COMSAE PHASE II & PHASE 111 FORM 114
PRACTICE EXAM QUESTIONS AND CORRECT
ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2025|2026 Q&A
SECTION 1: INTERNAL MEDICINE
1. A 65-year-old man with a 50 pack-year smoking history presents with painless
hematuria. What is the most likely diagnosis?
• A) Nephrolithiasis
• B) Bladder cancer (urothelial carcinoma)
• C) Urinary tract infection
• D) Glomerulonephritis
Correct Answer: B) Bladder cancer (urothelial carcinoma)
Rationale: Painless hematuria in an older smoker strongly suggests urothelial
carcinoma. The classic presentation is painless gross hematuria. Nephrolithiasis
typically presents with painful hematuria and flank pain. UTI presents with dysuria
and frequency .
2. A 65-year-old man presents with exertional substernal chest pain relieved by
rest. ECG is normal. What is the next best step?
• A) Echocardiogram
• B) Stress test
• C) Coronary angiography
• D) Cardiac enzymes
,Correct Answer: B) Stress test
Rationale: Classic stable angina is characterized by predictable chest pain
triggered by exertion and relieved by rest. A normal ECG at rest does not exclude
stable angina; provocative testing is often needed for diagnosis before invasive
steps .
3. A 67-year-old man with COPD has worsening dyspnea. ABG: pH 7.28, PaCO₂
68, HCO₃⁻ 32. What is the diagnosis?
• A) Metabolic acidosis
• B) Respiratory acidosis with metabolic compensation
• C) Mixed acidosis
• D) Metabolic alkalosis
Correct Answer: B) Respiratory acidosis with metabolic compensation
Rationale: Elevated CO₂ with compensatory HCO₃⁻ elevation indicates chronic
respiratory acidosis. The low pH confirms acidosis, the elevated CO₂ indicates a
respiratory cause, and the elevated HCO₃⁻ shows renal compensation .
4. A 45-year-old woman presents with episodic vertigo, fluctuating hearing loss,
tinnitus, and a sensation of aural fullness. Symptoms last several hours. What is
the most likely diagnosis?
• A) Vestibular neuritis
• B) Ménière disease
• C) Benign paroxysmal positional vertigo (BPPV)
• D) Acoustic neuroma
Correct Answer: B) Ménière disease
,Rationale: Ménière disease is characterized by the classic triad of episodic vertigo,
fluctuating hearing loss, and tinnitus with aural fullness. Symptoms typically last
hours. BPPV causes brief (seconds) positional vertigo without hearing loss .
5. A 45-year-old woman presents with central obesity, purple striae, and
hirsutism. Cortisol is not suppressed with high-dose dexamethasone. What is
the most likely source?
• A) Pituitary adenoma
• B) Adrenal adenoma
• C) Ectopic ACTH production
• D) Exogenous steroids
Correct Answer: C) Ectopic ACTH production
Rationale: Lack of suppression even at high dose suggests ectopic ACTH
production, most commonly from small cell lung cancer. Pituitary adenoma
(Cushing disease) typically suppresses with high-dose dexamethasone .
6. A 70-year-old man with sudden monocular painless vision loss; cherry-red
spot on fundoscopy. What is the immediate step?
• A) MRI brain
• B) Ocular massage + high-flow O₂
• C) Aspirin outpatient
• D) IV steroids
Correct Answer: B) Ocular massage + high-flow O₂
Rationale: Central retinal artery occlusion is an emergency. Attempt to dislodge
the embolus rapidly with ocular massage and high-flow oxygen. The cherry-red
spot is pathognomonic .
, 7. A 50-year-old woman with proximal muscle weakness, heliotrope rash, and
Gottron's papules. What is the most likely diagnosis?
• A) Dermatomyositis
• B) Polymyositis
• C) Systemic lupus erythematosus
• D) Rheumatoid arthritis
Correct Answer: A) Dermatomyositis
Rationale: Muscle weakness with characteristic skin findings (heliotrope rash,
Gottron's papules) is classic for dermatomyositis. Polymyositis has muscle
weakness without rash .
8. A 60-year-old man with severe back pain, anemia, hypercalcemia, and renal
insufficiency. X-ray shows lytic bone lesions. What is the most likely diagnosis?
• A) Osteoporosis
• B) Multiple myeloma
• C) Metastatic cancer
• D) Paget disease
Correct Answer: B) Multiple myeloma
Rationale: The classic presentation of multiple myeloma includes bone pain,
anemia, hypercalcemia, and renal insufficiency with lytic bone lesions on imaging .
9. A 54-year-old man has severe tearing chest pain radiating to the back with a
blood pressure difference between arms. What is the best initial imaging study?
• A) MRI chest
PRACTICE EXAM QUESTIONS AND CORRECT
ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2025|2026 Q&A
SECTION 1: INTERNAL MEDICINE
1. A 65-year-old man with a 50 pack-year smoking history presents with painless
hematuria. What is the most likely diagnosis?
• A) Nephrolithiasis
• B) Bladder cancer (urothelial carcinoma)
• C) Urinary tract infection
• D) Glomerulonephritis
Correct Answer: B) Bladder cancer (urothelial carcinoma)
Rationale: Painless hematuria in an older smoker strongly suggests urothelial
carcinoma. The classic presentation is painless gross hematuria. Nephrolithiasis
typically presents with painful hematuria and flank pain. UTI presents with dysuria
and frequency .
2. A 65-year-old man presents with exertional substernal chest pain relieved by
rest. ECG is normal. What is the next best step?
• A) Echocardiogram
• B) Stress test
• C) Coronary angiography
• D) Cardiac enzymes
,Correct Answer: B) Stress test
Rationale: Classic stable angina is characterized by predictable chest pain
triggered by exertion and relieved by rest. A normal ECG at rest does not exclude
stable angina; provocative testing is often needed for diagnosis before invasive
steps .
3. A 67-year-old man with COPD has worsening dyspnea. ABG: pH 7.28, PaCO₂
68, HCO₃⁻ 32. What is the diagnosis?
• A) Metabolic acidosis
• B) Respiratory acidosis with metabolic compensation
• C) Mixed acidosis
• D) Metabolic alkalosis
Correct Answer: B) Respiratory acidosis with metabolic compensation
Rationale: Elevated CO₂ with compensatory HCO₃⁻ elevation indicates chronic
respiratory acidosis. The low pH confirms acidosis, the elevated CO₂ indicates a
respiratory cause, and the elevated HCO₃⁻ shows renal compensation .
4. A 45-year-old woman presents with episodic vertigo, fluctuating hearing loss,
tinnitus, and a sensation of aural fullness. Symptoms last several hours. What is
the most likely diagnosis?
• A) Vestibular neuritis
• B) Ménière disease
• C) Benign paroxysmal positional vertigo (BPPV)
• D) Acoustic neuroma
Correct Answer: B) Ménière disease
,Rationale: Ménière disease is characterized by the classic triad of episodic vertigo,
fluctuating hearing loss, and tinnitus with aural fullness. Symptoms typically last
hours. BPPV causes brief (seconds) positional vertigo without hearing loss .
5. A 45-year-old woman presents with central obesity, purple striae, and
hirsutism. Cortisol is not suppressed with high-dose dexamethasone. What is
the most likely source?
• A) Pituitary adenoma
• B) Adrenal adenoma
• C) Ectopic ACTH production
• D) Exogenous steroids
Correct Answer: C) Ectopic ACTH production
Rationale: Lack of suppression even at high dose suggests ectopic ACTH
production, most commonly from small cell lung cancer. Pituitary adenoma
(Cushing disease) typically suppresses with high-dose dexamethasone .
6. A 70-year-old man with sudden monocular painless vision loss; cherry-red
spot on fundoscopy. What is the immediate step?
• A) MRI brain
• B) Ocular massage + high-flow O₂
• C) Aspirin outpatient
• D) IV steroids
Correct Answer: B) Ocular massage + high-flow O₂
Rationale: Central retinal artery occlusion is an emergency. Attempt to dislodge
the embolus rapidly with ocular massage and high-flow oxygen. The cherry-red
spot is pathognomonic .
, 7. A 50-year-old woman with proximal muscle weakness, heliotrope rash, and
Gottron's papules. What is the most likely diagnosis?
• A) Dermatomyositis
• B) Polymyositis
• C) Systemic lupus erythematosus
• D) Rheumatoid arthritis
Correct Answer: A) Dermatomyositis
Rationale: Muscle weakness with characteristic skin findings (heliotrope rash,
Gottron's papules) is classic for dermatomyositis. Polymyositis has muscle
weakness without rash .
8. A 60-year-old man with severe back pain, anemia, hypercalcemia, and renal
insufficiency. X-ray shows lytic bone lesions. What is the most likely diagnosis?
• A) Osteoporosis
• B) Multiple myeloma
• C) Metastatic cancer
• D) Paget disease
Correct Answer: B) Multiple myeloma
Rationale: The classic presentation of multiple myeloma includes bone pain,
anemia, hypercalcemia, and renal insufficiency with lytic bone lesions on imaging .
9. A 54-year-old man has severe tearing chest pain radiating to the back with a
blood pressure difference between arms. What is the best initial imaging study?
• A) MRI chest
