Emergency Medicine Prometric exam questions

The Emergency Medicine exam in every GCC country

From each regulator's own exam pages; anything a regulator does not publish says so. Assessment mode also depends on your licence title, so confirm your route on your eligibility notice.

12 worked Emergency Medicine practice questions

Original exam-style questions from the bank, spread across the blueprint domains. They are not real or recalled exam questions. Try each one, then open the answer for the rationale and reference. None of them appear in the free mock exam, so reading them will not spoil it.

1. Question 1 · Resuscitation, Shock and Airway Management

   A 40-year-old trauma patient has received 6 units of packed red cells, 6 units of plasma and tranexamic acid. He remains hypotensive with a widened QRS and an ionised calcium of 0.68 mmol/L. What is the most appropriate management of this abnormality?

   1. AWithhold calcium because it promotes coagulation activation and thrombosis
   2. BGive oral calcium carbonate and recheck in 4 hours
   3. CIncrease the rate of plasma transfusion, which will correct the calcium
   4. DAdminister intravenous calcium (for example calcium chloride 1 g or calcium gluconate 3 g) and recheck the ionised calcium
   Show answer and explanation

   Correct answer: D. Administer intravenous calcium (for example calcium chloride 1 g or calcium gluconate 3 g) and recheck the ionised calcium

   Citrate anticoagulant in stored blood products chelates ionised calcium, and hypocalcaemia impairs myocardial contractility, vascular tone and the coagulation cascade, forming part of the 'lethal diamond' with acidosis, hypothermia and coagulopathy. Ionised calcium should be monitored during massive transfusion and maintained above about 0.9 mmol/L with intravenous calcium chloride or gluconate. Withholding calcium worsens shock and coagulopathy, oral replacement is far too slow, and more plasma delivers more citrate and lowers ionised calcium further.

   Reference: Rossaint R et al. The European guideline on management of major bleeding and coagulopathy following trauma, 6th edition, Critical Care 2023

2. Question 2 · Cardiovascular and Respiratory Emergencies

   A 62-year-old man with metastatic pancreatic cancer presents with a massively swollen, tense, cyanotic left leg with severe pain, early blistering and a weak dorsalis pedis pulse. Duplex confirms extensive iliofemoral deep vein thrombosis. What is the most appropriate management?

   1. ACompression stockings, elevation and oral anticoagulation as an outpatient
   2. BFasciotomy of the anterior compartment as the first procedure
   3. CInsertion of an inferior vena cava filter as the sole intervention
   4. DImmediate anticoagulation plus urgent referral for catheter-directed thrombolysis or thrombectomy
   Show answer and explanation

   Correct answer: D. Immediate anticoagulation plus urgent referral for catheter-directed thrombolysis or thrombectomy

   This is phlegmasia cerulea dolens, a limb-threatening complication of extensive iliofemoral DVT in which venous outflow obstruction compromises arterial inflow and can progress to venous gangrene; management is immediate systemic anticoagulation, limb elevation and urgent referral for catheter-directed thrombolysis or thrombectomy. Outpatient conservative therapy is inadequate for a threatened limb. A vena cava filter prevents embolism but does not relieve outflow obstruction, and fasciotomy may be needed for established compartment syndrome but does not treat the underlying thrombotic occlusion.

   Reference: Rosen's Emergency Medicine: Concepts and Clinical Practice, 10th edition, 2023; ACCP Antithrombotic Therapy for VTE Disease, CHEST, 2021

3. Question 3 · Toxicology and Environmental Emergencies

   A 62-year-old man on long-term lithium therapy presents with confusion, coarse tremor and ataxia after several days of vomiting and diarrhoea. Serum lithium is 3.4 mmol/L, creatinine is 260 micromol/L (rising), and he remains encephalopathic after 4 hours of intravenous crystalloid. What is the most appropriate next step in enhancing elimination?

   1. AMultiple-dose activated charcoal
   2. BUrinary alkalinisation with sodium bicarbonate infusion
   3. CIntermittent haemodialysis
   4. DForced diuresis with intravenous furosemide
   Show answer and explanation

   Correct answer: C. Intermittent haemodialysis

   Lithium is a small, non-protein-bound ion with a low volume of distribution, making it highly dialysable, and haemodialysis is indicated when there is impaired kidney function with a level above about 4 mmol/L, or above 2.5 mmol/L with severe neurological features. Activated charcoal does not adsorb lithium, and urinary alkalinisation is used for salicylates and phenobarbital rather than lithium. Loop diuretics worsen volume depletion and sodium avidity, which increases rather than decreases lithium reabsorption.

   Reference: EXTRIP Workgroup recommendations on extracorporeal treatment for lithium poisoning (Decker et al., Clinical Journal of the American Society of Nephrology, 2015)

4. Question 4 · Orthopedic and Musculoskeletal Emergencies

   A 41-year-old man stepped awkwardly off a kerb. He has midfoot swelling, plantar ecchymosis of the medial midfoot and pain on pronation-abduction of the forefoot. Weight-bearing radiographs show a 3 mm gap between the bases of the first and second metatarsals. What is the most likely diagnosis and appropriate action?

   1. ALisfranc (tarsometatarsal) injury; non-weight-bearing immobilisation and urgent orthopaedic referral
   2. BMidfoot sprain; discharge with elastic bandage and immediate return to sport
   3. CIsolated second metatarsal stress fracture; walking boot only
   4. DCalcaneal fracture; CT of the hindfoot and axial heel views
   Show answer and explanation

   Correct answer: A. Lisfranc (tarsometatarsal) injury; non-weight-bearing immobilisation and urgent orthopaedic referral

   Plantar midfoot ecchymosis with tarsometatarsal tenderness and diastasis between the first and second metatarsal bases on weight-bearing views is classic for a Lisfranc injury, which is frequently missed and leads to chronic pain and post-traumatic arthritis if untreated. Management is non-weight-bearing immobilisation with prompt orthopaedic referral, as most displaced injuries require fixation. A simple sprain does not produce diastasis, a stress fracture has an insidious onset without acute diastasis, and calcaneal fracture causes hindfoot rather than midfoot findings.

   Reference: Rosen's Emergency Medicine, 10th edition, 2023; Myerson classification of Lisfranc injuries

5. Question 5 · Gastrointestinal and Abdominal Emergencies

   A 76-year-old woman with atrial fibrillation who stopped her anticoagulant two weeks ago presents with 3 hours of sudden severe periumbilical pain and one episode of vomiting. She appears distressed, but the abdomen is soft with minimal tenderness. Serum lactate is 1.8 mmol/L and the white cell count is 11 x10^9/L. What is the most appropriate next step?

   1. AReassure and reassess in 4 hours, as a normal lactate excludes bowel ischaemia
   2. BOrder erect chest and supine abdominal radiographs and manage as gastroenteritis if normal
   3. CArrange urgent CT angiography of the abdomen with arterial and portal venous phases
   4. DPerform transabdominal ultrasound of the mesenteric vessels as the definitive investigation
   Show answer and explanation

   Correct answer: C. Arrange urgent CT angiography of the abdomen with arterial and portal venous phases

   Pain out of proportion to examination findings in a patient with an embolic risk factor is classic acute mesenteric ischaemia, and biphasic CT angiography is the diagnostic test of choice and should not be delayed. Lactate rises late, once transmural infarction has developed, so a normal value does not exclude the diagnosis and must never be used to reassure. Plain radiographs are normal early and non-specific late, and ultrasound is operator-dependent, limited by bowel gas and cannot reliably exclude distal occlusion.

   Reference: European Society for Trauma and Emergency Surgery Guidelines on Acute Mesenteric Ischaemia (2016); American Gastroenterological Association Guideline on Acute Mesenteric Ischemia (2021)

6. Question 6 · Endocrine, Metabolic, Electrolyte, Renal and Genitourinary Emergencies

   A 55-year-old renal transplant recipient on tacrolimus was prescribed clarithromycin by a walk-in clinic 5 days ago for bronchitis. He now has tremor, headache, nausea and a creatinine that has risen from 110 to 205 micromol/L. He is afebrile with no graft tenderness. What is the most likely explanation?

   1. AAcute antibody-mediated rejection triggered by intercurrent infection
   2. BClarithromycin inhibition of CYP3A4 and P-glycoprotein causing tacrolimus toxicity
   3. CDirect nephrotoxicity of clarithromycin causing acute interstitial nephritis
   4. DRenal artery stenosis of the transplanted kidney
   Show answer and explanation

   Correct answer: B. Clarithromycin inhibition of CYP3A4 and P-glycoprotein causing tacrolimus toxicity

   Macrolides such as clarithromycin and erythromycin, along with azole antifungals, diltiazem and grapefruit juice, potently inhibit CYP3A4 and P-glycoprotein, causing tacrolimus levels to rise steeply within days and producing tremor, headache, nausea and a reversible reduction in glomerular filtration. The immediate steps are an urgent tacrolimus level, stopping or substituting the interacting drug (for example with azithromycin) and transplant-team consultation. Rejection at this stage would not be explained by the drug timing and usually lacks neurotoxic symptoms, interstitial nephritis from clarithromycin is rare and would not cause tremor, and transplant renal artery stenosis presents with refractory hypertension over a longer course.

   Reference: KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients (2009); Tintinalli's Emergency Medicine, 9th edition (2020)

7. Question 7 · Infectious Disease, HEENT, Ophthalmology, Dermatology and Palliative/End-of-Life Care

   A 45-year-old diabetic man presents with two days of rapidly worsening submandibular swelling after dental pain. The floor of the mouth is elevated and indurated bilaterally, the tongue is displaced upward, and he is drooling with muffled speech and mild stridor. Which management priority is correct?

   1. ACT neck first, with airway management deferred until imaging is complete
   2. BImmediate needle aspiration of the submandibular swelling at the bedside
   3. CEarly definitive airway management with senior anaesthetic and ENT presence and a surgical airway plan, alongside broad-spectrum antibiotics
   4. DBlind nasotracheal intubation on the ward
   Show answer and explanation

   Correct answer: C. Early definitive airway management with senior anaesthetic and ENT presence and a surgical airway plan, alongside broad-spectrum antibiotics

   Ludwig angina is a rapidly progressive bilateral submandibular space cellulitis in which airway obstruction is the leading cause of death; drooling, muffled voice and stridor signal impending obstruction, so a planned definitive airway (awake fibreoptic or awake tracheostomy) with double set-up for a surgical airway takes precedence. Antibiotics covering oral flora including anaerobes and drainage of any collection follow. Bedside aspiration, blind nasotracheal intubation and deferring the airway for imaging all risk catastrophic loss of the airway in an uncontrolled setting.

   Reference: Rosen's Emergency Medicine, 10th edition, 2023; Difficult Airway Society guidelines for management of the anticipated difficult airway, 2015

8. Question 8 · Trauma, EMS, Prehospital and Disaster Medicine

   A 56-year-old man with a vertical shear pelvic fracture remains hypotensive at 80/50 mmHg despite a correctly applied pelvic binder and 6 units of red cells with balanced plasma and platelets. eFAST is negative, the chest radiograph is normal and there is no external bleeding. What is the most appropriate next intervention?

   1. AUrgent pelvic angiography with angioembolisation, or preperitoneal pelvic packing if angiography is not immediately available
   2. BEmergency laparotomy with splenic and hepatic packing
   3. CFurther crystalloid loading and repeat eFAST in 30 minutes
   4. DImmediate external fixation in the emergency department followed by CT of the whole body
   Show answer and explanation

   Correct answer: A. Urgent pelvic angiography with angioembolisation, or preperitoneal pelvic packing if angiography is not immediately available

   With a negative eFAST and normal chest imaging, the pelvic retroperitoneum is the presumed source of ongoing exsanguination, and the two accepted haemorrhage-control options are angioembolisation for arterial bleeding or preperitoneal pelvic packing where angiography is unavailable or the patient is too unstable to transfer. Resuscitative endovascular balloon occlusion of the aorta in zone III may be used as a bridge in selected systems. Laparotomy is not indicated with a negative FAST and no peritoneal signs, crystalloid worsens coagulopathy, and taking a persistently unstable patient to CT is unsafe.

   Reference: Cullinane DC et al. EAST Practice Management Guideline: hemorrhage in pelvic fracture. J Trauma 2011;71:1850-68; WSES classification and guidelines for pelvic trauma, World J Emerg Surg 2017

9. Question 9 · Patient Safety, Professionalism, Ethics, Evidence and ED Operations

   An emergency department wishes to reduce missed diagnoses of subarachnoid haemorrhage and aortic dissection. Which strategy has the strongest supporting evidence for reducing diagnostic error in practice?

   1. AA one-off lecture cataloguing the named cognitive biases for all staff
   2. BAdvising clinicians to rely more on rapid intuitive pattern recognition to save time
   3. CEncouraging clinicians to increase confidence in their first impression to avoid over-testing
   4. DEmbedding validated clinical decision rules, structured reassessment before discharge and systematic feedback on diagnostic outcomes into the workflow
   Show answer and explanation

   Correct answer: D. Embedding validated clinical decision rules, structured reassessment before discharge and systematic feedback on diagnostic outcomes into the workflow

   Interventions that change the system, such as decision support with validated rules, mandatory reassessment of abnormal vital signs before discharge and routine outcome feedback so clinicians learn what they missed, have the best evidence for reducing diagnostic error. Teaching a taxonomy of biases in isolation has repeatedly failed to change diagnostic accuracy, and deliberately increasing reliance on unchecked intuition or first-impression confidence worsens premature closure. Debiasing works best when it is built into the process rather than left to individual vigilance.

   Reference: National Academies of Sciences, Engineering, and Medicine, Improving Diagnosis in Health Care, 2015; Graber ML et al, Cognitive interventions to reduce diagnostic error, BMJ Quality and Safety, 2012

10. Question 10 · Pediatric Emergencies

    A 3-week-old term infant presents with two episodes of green bilious vomiting today. He is mildly unsettled, the abdomen is soft and non-distended, and the plain abdominal film is non-specific. What is the most appropriate investigation?

    1. AAbdominal ultrasound measuring pyloric muscle thickness
    2. BPlain abdominal radiography alone, with discharge if bowel gas is distributed normally
    3. CContrast enema to assess the rectosigmoid transition zone
    4. DUrgent upper gastrointestinal contrast study to exclude malrotation with midgut volvulus
    Show answer and explanation

    Correct answer: D. Urgent upper gastrointestinal contrast study to exclude malrotation with midgut volvulus

    Bilious vomiting in a neonate is malrotation with midgut volvulus until proven otherwise, and the diagnostic test of choice is an urgent upper gastrointestinal contrast study demonstrating the position of the duodenojejunal flexure; delay risks irreversible midgut infarction. Pyloric stenosis causes non-bilious projectile vomiting because the obstruction is proximal to the ampulla. A normal plain film does not exclude volvulus, and contrast enema is the investigation for Hirschsprung disease rather than for malrotation.

    Reference: Nelson Textbook of Pediatrics, 21st edition (2020); American Pediatric Surgical Association guidance on malrotation

11. Question 11 · Neurologic and Psychiatric Emergencies

    A 22-year-old woman who has taken a paracetamol overdose two hours ago refuses treatment and demands to leave. She is drowsy, tearful, gives inconsistent answers, cannot repeat back the explanation of what untreated paracetamol poisoning would do to her, and states she wants to die. What is the most appropriate action?

    1. ARespect her refusal and document that she left against medical advice
    2. BDetain and treat her under the applicable mental health or common law emergency provision, as she lacks capacity for this decision
    3. CAsk a relative to sign a consent form on her behalf
    4. DDischarge her with an outpatient psychiatric appointment and written safety-netting advice
    Show answer and explanation

    Correct answer: B. Detain and treat her under the applicable mental health or common law emergency provision, as she lacks capacity for this decision

    Capacity requires the ability to understand, retain, weigh and communicate a decision, and her drowsiness with inability to retain or repeat the consequences of refusal demonstrates that this is absent, so treatment in her best interests under the relevant legal framework is both lawful and required. Accepting refusal from an incapacitous patient with a treatable lethal ingestion would be negligent. Relatives cannot generally consent on behalf of a competent-age adult in most jurisdictions. Discharge in this circumstance is unsafe.

    Reference: UK Mental Capacity Act 2005 principles and equivalent GCC health authority consent standards; Royal College of Emergency Medicine best practice guidance on capacity

12. Question 12 · Gastrointestinal and Abdominal Emergencies

    A 42-year-old woman presents 5 days after a laparoscopic Roux-en-Y gastric bypass with vague abdominal pain, left shoulder tip discomfort and a feeling of anxiety. Temperature is 37.6 C, heart rate is 128/min, blood pressure 108/68 mmHg and respiratory rate 24/min. The abdomen is only mildly tender. Which statement should most influence your management?

    1. AAnastomotic leak can be excluded by a benign abdominal examination and the absence of high fever
    2. BPersistent tachycardia above 120/min is often the earliest and most reliable sign of an anastomotic leak in bariatric patients and warrants urgent imaging and bariatric surgical consultation
    3. CA normal white cell count reliably excludes a leak in the first postoperative week
    4. DShoulder tip pain after bariatric surgery is always residual carbon dioxide and requires only reassurance
    Show answer and explanation

    Correct answer: B. Persistent tachycardia above 120/min is often the earliest and most reliable sign of an anastomotic leak in bariatric patients and warrants urgent imaging and bariatric surgical consultation

    Bariatric patients frequently lack classic peritonitis because of body habitus and the small contained leaks that occur, so unexplained persistent tachycardia, tachypnoea, anxiety or a sense of impending doom is the most sensitive early warning of an anastomotic leak and mandates urgent CT with oral contrast or a contrast study and immediate surgical involvement. A benign abdomen, absent fever and a normal white cell count do not exclude a leak. Referred shoulder pain in this context can indicate subdiaphragmatic contamination and should never be dismissed.

    Reference: American Society for Metabolic and Bariatric Surgery guidance on the management of leaks after bariatric surgery (2015); Tintinalli's Emergency Medicine, 9th edition (2020)

Emergency Medicine reference books and guidelines

Every question in this bank names the textbook or guideline its answer rests on. These are the sources our Emergency Medicine questions cite most often - the reading list to revise from alongside the bank.

Where your regulator publishes a reading list, use the editions it names. Exam questions are not taken from any one book.