COMSAE Phase 2 Form 118 Exam
QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES
COMSAE Phase 2 Form 118 exam
Question 1
A 62-year-old man presents with crushing substernal chest pain radiating to his left arm for 45
minutes. ECG shows ST-segment elevation in leads II, III, and aVF. Which coronary artery is most
likely occluded?
A) Left anterior descending artery
B) Right coronary artery
C) Left circumflex artery
D) Posterior descending artery
E) Left main coronary artery
Answer: B) Right coronary artery
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall myocardial infarction.
The inferior wall is typically supplied by the right coronary artery (RCA). The RCA also supplies
the AV node in most individuals, making heart block a possible complication. LAD occlusion
causes anterior wall MI (V1-V4), circumflex occlusion causes lateral wall MI (I, aVL, V5-V6), and
left main disease typically causes widespread ischemic changes.
Question 2
A 72-year-old man presents with exertional syncope, angina, and progressive dyspnea. Cardiac
auscultation reveals a harsh crescendo-decrescendo systolic murmur at the right second
intercostal space that radiates to the carotids. Which hemodynamic abnormality is most
characteristic of this patient's condition?
A) Increased left ventricular compliance
B) Decreased left ventricular end-diastolic pressure
C) Increased left ventricular afterload
D) Decreased aortic systolic pressure
E) Increased mitral valve opening pressure
Answer: C) Increased left ventricular afterload
,Rationale: This patient has severe aortic stenosis, characterized by left ventricular outflow
obstruction. This creates increased afterload, prompting the left ventricle to compensate
through concentric hypertrophy. While this initially maintains cardiac output, it eventually leads
to diastolic dysfunction, reduced coronary perfusion, and the classic triad of angina, syncope,
and heart failure.
Question 3
A patient presents with chest pain that is relieved by leaning forward. ECG demonstrates diffuse
ST-segment elevations and PR depressions. What is the most likely diagnosis?
A) STEMI
B) Pulmonary embolism
C) Aortic dissection
D) Stable angina
E) Acute pericarditis
Answer: E) Acute pericarditis
Rationale: Acute pericarditis classically presents with pleuritic chest pain improved by sitting
forward. ECG findings include diffuse ST-segment elevations and PR-segment depressions,
distinguishing it from myocardial infarction. The pain worsens with lying flat and improves with
leaning forward due to reduced pericardial irritation.
Question 4
A patient with atrial fibrillation develops sudden left-sided weakness and aphasia. Which
vascular territory is most likely affected?
A) Posterior cerebral artery
B) Anterior cerebral artery
C) Basilar artery
D) Vertebral artery
E) Middle cerebral artery
Answer: E) Middle cerebral artery
Rationale: The MCA supplies regions responsible for motor function of the face and upper
extremity as well as language centers (Broca's and Wernicke's areas) in the dominant
,hemisphere. Atrial fibrillation predisposes to left atrial thrombus formation, and emboli
commonly lodge in the MCA.
Question 5
A patient develops severe abdominal pain out of proportion to physical examination findings.
Atrial fibrillation is present. What is the most likely diagnosis?
A) Diverticulitis
B) Pancreatitis
C) Cholecystitis
D) Appendicitis
E) Acute mesenteric ischemia
Answer: E) Acute mesenteric ischemia
Rationale: Embolization from atrial fibrillation is a common cause of acute mesenteric ischemia.
The classic presentation is severe abdominal pain with minimal physical examination findings—
"pain out of proportion to exam." This is a surgical emergency requiring prompt intervention.
Question 6
A patient develops acute respiratory distress syndrome (ARDS). Which pathophysiologic
mechanism is responsible?
A) Increased left atrial pressure
B) Bronchospasm
C) Pulmonary embolism
D) Alveolar hypoventilation
E) Diffuse alveolar-capillary membrane injury
Answer: E) Diffuse alveolar-capillary membrane injury
Rationale: ARDS results from inflammatory injury to the alveolar-capillary barrier, causing
increased permeability, pulmonary edema, severe hypoxemia, and reduced lung compliance.
This is distinct from cardiogenic pulmonary edema, which results from increased hydrostatic
pressure due to left heart failure.
Question 7
, Which finding is most characteristic of aortic regurgitation on physical examination?
A) Opening snap followed by diastolic rumble
B) Holosystolic murmur radiating to the axilla
C) Crescendo-decrescendo systolic ejection murmur
D) Early diastolic decrescendo murmur at the left sternal border
E) Continuous machinery murmur
Answer: D) Early diastolic decrescendo murmur at the left sternal border
Rationale: Aortic regurgitation produces an early diastolic decrescendo murmur best heard at
the left sternal border. The murmur results from the backflow of blood from the aorta into the
left ventricle during diastole. Associated findings include bounding pulses and widened pulse
pressure.
Question 8
A patient with chronic aortic stenosis develops left ventricular hypertrophy. Which type of
hypertrophy occurs?
A) Eccentric hypertrophy from volume overload
B) Concentric hypertrophy from pressure overload
C) Right ventricular hypertrophy
D) Dilated hypertrophy with reduced wall thickness
E) Atrial hypertrophy
Answer: B) Concentric hypertrophy from pressure overload
Rationale: Aortic stenosis creates chronic pressure overload on the left ventricle. The ventricle
compensates by adding sarcomeres in parallel, producing concentric hypertrophy (thickening of
the ventricular wall). This initially maintains wall stress but eventually leads to diastolic
dysfunction and reduced coronary perfusion.
Question 9
A 65-year-old woman has progressive exertional dyspnea. Echocardiography shows thickened
aortic valve leaflets with reduced mobility. Which finding would indicate severe aortic stenosis?
A) Increased aortic valve area
B) Low transvalvular pressure gradient
C) Reduced left ventricular wall thickness
QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES
COMSAE Phase 2 Form 118 exam
Question 1
A 62-year-old man presents with crushing substernal chest pain radiating to his left arm for 45
minutes. ECG shows ST-segment elevation in leads II, III, and aVF. Which coronary artery is most
likely occluded?
A) Left anterior descending artery
B) Right coronary artery
C) Left circumflex artery
D) Posterior descending artery
E) Left main coronary artery
Answer: B) Right coronary artery
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall myocardial infarction.
The inferior wall is typically supplied by the right coronary artery (RCA). The RCA also supplies
the AV node in most individuals, making heart block a possible complication. LAD occlusion
causes anterior wall MI (V1-V4), circumflex occlusion causes lateral wall MI (I, aVL, V5-V6), and
left main disease typically causes widespread ischemic changes.
Question 2
A 72-year-old man presents with exertional syncope, angina, and progressive dyspnea. Cardiac
auscultation reveals a harsh crescendo-decrescendo systolic murmur at the right second
intercostal space that radiates to the carotids. Which hemodynamic abnormality is most
characteristic of this patient's condition?
A) Increased left ventricular compliance
B) Decreased left ventricular end-diastolic pressure
C) Increased left ventricular afterload
D) Decreased aortic systolic pressure
E) Increased mitral valve opening pressure
Answer: C) Increased left ventricular afterload
,Rationale: This patient has severe aortic stenosis, characterized by left ventricular outflow
obstruction. This creates increased afterload, prompting the left ventricle to compensate
through concentric hypertrophy. While this initially maintains cardiac output, it eventually leads
to diastolic dysfunction, reduced coronary perfusion, and the classic triad of angina, syncope,
and heart failure.
Question 3
A patient presents with chest pain that is relieved by leaning forward. ECG demonstrates diffuse
ST-segment elevations and PR depressions. What is the most likely diagnosis?
A) STEMI
B) Pulmonary embolism
C) Aortic dissection
D) Stable angina
E) Acute pericarditis
Answer: E) Acute pericarditis
Rationale: Acute pericarditis classically presents with pleuritic chest pain improved by sitting
forward. ECG findings include diffuse ST-segment elevations and PR-segment depressions,
distinguishing it from myocardial infarction. The pain worsens with lying flat and improves with
leaning forward due to reduced pericardial irritation.
Question 4
A patient with atrial fibrillation develops sudden left-sided weakness and aphasia. Which
vascular territory is most likely affected?
A) Posterior cerebral artery
B) Anterior cerebral artery
C) Basilar artery
D) Vertebral artery
E) Middle cerebral artery
Answer: E) Middle cerebral artery
Rationale: The MCA supplies regions responsible for motor function of the face and upper
extremity as well as language centers (Broca's and Wernicke's areas) in the dominant
,hemisphere. Atrial fibrillation predisposes to left atrial thrombus formation, and emboli
commonly lodge in the MCA.
Question 5
A patient develops severe abdominal pain out of proportion to physical examination findings.
Atrial fibrillation is present. What is the most likely diagnosis?
A) Diverticulitis
B) Pancreatitis
C) Cholecystitis
D) Appendicitis
E) Acute mesenteric ischemia
Answer: E) Acute mesenteric ischemia
Rationale: Embolization from atrial fibrillation is a common cause of acute mesenteric ischemia.
The classic presentation is severe abdominal pain with minimal physical examination findings—
"pain out of proportion to exam." This is a surgical emergency requiring prompt intervention.
Question 6
A patient develops acute respiratory distress syndrome (ARDS). Which pathophysiologic
mechanism is responsible?
A) Increased left atrial pressure
B) Bronchospasm
C) Pulmonary embolism
D) Alveolar hypoventilation
E) Diffuse alveolar-capillary membrane injury
Answer: E) Diffuse alveolar-capillary membrane injury
Rationale: ARDS results from inflammatory injury to the alveolar-capillary barrier, causing
increased permeability, pulmonary edema, severe hypoxemia, and reduced lung compliance.
This is distinct from cardiogenic pulmonary edema, which results from increased hydrostatic
pressure due to left heart failure.
Question 7
, Which finding is most characteristic of aortic regurgitation on physical examination?
A) Opening snap followed by diastolic rumble
B) Holosystolic murmur radiating to the axilla
C) Crescendo-decrescendo systolic ejection murmur
D) Early diastolic decrescendo murmur at the left sternal border
E) Continuous machinery murmur
Answer: D) Early diastolic decrescendo murmur at the left sternal border
Rationale: Aortic regurgitation produces an early diastolic decrescendo murmur best heard at
the left sternal border. The murmur results from the backflow of blood from the aorta into the
left ventricle during diastole. Associated findings include bounding pulses and widened pulse
pressure.
Question 8
A patient with chronic aortic stenosis develops left ventricular hypertrophy. Which type of
hypertrophy occurs?
A) Eccentric hypertrophy from volume overload
B) Concentric hypertrophy from pressure overload
C) Right ventricular hypertrophy
D) Dilated hypertrophy with reduced wall thickness
E) Atrial hypertrophy
Answer: B) Concentric hypertrophy from pressure overload
Rationale: Aortic stenosis creates chronic pressure overload on the left ventricle. The ventricle
compensates by adding sarcomeres in parallel, producing concentric hypertrophy (thickening of
the ventricular wall). This initially maintains wall stress but eventually leads to diastolic
dysfunction and reduced coronary perfusion.
Question 9
A 65-year-old woman has progressive exertional dyspnea. Echocardiography shows thickened
aortic valve leaflets with reduced mobility. Which finding would indicate severe aortic stenosis?
A) Increased aortic valve area
B) Low transvalvular pressure gradient
C) Reduced left ventricular wall thickness
