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COMSAE Phase 2 Form 116 Practice Examination
150 Multiple-Choice Questions with Verified Answers and
Detailed Rationales in Italics
EXAM FORMAT & BLUEPRINT INFORMATION
This practice examination is designed to mirror the content and structure of the COMSAE Phase 2 Form 116, which is aligned with the COMLEX-USA Level 2-CE blueprint. The actual COMSAE Phase 2 examination contains 160 items divided into four sections of 40 questions each. All questions are single-best-answer, multiple- choice format, and some include images or visual exhibits. Key Content Areas Tested: Internal Medicine (Cardiovascular, Pulmonary, Endocrine, Nephrology, GI, Infectious Disease) Emergency Medicine & Critical Care Family Medicine & Preventive Care Obstetrics & Gynecology Pediatrics Psychiatry & Behavioral Health Surgery & Perioperative Care Osteopathic Principles & Manipulative Medicine (OPP/OMM) Ethics, Professionalism & Systems-Based Practice
SECTION 1: CARDIOLOGY & VASCULAR MEDICINE
(Questions 1-25)
QUESTION 1
A 55-year-old man with a history of hypertension presents with acute substernal chest pain radiating to the jaw. ECG shows ST-segment elevations in leads V2-V4. Troponin I is elevated. Which is the most appropriate immediate management? A. Sublingual nitroglycerin and observation B. Aspirin, oxygen, and primary percutaneous coronary intervention (PCI) C. Thrombolytic therapy with tenecteplase D. Heparin infusion and admission to medical floor Correct Answer: B Rationale: This patient is presenting with an acute anterior ST-elevation myocardial infarction (STEMI), as evidenced by ST elevations in the anterior leads (V2-V4). Primary PCI is the preferred reperfusion strategy if it can be performed within 90-120 minutes of first medical contact. Aspirin and oxygen are immediate adjunctive therapies. Thrombolytics are an alternative if PCI is not available within the recommended timeframe, but PCI is preferred. Observation or heparin alone would not provide definitive reperfusion. QUESTION 2 A 72-year-old man with atrial fibrillation on warfarin presents with sudden severe headache and vomiting. INR is 4.8. CT head shows a right frontal intraparenchymal hemorrhage. Which is the most appropriate immediate treatment? A. Vitamin K 10 mg IV B. Fresh frozen plasma (FFP) C. Prothrombin complex concentrate (PCC) D. Hold warfarin and observe Correct Answer: C Rationale: Prothrombin complex concentrate (PCC) rapidly reverses warfarin in intracranial hemorrhage and is the preferred agent. FFP is slower and less effective, requiring large volumes and lengthy infusion times. Vitamin K takes hours to work and should be given as an adjunct to PCC, not as the sole therapy. Holding warfarin and observing would allow continued bleeding expansion and is contraindicated in intracranial
SVT. If vagal maneuvers fail, IV adenosine (6 mg rapid IV push followed by saline flush) is the next step. Synchronized cardioversion is reserved for unstable SVT with hypotension or signs of poor perfusion. Amiodarone is not first-line for SVT. QUESTION 5 A 66-year-old man presents with acute right-sided weakness and aphasia. Last known well time was 2 hours ago. CT head is negative for hemorrhage. BP is 185/102 mmHg. Which additional finding would exclude IV tPA administration? A. Age 66 B. Glucose 46 mg/dL C. History of hypertension D. INR 1. Correct Answer: B Rationale: Hypoglycemia (glucose < 50 mg/dL) mimics stroke and must be corrected before tPA administration. Contraindications for IV tPA include: recent intracranial hemorrhage, uncontrolled hypertension (>185/110 mmHg), active bleeding, coagulopathy (INR > 1.7), and glucose < 50 mg/dL. Age > 80 years is a relative contraindication, but age 66 does not exclude tPA. A history of hypertension alone is not a contraindication if BP is controlled. QUESTION 6 A 45-year-old woman with a history of mitral valve prolapse presents with fever, new murmur, and Janeway lesions. Blood cultures are positive for viridans group streptococci. Which is the most appropriate diagnosis and treatment? A. Acute rheumatic fever; penicillin G B. Infective endocarditis; penicillin G and gentamicin C. Marantic endocarditis; warfarin D. Libman-Sacks endocarditis; corticosteroids Correct Answer: B
Rationale: This patient has infective endocarditis with peripheral manifestations (Janeway lesions, new murmur) in the setting of a predisposing valvular lesion (mitral valve prolapse). The causative organism (viridans group streptococci) is a common pathogen in subacute native valve endocarditis. Treatment involves IV penicillin G and gentamicin. Acute rheumatic fever follows group A streptococcal pharyngitis and is not associated with Janeway lesions or positive blood cultures. QUESTION 7 A 68-year-old woman with a history of heart failure with reduced ejection fraction (HFrEF) presents with progressive dyspnea and peripheral edema. She is on lisinopril, carvedilol, and furosemide. Which additional medication has been shown to reduce mortality in HFrEF? A. Digoxin B. Spironolactone C. Diltiazem D. Dobutamine Correct Answer: B Rationale: Spironolactone (an aldosterone antagonist) has been shown to reduce mortality and hospitalizations in patients with HFrEF (NYHA class III-IV) when added to standard therapy with ACE inhibitors and beta-blockers. Digoxin reduces hospitalizations but has not been shown to reduce mortality. Calcium channel blockers (diltiazem) are generally contraindicated in HFrEF. Dobutamine is an acute therapy and does not improve long- term mortality. QUESTION 8 A 32-year-old woman presents with palpitations, heat intolerance, and weight loss. On examination, she has tachycardia and a fine tremor. Laboratory studies reveal suppressed TSH and elevated free T4. Which antibody is most likely to be positive? A. Anti-TPO (thyroid peroxidase) B. Anti-TSH receptor (TRAb)
A. Anti-centromere antibody B. Anti-Scl-70 (anti-topoisomerase I) C. Anti-dsDNA D. Anti-Sm Correct Answer: B Rationale: This patient has systemic sclerosis (scleroderma) with progressive skin thickening, Raynaud's, GERD, and pulmonary involvement. Anti-Scl-70 (anti- topoisomerase I) is specific for diffuse systemic sclerosis and is associated with interstitial lung disease. Anti-centromere antibody is associated with limited cutaneous systemic sclerosis (CREST syndrome). Anti-dsDNA and anti-Sm are specific for systemic lupus erythematosus. QUESTION 11 A 65-year-old man with a history of hypertension and diabetes presents with sudden onset of severe left flank pain radiating to the groin. Urinalysis shows gross hematuria. Which is the most appropriate initial imaging study? A. CT abdomen/pelvis without contrast B. CT abdomen/pelvis with contrast C. Renal ultrasound D. KUB (kidney, ureter, bladder) X-ray Correct Answer: B Rationale: This patient has classic symptoms of nephrolithiasis (renal colic) with flank pain radiating to the groin and hematuria. Non-contrast CT of the abdomen and pelvis is the gold standard for diagnosing urinary tract stones, as it provides high sensitivity and specificity for detecting even small stones. Renal ultrasound is useful for hydronephrosis but may miss small stones. KUB X-ray has lower sensitivity, especially for uric acid stones. Contrast CT is not necessary and may delay diagnosis. QUESTION 12
A 34-year-old woman with a history of systemic lupus erythematosus presents with progressive dyspnea and pleuritic chest pain. ECG shows diffuse ST-segment elevations. Troponin is mildly elevated. Which is the most likely diagnosis? A. Acute myocardial infarction B. Pulmonary embolism C. Pericarditis D. Aortic dissection Correct Answer: C Rationale: This patient has pericarditis, which is common in systemic lupus erythematosus. The classic presentation includes pleuritic chest pain, pericardial friction rub, and diffuse ST-segment elevations on ECG. Troponin may be mildly elevated due to associated myocarditis (myopericarditis). Acute MI would have regional ST elevations and a more pronounced troponin rise. Pulmonary embolism would present with tachycardia and hypoxia. Aortic dissection would present with tearing chest or back pain. QUESTION 13 A 72-year-old woman presents with palpitations and lightheadedness. ECG shows an irregularly irregular rhythm with no distinct P waves. Which is the most appropriate initial therapy for rate control? A. Digoxin B. Amiodarone C. Metoprolol D. Diltiazem Correct Answer: C Rationale: This patient has atrial fibrillation (irregularly irregular rhythm, absent P waves). Beta-blockers (e.g., metoprolol) and non-dihydropyridine calcium channel blockers (diltiazem or verapamil) are first-line agents for rate control in atrial fibrillation. Digoxin is used in patients with heart failure or as a second-line agent. Amiodarone is used for rhythm control, not rate control, and has significant toxicity.
QUESTION 16
A 48-year-old man with a history of heavy alcohol use presents with acute upper abdominal pain radiating to the back. Serum lipase is elevated to 1,200 U/L. Which finding on abdominal CT would confirm the diagnosis and indicate the most severe form? A. Pancreatic edema B. Peripancreatic fluid collections C. Pancreatic necrosis D. Pseudocyst formation Correct Answer: C Rationale: This patient has acute pancreatitis (elevated lipase, epigastric pain radiating to back). CT with IV contrast is the gold standard for assessing severity. Pancreatic necrosis is the most severe finding on CT and is associated with increased morbidity and mortality. Pancreatic edema indicates mild pancreatitis. Peripancreatic fluid collections and pseudocysts are complications that can occur but are not as immediately severe as necrosis. QUESTION 17 A 35-year-old woman presents with palpitations, diaphoresis, and a feeling of impending doom. Her pulse is 135/min and blood pressure is 100/70 mmHg. ECG shows a narrow-complex tachycardia at 135 bpm with P waves preceding each QRS. Which is the most likely rhythm? A. Supraventricular tachycardia B. Atrial fibrillation C. Sinus tachycardia D. Ventricular tachycardia Correct Answer: C Rationale: This patient has sinus tachycardia. The presence of P waves preceding each QRS complex with a rate of 135 bpm is consistent with sinus tachycardia. The clinical context (anxiety, diaphoresis) supports a physiologic response rather than an arrhythmia. SVT
typically has rates > 150-180 bpm with absent P waves. Atrial fibrillation is irregularly irregular. Ventricular tachycardia would have wide QRS complexes. QUESTION 18 A 62-year-old man with a history of diabetes and hypertension presents with a painless, non-healing ulcer on his right heel. Dorsalis pedis and posterior tibial pulses are diminished. Which is the most appropriate initial management? A. Debridement and local wound care B. Vascular surgery consultation for revascularization C. Antibiotic therapy D. Hyperbaric oxygen therapy Correct Answer: B Rationale: This patient has a non-healing ulcer with diminished distal pulses, suggestive of peripheral arterial disease (PAD) and critical limb ischemia. The most appropriate initial management is vascular surgery consultation for revascularization. While wound care and antibiotics are important adjuncts, they do not address the underlying vascular insufficiency. Hyperbaric oxygen is not first-line therapy. QUESTION 19 A 55-year-old woman presents with progressive dyspnea, fatigue, and leg swelling. Jugular venous pressure is elevated at 15 cm H₂O. Echocardiogram shows a thickened, calcified pericardium with diastolic dysfunction. Which is the most likely diagnosis? A. Constrictive pericarditis B. Cardiac tamponade C. Dilated cardiomyopathy D. Hypertrophic cardiomyopathy Correct Answer: A
C. Dobutamine infusion D. Digoxin Correct Answer: A Rationale: This patient has acute decompensated heart failure with volume overload (dyspnea, orthopnea, edema, crackles, S3 gallop). The most appropriate initial therapy is IV loop diuretic (furosemide) to reduce preload and relieve pulmonary congestion. Nitroglycerin may be added for afterload reduction but is not first-line. Dobutamine is used for cardiogenic shock with low cardiac output. Digoxin is used for chronic management, not acute decompensation. QUESTION 22 A 52-year-old man presents with sudden onset of severe chest pain that worsens with inspiration and improves when leaning forward. ECG shows diffuse ST-segment elevations. Which is the most likely diagnosis? A. Acute myocardial infarction B. Pericarditis C. Pulmonary embolism D. Aortic dissection Correct Answer: B Rationale: This patient has acute pericarditis. Classic features include pleuritic chest pain that worsens with inspiration and improves with leaning forward, with diffuse ST-segment elevations on ECG. Acute MI would have regional ST elevations. Pulmonary embolism would present with tachycardia and hypoxia. Aortic dissection would present with tearing pain radiating to the back. QUESTION 23 A 60-year-old woman with a history of hypertension and hyperlipidemia presents with a 1 - hour history of chest pressure and nausea. ECG shows ST depressions in leads V5-V and I, aVL. Troponin is initially negative. Which is the most appropriate management?
A. Discharge home with aspirin B. Admission to observation unit with serial troponins and ECG C. Immediate coronary angiography D. Thrombolytic therapy Correct Answer: B Rationale: This patient has unstable angina or non-ST-elevation myocardial infarction (NSTEMI) with ischemic ECG changes (ST depressions in lateral leads). The most appropriate management includes admission, serial troponins, and ECG monitoring to rule out MI. High-risk patients (ongoing pain, hemodynamic instability, dynamic ECG changes) may warrant immediate catheterization, but initial negative troponin does not exclude MI. Discharge home would be unsafe. Thrombolytics are not indicated for NSTEMI. QUESTION 24 A 48-year-old man with a history of hypertension presents with a sudden, severe headache described as "the worst headache of my life." CT head is negative for hemorrhage. Which is the most appropriate next step? A. Discharge with migraine medication B. MRI of the brain C. Lumbar puncture D. CT angiography of the head and neck Correct Answer: C Rationale: A "thunderclap" headache (sudden, severe, worst of life) is concerning for subarachnoid hemorrhage (SAH). If CT head is negative (within 6 hours of onset), the next step is a lumbar puncture to evaluate for xanthochromia and RBCs in the CSF. MRI is less sensitive than CT for acute hemorrhage. CT angiography would evaluate for aneurysm but is performed after confirmation of SAH. QUESTION 25
Rationale: This patient has a severe asthma exacerbation (tachypnea, tachycardia, hypoxia, failure of home therapy). The most appropriate initial management includes nebulized albuterol with ipratropium bromide, systemic corticosteroids, and high-flow oxygen. Intubation is indicated if the patient is unable to maintain ventilation or becomes obtunded. Discharge home would be unsafe. Increasing the frequency of albuterol alone is insufficient. QUESTION 27 A 45-year-old woman presents with progressive dyspnea on exertion and a dry cough. HRCT shows bilateral ground-glass opacities and intralobular septal thickening with a "crazy-paving" pattern. Which is the most likely diagnosis? A. Idiopathic pulmonary fibrosis (IPF) B. Pulmonary alveolar proteinosis (PAP) C. Hypersensitivity pneumonitis D. Sarcoidosis Correct Answer: B Rationale: The "crazy-paving" pattern on HRCT (ground-glass opacities with intralobular septal thickening) is classic for pulmonary alveolar proteinosis (PAP). The diagnosis is confirmed by PAS-positive material on bronchoalveolar lavage (BAL). IPF shows honeycombing and usual interstitial pneumonia (UIP) pattern. Hypersensitivity pneumonitis shows centrilobular nodules. Sarcoidosis shows hilar adenopathy and perilymphatic nodules. QUESTION 28 A 35-year-old woman with a history of systemic lupus erythematosus presents with sudden onset of pleuritic chest pain and dyspnea. Spirometry shows a restrictive pattern. Which is the most likely diagnosis? A. Acute pericarditis B. Pulmonary embolism
C. Pleuritis with effusion D. Pneumonia Correct Answer: C Rationale: This patient has pleuritis with pleural effusion, which is a common pulmonary manifestation of SLE. The pleuritic chest pain and restrictive pattern on spirometry are consistent with pleural involvement. Pericarditis would have ECG changes (diffuse ST elevations). Pulmonary embolism would present with tachycardia and hypoxia. Pneumonia would have fever and productive cough. QUESTION 29 A 65-year-old man with a 50-pack-year smoking history presents with a 3-month history of worsening cough, hemoptysis, and weight loss. Chest X-ray shows a right hilar mass and right upper lobe atelectasis. Which is the most likely diagnosis and appropriate initial diagnostic test? A. Small cell lung cancer; sputum cytology B. Non-small cell lung cancer; CT-guided biopsy C. Mesothelioma; thoracentesis D. Tuberculosis; PPD Correct Answer: B Rationale: This patient has central lung cancer (hilar mass, upper lobe atelectasis, hemoptysis, weight loss) in a heavy smoker. Non-small cell lung cancer (NSCLC) is the most likely type, given the central location. CT-guided biopsy is the appropriate initial diagnostic test. Sputum cytology has lower sensitivity. Mesothelioma is associated with asbestos exposure. Tuberculosis would present with fever and night sweats. QUESTION 30 A 42-year-old man presents with a sudden onset of shortness of breath and sharp chest pain on the right side after a long flight. He is tachypneic and hypoxic on pulse oximetry. Which is the most likely diagnosis and appropriate immediate test?
A 25-year-old man presents with sudden onset of chest pain and shortness of breath while playing basketball. He is tall and thin with a hyperresonant right hemithorax and decreased breath sounds on the right side. Which is the most likely diagnosis? A. Spontaneous pneumothorax B. Pericarditis C. Pulmonary embolism D. Asthma exacerbation Correct Answer: A Rationale: This patient has a spontaneous pneumothorax, which is common in tall, thin young males (Marfanoid habitus). The sudden onset of chest pain, dyspnea, hyperresonance, and decreased breath sounds on the affected side are classic findings. Pericarditis would have pain improved by leaning forward. Pulmonary embolism would have tachycardia and hypoxia. Asthma exacerbation would have wheezing. QUESTION 33 A 60-year-old man with a history of COPD presents with increasing dyspnea and purulent sputum production. He is febrile to 38.5°C. Spirometry is unchanged from baseline. Which is the most appropriate management? A. Antibiotics and corticosteroids B. Home oxygen therapy C. Pulmonary rehabilitation D. Influenza vaccination Correct Answer: A Rationale: This patient has an acute exacerbation of COPD (increased dyspnea, sputum purulence, fever). The most appropriate management includes antibiotics (for purulent sputum) and systemic corticosteroids (for airway inflammation). Home oxygen therapy is for chronic hypoxemia. Pulmonary rehabilitation is for stable COPD. Influenza vaccination is for prevention, not treatment of acute exacerbation.
QUESTION 34
A 28-year-old woman with a history of asthma presents with a 2-day history of worsening cough and wheezing. She is using her albuterol inhaler every 2 hours. Examination reveals use of accessory muscles and decreased breath sounds with minimal wheezing. SpO₂ is 85% on room air. Which is the most appropriate immediate management? A. Continue home medications and follow up in clinic B. Nebulized albuterol, ipratropium, and systemic corticosteroids C. Intubation and mechanical ventilation D. High-flow oxygen alone Correct Answer: B Rationale: This patient has a severe asthma exacerbation (decreased breath sounds with minimal wheezing, accessory muscle use, hypoxia). The "silent chest" (decreased breath sounds with minimal wheezing) indicates severe airflow obstruction. The most appropriate immediate management is nebulized albuterol, ipratropium, systemic corticosteroids, and high-flow oxygen. Intubation is indicated if the patient fails to improve or becomes obtunded. QUESTION 35 A 50-year-old man with a history of silicosis presents with progressive dyspnea, cough, and weight loss. Chest X-ray shows bilateral upper lobe masses. Which is the most likely diagnosis? A. Tuberculosis B. Silicosis with progressive massive fibrosis C. Silicosis with lung cancer D. Sarcoidosis Correct Answer: C Rationale: Silicosis is a risk factor for lung cancer. Bilateral upper lobe masses in a silicosis patient should raise concern for lung cancer. Progressive massive fibrosis (PMF) typically shows conglomerate masses that are symmetric. Tuberculosis would show upper lobe cavities. Sarcoidosis would show bilateral hilar adenopathy.
