Page 1 of 208
COMSAE Phase 2 – Form 109 Exam QUESTIONS
AND DETAILED SOLUTIONS JUST RELEASED
POINT-FORM SUMMARIZED EXAM COVERAGE (COMSAE Phase 2 – Form 109)
• Cardiovascular: Acute coronary syndromes (inferior, anterior, lateral MI on ECG), aortic
dissection (tearing pain, BP differential), heart failure (S3, JVD, pulmonary edema), hypertension
urgency/emergency (papilledema, encephalopathy), peripheral vascular disease
• Pulmonary: Pulmonary embolism (sudden dyspnea, pleuritic pain, DVT history), COPD
exacerbation, community-acquired pneumonia, tuberculosis (cavitary lesions, hemoptysis),
pneumothorax
• Neurology: Stroke (ischemic vs hemorrhagic, tPA window, NIHSS, MCA syndromes),
subarachnoid hemorrhage (thunderclap headache, photophobia, LP after negative CT),
meningitis (Kernig/Brudzinski, empiric antibiotics), seizure disorders, Parkinson disease (resting
tremor, bradykinesia)
• Gastroenterology: Upper GI bleed (melena, hematemesis), lower GI bleed, acute pancreatitis
(epigastric pain radiating to back, elevated lipase), cholecystitis (RUQ pain, Murphy sign),
cholangitis (Charcot triad), hepatitis, cirrhosis complications (ascites, variceal bleed),
inflammatory bowel disease
• Nephrology: Acute kidney injury (prerenal, intrinsic, postrenal), chronic kidney disease
(hyperkalemia, metabolic acidosis), nephrolithiasis (flank pain, hematuria), urinary tract
infection
• Endocrinology: Diabetes mellitus (DKA: fruity breath, Kussmaul, pH <7.3),
hyperthyroidism/Graves disease (tremor, heat intolerance, exophthalmos, TSI antibodies),
hypothyroidism (fatigue, cold intolerance, elevated TSH), adrenal insufficiency
• Infectious Disease: Sepsis/septic shock, endocarditis (IV drug use → S. aureus, tricuspid),
meningitis (bacterial vs viral), UTI (pyelonephritis, cystitis), STIs (gonorrhea, chlamydia, PID
treatment: ceftriaxone + doxycycline)
• Hematology/Oncology: Anemia (microcytic: iron deficiency menorrhagia/pica; macrocytic:
B12/folate), multiple myeloma (CRAB: hypercalcemia, renal failure, anemia, bone lesions; M
spike), leukemia, lymphoma, lung cancer (spiculated nodule, biopsy), breast cancer
• Rheumatology: Gout/pseudogout (crystal analysis), rheumatoid arthritis, osteoarthritis, SLE
(ANA, anti-dsDNA, malar rash), vasculitis
• Obstetrics/Gynecology: Normal pregnancy, preeclampsia/eclampsia (HTN, proteinuria, seizures),
gestational diabetes, preterm labor, PROM, postpartum hemorrhage, contraception, STI
screening, ovarian torsion (sudden pain, adnexal mass)
• Pediatrics: Failure to thrive, congenital heart disease (PDA: continuous murmur), croup (barking
cough, stridor), bronchiolitis (RSV), immunodeficiencies (DiGeorge: absent thymus,
hypocalcemia)
• Psychiatry: Major depressive disorder, generalized anxiety disorder, panic disorder, bipolar
disorder, schizophrenia, substance use disorders, suicide risk assessment
• Ethics/Professionalism: Informed consent (capacity, competence, minors, emergencies),
confidentiality (HIPAA, minor consent, STI reporting, duty to warn), end-of-life care (advance
directives, DNR, physician aid in dying laws), physician impairment, conflict of interest, patient
autonomy
• Biostatistics/EBM: Sensitivity, specificity, PPV, NPV, likelihood ratios, NNT, NNH, absolute risk
reduction, relative risk reduction, odds ratio, confidence intervals, p-values, Type I & II errors,
, Page 2 of 208
power, study design (RCT, cohort, case-control, cross-sectional, meta-analysis), bias,
confounding, effect modification
Question 1 A 45-year-old man presents with sudden-onset chest pain radiating to his left arm. He is
diaphoretic and nauseated. ECG shows ST-segment elevation in leads II, III, and aVF. Which is the most
likely diagnosis?
A) Pulmonary embolism
B) Acute inferior myocardial infarction
C) Aortic dissection
D) Pericarditis
Answer: B
Rationale: ST elevation in leads II, III, and aVF indicates inferior wall MI. The right coronary artery (RCA)
typically supplies this territory. The symptoms of chest pain radiating to the arm, diaphoresis, and
nausea support an acute coronary syndrome .
, Page 3 of 208
Question 2 A 32-year-old woman presents with fatigue, pallor, and heavy menstrual periods. Labs reveal
hemoglobin 9 g/dL and microcytic anemia. The most likely cause is:
A) Vitamin B12 deficiency
B) Iron deficiency anemia
C) Hemolytic anemia
D) Aplastic anemia
Answer: B
Rationale: Microcytic anemia (low MCV) with chronic blood loss from menorrhagia suggests iron
deficiency. The pallor, fatigue, and heavy menses are classic risk factors. B12 deficiency causes
macrocytic anemia .
Question 3 A 60-year-old man with a history of hypertension presents with sudden severe headache,
neck stiffness, and photophobia. Which is the next best step?
, Page 4 of 208
A) MRI of the brain
B) Non-contrast CT of the head
C) Lumbar puncture immediately
D) Start empiric antibiotics
Answer: B
Rationale: Sudden severe "thunderclap" headache with nuchal rigidity suggests subarachnoid
hemorrhage. Non-contrast head CT is the initial test of choice (high sensitivity within 6 hours). Lumbar
puncture is next if CT is negative .
Question 4 A 28-year-old woman presents with fever, dysuria, and urgency. Urinalysis shows positive
nitrites and leukocyte esterase. The most appropriate initial therapy is:
A) IV vancomycin
B) Oral trimethoprim-sulfamethoxazole
C) Oral ciprofloxacin
D) Observation only
COMSAE Phase 2 – Form 109 Exam QUESTIONS
AND DETAILED SOLUTIONS JUST RELEASED
POINT-FORM SUMMARIZED EXAM COVERAGE (COMSAE Phase 2 – Form 109)
• Cardiovascular: Acute coronary syndromes (inferior, anterior, lateral MI on ECG), aortic
dissection (tearing pain, BP differential), heart failure (S3, JVD, pulmonary edema), hypertension
urgency/emergency (papilledema, encephalopathy), peripheral vascular disease
• Pulmonary: Pulmonary embolism (sudden dyspnea, pleuritic pain, DVT history), COPD
exacerbation, community-acquired pneumonia, tuberculosis (cavitary lesions, hemoptysis),
pneumothorax
• Neurology: Stroke (ischemic vs hemorrhagic, tPA window, NIHSS, MCA syndromes),
subarachnoid hemorrhage (thunderclap headache, photophobia, LP after negative CT),
meningitis (Kernig/Brudzinski, empiric antibiotics), seizure disorders, Parkinson disease (resting
tremor, bradykinesia)
• Gastroenterology: Upper GI bleed (melena, hematemesis), lower GI bleed, acute pancreatitis
(epigastric pain radiating to back, elevated lipase), cholecystitis (RUQ pain, Murphy sign),
cholangitis (Charcot triad), hepatitis, cirrhosis complications (ascites, variceal bleed),
inflammatory bowel disease
• Nephrology: Acute kidney injury (prerenal, intrinsic, postrenal), chronic kidney disease
(hyperkalemia, metabolic acidosis), nephrolithiasis (flank pain, hematuria), urinary tract
infection
• Endocrinology: Diabetes mellitus (DKA: fruity breath, Kussmaul, pH <7.3),
hyperthyroidism/Graves disease (tremor, heat intolerance, exophthalmos, TSI antibodies),
hypothyroidism (fatigue, cold intolerance, elevated TSH), adrenal insufficiency
• Infectious Disease: Sepsis/septic shock, endocarditis (IV drug use → S. aureus, tricuspid),
meningitis (bacterial vs viral), UTI (pyelonephritis, cystitis), STIs (gonorrhea, chlamydia, PID
treatment: ceftriaxone + doxycycline)
• Hematology/Oncology: Anemia (microcytic: iron deficiency menorrhagia/pica; macrocytic:
B12/folate), multiple myeloma (CRAB: hypercalcemia, renal failure, anemia, bone lesions; M
spike), leukemia, lymphoma, lung cancer (spiculated nodule, biopsy), breast cancer
• Rheumatology: Gout/pseudogout (crystal analysis), rheumatoid arthritis, osteoarthritis, SLE
(ANA, anti-dsDNA, malar rash), vasculitis
• Obstetrics/Gynecology: Normal pregnancy, preeclampsia/eclampsia (HTN, proteinuria, seizures),
gestational diabetes, preterm labor, PROM, postpartum hemorrhage, contraception, STI
screening, ovarian torsion (sudden pain, adnexal mass)
• Pediatrics: Failure to thrive, congenital heart disease (PDA: continuous murmur), croup (barking
cough, stridor), bronchiolitis (RSV), immunodeficiencies (DiGeorge: absent thymus,
hypocalcemia)
• Psychiatry: Major depressive disorder, generalized anxiety disorder, panic disorder, bipolar
disorder, schizophrenia, substance use disorders, suicide risk assessment
• Ethics/Professionalism: Informed consent (capacity, competence, minors, emergencies),
confidentiality (HIPAA, minor consent, STI reporting, duty to warn), end-of-life care (advance
directives, DNR, physician aid in dying laws), physician impairment, conflict of interest, patient
autonomy
• Biostatistics/EBM: Sensitivity, specificity, PPV, NPV, likelihood ratios, NNT, NNH, absolute risk
reduction, relative risk reduction, odds ratio, confidence intervals, p-values, Type I & II errors,
, Page 2 of 208
power, study design (RCT, cohort, case-control, cross-sectional, meta-analysis), bias,
confounding, effect modification
Question 1 A 45-year-old man presents with sudden-onset chest pain radiating to his left arm. He is
diaphoretic and nauseated. ECG shows ST-segment elevation in leads II, III, and aVF. Which is the most
likely diagnosis?
A) Pulmonary embolism
B) Acute inferior myocardial infarction
C) Aortic dissection
D) Pericarditis
Answer: B
Rationale: ST elevation in leads II, III, and aVF indicates inferior wall MI. The right coronary artery (RCA)
typically supplies this territory. The symptoms of chest pain radiating to the arm, diaphoresis, and
nausea support an acute coronary syndrome .
, Page 3 of 208
Question 2 A 32-year-old woman presents with fatigue, pallor, and heavy menstrual periods. Labs reveal
hemoglobin 9 g/dL and microcytic anemia. The most likely cause is:
A) Vitamin B12 deficiency
B) Iron deficiency anemia
C) Hemolytic anemia
D) Aplastic anemia
Answer: B
Rationale: Microcytic anemia (low MCV) with chronic blood loss from menorrhagia suggests iron
deficiency. The pallor, fatigue, and heavy menses are classic risk factors. B12 deficiency causes
macrocytic anemia .
Question 3 A 60-year-old man with a history of hypertension presents with sudden severe headache,
neck stiffness, and photophobia. Which is the next best step?
, Page 4 of 208
A) MRI of the brain
B) Non-contrast CT of the head
C) Lumbar puncture immediately
D) Start empiric antibiotics
Answer: B
Rationale: Sudden severe "thunderclap" headache with nuchal rigidity suggests subarachnoid
hemorrhage. Non-contrast head CT is the initial test of choice (high sensitivity within 6 hours). Lumbar
puncture is next if CT is negative .
Question 4 A 28-year-old woman presents with fever, dysuria, and urgency. Urinalysis shows positive
nitrites and leukocyte esterase. The most appropriate initial therapy is:
A) IV vancomycin
B) Oral trimethoprim-sulfamethoxazole
C) Oral ciprofloxacin
D) Observation only
