COMSAE Phase 2 (Form 116) Intensive
Review: Exam-Focused Practice
Questions, Detailed Answer Keys, and
Step-by-Step Rationales for Success
1. A 32-year-old woman presents with right lower quadrant
pain, nausea, and fever. She notes similar self-resolving
episodes in the past. Physical exam reveals focal
tenderness with rebound in the right lower quadrant.
Pelvic ultrasound reveals a noncompressible tubular
structure 9 mm in diameter. Which of the following is
the most likely diagnosis?
A. Ovarian torsion
B. Ruptured ovarian cyst
C. Acute appendicitis
D. Pelvic inflammatory disease
E. Ectopic pregnancy
Rationale: The clinical triad of fever, localized right lower
quadrant pain, and rebound tenderness combined with an
ultrasound showing a noncompressible, aperistaltic tubular
structure greater than 6 mm is diagnostic for acute
appendicitis.
, 2. A 4-year-old boy is brought to the clinic for a routine
checkup. On cardiac auscultation, a harsh, holosystolic
murmur is best appreciated at the lower left sternal
border. The child is active, meets all developmental
milestones, and shows no signs of cyanosis or digital
clubbing. Which of the following is the most likely
diagnosis?
A. Patent ductus arteriosus
B. Ventricular septal defect
C. Tetralogy of Fallot
D. Atrial septal defect
Rationale: A harsh, holosystolic murmur heard best at the
lower left sternal border is the classic presentation of a
ventricular septal defect (VSD). Small defects are often
asymptomatic aside from the loud murmur.
3. A 65-year-old man with a history of severe chronic
obstructive pulmonary disease (COPD) presents to the
emergency department with a 3-day history of increased
sputum production, purulence, progressive dyspnea,
and diffuse wheezing. His oxygen saturation is 86% on
room air. Which of the following is the most appropriate
next step in medical management?
A. Chest X-ray only
B. Oral prednisone alone
C. Nebulized bronchodilators, systemic corticosteroids, and
antibiotics
,D. Endotracheal intubation immediately
Rationale: An acute exacerbation of COPD presenting with the
classic triad of increased dyspnea, sputum volume, and
sputum purulence requires prompt treatment with short-
acting bronchodilators, systemic steroids, and empiric
antibiotics.
4. A 22-year-old woman presents with a 4-day history of
lower abdominal pain, deep dyspareunia, and an
abnormal vaginal discharge. On pelvic examination, she
exhibits significant cervical motion tenderness and
mucopurulent cervical discharge. A urine pregnancy test
is negative. Which of the following is the most likely
diagnosis?
A. Endometriosis
B. Pelvic inflammatory disease
C. Ruptured ovarian cyst
D. Ectopic pregnancy
Rationale: The findings of lower abdominal pain,
mucopurulent cervical discharge, and cervical motion
tenderness ("Chandelier sign") in a young woman are highly
specific for pelvic inflammatory disease (PID).
5. A 16-year-old tall, thin male high school athlete develops
sudden-onset, sharp right-sided chest pain and
shortness of breath during a basketball game. There is
no history of trauma. Physical examination reveals
decreased breath sounds and hyperresonance to
, percussion on the right side. Which of the following is
the most likely diagnosis?
A. Pulmonary embolism
B. Spontaneous pneumothorax
C. Acute asthma exacerbation
D. Costochondritis
Rationale: Primary spontaneous pneumothorax
characteristically occurs in tall, thin adolescent males due to
the rupture of subpleural apical blebs. Diagnosis is confirmed
by a chest radiograph showing a visceral pleural line.
6. A 55-year-old man with a 15-year history of type 2
diabetes mellitus presents with a gradual onset of
numbness and a "pins and needles" sensation in both
feet. Physical examination demonstrates decreased
sensation to light touch, pinprick, and vibration in a
symmetrical distribution up to the mid-calf.
Monofilament testing is abnormal. Which of the
following is the most likely diagnosis?
A. Charcot arthropathy
B. Distal symmetric polyneuropathy
C. Guillain-Barré syndrome
D. Myasthenia gravis
Rationale: Chronic poorly controlled diabetes causes distal
symmetric polyneuropathy due to metabolic and ischemic
Review: Exam-Focused Practice
Questions, Detailed Answer Keys, and
Step-by-Step Rationales for Success
1. A 32-year-old woman presents with right lower quadrant
pain, nausea, and fever. She notes similar self-resolving
episodes in the past. Physical exam reveals focal
tenderness with rebound in the right lower quadrant.
Pelvic ultrasound reveals a noncompressible tubular
structure 9 mm in diameter. Which of the following is
the most likely diagnosis?
A. Ovarian torsion
B. Ruptured ovarian cyst
C. Acute appendicitis
D. Pelvic inflammatory disease
E. Ectopic pregnancy
Rationale: The clinical triad of fever, localized right lower
quadrant pain, and rebound tenderness combined with an
ultrasound showing a noncompressible, aperistaltic tubular
structure greater than 6 mm is diagnostic for acute
appendicitis.
, 2. A 4-year-old boy is brought to the clinic for a routine
checkup. On cardiac auscultation, a harsh, holosystolic
murmur is best appreciated at the lower left sternal
border. The child is active, meets all developmental
milestones, and shows no signs of cyanosis or digital
clubbing. Which of the following is the most likely
diagnosis?
A. Patent ductus arteriosus
B. Ventricular septal defect
C. Tetralogy of Fallot
D. Atrial septal defect
Rationale: A harsh, holosystolic murmur heard best at the
lower left sternal border is the classic presentation of a
ventricular septal defect (VSD). Small defects are often
asymptomatic aside from the loud murmur.
3. A 65-year-old man with a history of severe chronic
obstructive pulmonary disease (COPD) presents to the
emergency department with a 3-day history of increased
sputum production, purulence, progressive dyspnea,
and diffuse wheezing. His oxygen saturation is 86% on
room air. Which of the following is the most appropriate
next step in medical management?
A. Chest X-ray only
B. Oral prednisone alone
C. Nebulized bronchodilators, systemic corticosteroids, and
antibiotics
,D. Endotracheal intubation immediately
Rationale: An acute exacerbation of COPD presenting with the
classic triad of increased dyspnea, sputum volume, and
sputum purulence requires prompt treatment with short-
acting bronchodilators, systemic steroids, and empiric
antibiotics.
4. A 22-year-old woman presents with a 4-day history of
lower abdominal pain, deep dyspareunia, and an
abnormal vaginal discharge. On pelvic examination, she
exhibits significant cervical motion tenderness and
mucopurulent cervical discharge. A urine pregnancy test
is negative. Which of the following is the most likely
diagnosis?
A. Endometriosis
B. Pelvic inflammatory disease
C. Ruptured ovarian cyst
D. Ectopic pregnancy
Rationale: The findings of lower abdominal pain,
mucopurulent cervical discharge, and cervical motion
tenderness ("Chandelier sign") in a young woman are highly
specific for pelvic inflammatory disease (PID).
5. A 16-year-old tall, thin male high school athlete develops
sudden-onset, sharp right-sided chest pain and
shortness of breath during a basketball game. There is
no history of trauma. Physical examination reveals
decreased breath sounds and hyperresonance to
, percussion on the right side. Which of the following is
the most likely diagnosis?
A. Pulmonary embolism
B. Spontaneous pneumothorax
C. Acute asthma exacerbation
D. Costochondritis
Rationale: Primary spontaneous pneumothorax
characteristically occurs in tall, thin adolescent males due to
the rupture of subpleural apical blebs. Diagnosis is confirmed
by a chest radiograph showing a visceral pleural line.
6. A 55-year-old man with a 15-year history of type 2
diabetes mellitus presents with a gradual onset of
numbness and a "pins and needles" sensation in both
feet. Physical examination demonstrates decreased
sensation to light touch, pinprick, and vibration in a
symmetrical distribution up to the mid-calf.
Monofilament testing is abnormal. Which of the
following is the most likely diagnosis?
A. Charcot arthropathy
B. Distal symmetric polyneuropathy
C. Guillain-Barré syndrome
D. Myasthenia gravis
Rationale: Chronic poorly controlled diabetes causes distal
symmetric polyneuropathy due to metabolic and ischemic
