauma, a patient becomes hypotensive and severely dyspneic with absent left breath sounds. Perform immediate pleural decompression and arrange definitive drainage rather than transferring the unstable patient to CT to confirm the suspected diagnosis.

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A patient with major extremity bleeding remains hypotensive despite initial replacement. Apply effective hemorrhage control and activate definitive trauma care while continuing appropriate resuscitation, rather than repeatedly increasing fluid delivery while blood continues to leave the circulation.

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A patient arrives 70 minutes after a collision with ongoing major hemorrhage. Include early tranexamic acid in the hemorrhage protocol while arranging blood support and source control, rather than delaying it until laboratory evidence of hyperfibrinolysis becomes available.

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A bleeding trauma patient becomes progressively colder during assessment and transfusion. Minimize unnecessary exposure, apply active warming, and use appropriate warmed replacement products while the team continues hemorrhage control and correction of other contributors to coagulopathy.

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After blunt chest trauma, a stable, spontaneously breathing adult has normal oxygenation and no respiratory distress. An upright posteroanterior chest radiograph shows a 1.5-cm vertical air rim between the lung apex's visceral pleural line and the inner apical chest wall. Observation for at least 24 hours with repeated clinical assessment is reasonable under the guideline's separately described apical-rim convention. Deterioration or a new requirement for positive-pressure ventilation prompts reassessment for drainage.

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A team compresses at 145/min with shallow depth and persistent leaning. Coach a rate of 100–120/min, adequate depth, and full release, and arrange timely compressor changes while avoiding unnecessary pauses during the correction.

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After intubation, the chest appears to move but no sustained carbon dioxide waveform is present. Immediately reassess tube position, ventilation, equipment, and circulation rather than accepting chest movement as definitive confirmation that the airway is secure.

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During CPR after endotracheal intubation, a rescuer delivers rapid large breaths. Reduce ventilation to approximately ten breaths per minute with visible chest rise while maintaining continuous compressions and monitoring airway function and the patient's resuscitation response.

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After a shock for ventricular fibrillation, an organized tracing appears. Resume compressions promptly rather than spending a prolonged interval palpating for a pulse, and continue coordinated rhythm assessments according to the arrest algorithm and any clear signs of circulation.

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During resuscitation, the team suspects tamponade. An experienced operator prepares the probe before the scheduled rhythm check and captures a brief view without extending the pause, allowing compressions to resume immediately while the image is interpreted.

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A patient refuses admission and accurately repeats the diagnosis but insists the described danger cannot apply to them without explanation. Explore appreciation and reasoning rather than declaring capacity solely because the patient knows the date and can repeat medical facts.