COMSAE level 2 111 COMPREHENSIVE EXAM
2026 QUESTIONS WITH SOLUTIONS GRADED A+
INTERNAL MEDICINE
1. A 62-year-old man with long-standing hypertension presents with progressive
exertional dyspnea and bilateral lower-extremity edema. Echocardiogram shows
concentric LV hypertrophy with preserved EF. Most likely diagnosis?
A. Dilated cardiomyopathy
B. Restrictive cardiomyopathy
C. Heart failure with preserved ejection fraction
D. Acute systolic heart failure
Correct Answer: C
Big Rationale:
HFpEF is classic in older patients with chronic hypertension. Concentric LV
hypertrophy causes diastolic dysfunction while EF remains normal. COMSAE loves
this presentation. Dilated cardiomyopathy would show reduced EF and chamber
dilation.
2. A patient with atrial fibrillation develops sudden onset left arm weakness and
slurred speech. Best initial imaging?
A. MRI brain with contrast
B. CT head without contrast
C. Carotid Doppler
D. CT angiography
, Correct Answer: B
Big Rationale:
Non-contrast CT head is ALWAYS first in suspected stroke to rule out hemorrhage.
NBOME heavily tests sequencing before advanced imaging.
3. Which lab abnormality is most consistent with SIADH?
A. Hypernatremia
B. High serum osmolality
C. Low urine sodium
D. Low serum osmolality
Correct Answer: D
Big Rationale:
SIADH causes euvolemic hyponatremia, low serum osmolality, and
inappropriately concentrated urine. COMSAE tests pattern recognition.
4. A diabetic patient presents with nausea, abdominal pain, and Kussmaul
respirations. Most important initial treatment?
A. IV insulin
B. IV bicarbonate
C. IV fluids
D. Potassium replacement
Correct Answer: C
Big Rationale:
In DKA, IV fluids come first, even before insulin. Insulin without volume
resuscitation worsens hypotension. NBOME loves “FIRST step” questions.
, 5. A patient with chronic kidney disease develops secondary
hyperparathyroidism. What lab finding is expected?
A. Increased calcium
B. Decreased phosphate
C. Increased PTH
D. Increased vitamin D
Correct Answer: C
Big Rationale:
CKD → phosphate retention → ↓ calcium → ↑ PTH. COMSAE frequently tests renal-
bone physiology.
PULMONOLOGY
6. A smoker presents with chronic productive cough for 3 months over 2
consecutive years. Diagnosis?
A. Emphysema
B. Chronic bronchitis
C. Asthma
D. Bronchiectasis
Correct Answer: B
Big Rationale:
Chronic bronchitis = productive cough ≥3 months for 2 years. This definition is
NBOME gold.
7. Best next step in suspected pulmonary embolism with hemodynamic
instability?
2026 QUESTIONS WITH SOLUTIONS GRADED A+
INTERNAL MEDICINE
1. A 62-year-old man with long-standing hypertension presents with progressive
exertional dyspnea and bilateral lower-extremity edema. Echocardiogram shows
concentric LV hypertrophy with preserved EF. Most likely diagnosis?
A. Dilated cardiomyopathy
B. Restrictive cardiomyopathy
C. Heart failure with preserved ejection fraction
D. Acute systolic heart failure
Correct Answer: C
Big Rationale:
HFpEF is classic in older patients with chronic hypertension. Concentric LV
hypertrophy causes diastolic dysfunction while EF remains normal. COMSAE loves
this presentation. Dilated cardiomyopathy would show reduced EF and chamber
dilation.
2. A patient with atrial fibrillation develops sudden onset left arm weakness and
slurred speech. Best initial imaging?
A. MRI brain with contrast
B. CT head without contrast
C. Carotid Doppler
D. CT angiography
, Correct Answer: B
Big Rationale:
Non-contrast CT head is ALWAYS first in suspected stroke to rule out hemorrhage.
NBOME heavily tests sequencing before advanced imaging.
3. Which lab abnormality is most consistent with SIADH?
A. Hypernatremia
B. High serum osmolality
C. Low urine sodium
D. Low serum osmolality
Correct Answer: D
Big Rationale:
SIADH causes euvolemic hyponatremia, low serum osmolality, and
inappropriately concentrated urine. COMSAE tests pattern recognition.
4. A diabetic patient presents with nausea, abdominal pain, and Kussmaul
respirations. Most important initial treatment?
A. IV insulin
B. IV bicarbonate
C. IV fluids
D. Potassium replacement
Correct Answer: C
Big Rationale:
In DKA, IV fluids come first, even before insulin. Insulin without volume
resuscitation worsens hypotension. NBOME loves “FIRST step” questions.
, 5. A patient with chronic kidney disease develops secondary
hyperparathyroidism. What lab finding is expected?
A. Increased calcium
B. Decreased phosphate
C. Increased PTH
D. Increased vitamin D
Correct Answer: C
Big Rationale:
CKD → phosphate retention → ↓ calcium → ↑ PTH. COMSAE frequently tests renal-
bone physiology.
PULMONOLOGY
6. A smoker presents with chronic productive cough for 3 months over 2
consecutive years. Diagnosis?
A. Emphysema
B. Chronic bronchitis
C. Asthma
D. Bronchiectasis
Correct Answer: B
Big Rationale:
Chronic bronchitis = productive cough ≥3 months for 2 years. This definition is
NBOME gold.
7. Best next step in suspected pulmonary embolism with hemodynamic
instability?
