COMSAE Phase II Form 114 Practice Exam with
Explanations Latest Update This Year Instant
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Q1. A 68-year-old woman with hypertension and diabetes presents with acute-onset chest
pain radiating to the back. Blood pressure is 210/110 mmHg, heart rate 102 bpm. CXR
shows a widened mediastinum. What is the most appropriate next step in diagnosis?
A) Transthoracic echocardiogram
B) CT angiography of the chest
C) Transesophageal echocardiogram
D) Aortography
E) D-dimer assay
Answer: B) CT angiography of the chest
The presentation (severe chest pain radiating to the back, hypertension, widened
mediastinum) suggests aortic dissection. CT angiography is the diagnostic test of choice
due to rapid acquisition and high sensitivity/specificity. TEE is an alternative but not first-line
in stable patients. CXR alone cannot exclude dissection.
Q2. A 55-year-old man with cirrhosis due to hepatitis C presents with increasing abdominal
girth and shifting dullness. Diagnostic paracentesis yields fluid with a serum-ascites albumin
gradient (SAAG) of 1.8 g/dL. What is the pathophysiology of his ascites?
A) Peritoneal carcinomatosis
B) Portal hypertension
C) Nephrotic syndrome
,D) Pancreatic duct leak
E) Tuberculous peritonitis
Answer: B) Portal hypertension
A SAAG ≥1.1 g/dL indicates portal hypertension (cirrhosis, heart failure, Budd-Chiari). The
high gradient reflects increased hydrostatic pressure in the hepatic sinusoids. SAAG <1.1
suggests non-portal hypertensive causes (malignancy, infection, pancreatitis).
Q3. A 30-year-old woman at 32 weeks gestation presents with severe headache, blurred
vision, and right upper quadrant pain. BP is 170/110 mmHg, urine dipstick shows 3+
protein. What is the most appropriate initial medication?
A) Labetalol IV
B) Magnesium sulfate IV
C) Hydralazine IV
D) Nifedipine PO
E) Furosemide IV
Answer: B) Magnesium sulfate IV
This patient has severe preeclampsia with severe features (severe hypertension, headache,
visual changes, RUQ pain). Magnesium sulfate is the first-line agent for seizure prophylaxis
in severe preeclampsia. Antihypertensives (labetalol, hydralazine, nifedipine) are used to
control severe hypertension but do not prevent eclampsia.
Q4. A 72-year-old man with BPH presents with acute urinary retention. A foley catheter is
placed. What is the most appropriate next step in management?
,A) Start an alpha-blocker and re-attempt voiding trial in 3 days
B) Immediate transurethral resection of the prostate
C) Discontinue catheter and observe
D) Start a 5-alpha-reductase inhibitor and remove catheter
E) Perform urodynamic studies
Answer: A) Start an alpha-blocker and re-attempt voiding trial in 3 days
Acute urinary retention in BPH is managed initially with catheterization and an alpha-blocker
(e.g., tamsulosin) to relax the prostatic smooth muscle. A voiding trial is attempted after 3-7
days. 5-alpha-reductase inhibitors take weeks to months for effect. Surgery is reserved for
recurrent or refractory cases.
Q5. A 25-year-old man presents with low back pain and morning stiffness that improves with
exercise and worsens with rest. Schober test is positive. What is the most likely diagnosis?
A) Lumbar disc herniation
B) Ankylosing spondylitis
C) Lumbar spinal stenosis
D) Mechanical low back pain
E) Sacroiliac joint dysfunction
Answer: B) Ankylosing spondylitis
Ankylosing spondylitis presents with inflammatory low back pain (improves with activity,
worsens with rest), morning stiffness, and a positive Schober test (limited lumbar flexion).
Sacroiliitis is the hallmark finding. HLA-B27 is strongly associated. OMT can provide
symptomatic relief but does not alter disease progression.
, Q6. A 45-year-old woman with asthma presents with acute dyspnea and wheezing. Her
peak expiratory flow is 40% of predicted. She has used her albuterol inhaler every 2 hours
without relief. What is the most appropriate next step?
A) Inhaled corticosteroid
B) Oral prednisone
C) IV methylprednisolone
D) IV magnesium sulfate
E) Continuous nebulized albuterol and ipratropium
Answer: E) Continuous nebulized albuterol and ipratropium
This patient is in a severe asthma exacerbation (PEF <50%). Initial treatment is continuous
inhaled beta-agonists (albuterol) plus ipratropium. Systemic corticosteroids (oral or IV)
should be administered within 1 hour but are not the immediate next step. Rib raising to T2-
T6 can be used as adjunctive OMT.
Q7. A 60-year-old man presents with progressive dysphagia to solids, weight loss, and
hoarseness. Barium swallow shows an irregular filling defect in the mid-esophagus. What is
the most likely diagnosis?
A) Achalasia
B) Esophageal carcinoma
C) Esophageal web
D) Zenker diverticulum
E) Diffuse esophageal spasm
Answer: B) Esophageal carcinoma
Progressive dysphagia to solids, weight loss, and hoarseness (recurrent laryngeal nerve
involvement) with an irregular filling defect is classic for esophageal carcinoma (squamous
Explanations Latest Update This Year Instant
Download Pdf
Q1. A 68-year-old woman with hypertension and diabetes presents with acute-onset chest
pain radiating to the back. Blood pressure is 210/110 mmHg, heart rate 102 bpm. CXR
shows a widened mediastinum. What is the most appropriate next step in diagnosis?
A) Transthoracic echocardiogram
B) CT angiography of the chest
C) Transesophageal echocardiogram
D) Aortography
E) D-dimer assay
Answer: B) CT angiography of the chest
The presentation (severe chest pain radiating to the back, hypertension, widened
mediastinum) suggests aortic dissection. CT angiography is the diagnostic test of choice
due to rapid acquisition and high sensitivity/specificity. TEE is an alternative but not first-line
in stable patients. CXR alone cannot exclude dissection.
Q2. A 55-year-old man with cirrhosis due to hepatitis C presents with increasing abdominal
girth and shifting dullness. Diagnostic paracentesis yields fluid with a serum-ascites albumin
gradient (SAAG) of 1.8 g/dL. What is the pathophysiology of his ascites?
A) Peritoneal carcinomatosis
B) Portal hypertension
C) Nephrotic syndrome
,D) Pancreatic duct leak
E) Tuberculous peritonitis
Answer: B) Portal hypertension
A SAAG ≥1.1 g/dL indicates portal hypertension (cirrhosis, heart failure, Budd-Chiari). The
high gradient reflects increased hydrostatic pressure in the hepatic sinusoids. SAAG <1.1
suggests non-portal hypertensive causes (malignancy, infection, pancreatitis).
Q3. A 30-year-old woman at 32 weeks gestation presents with severe headache, blurred
vision, and right upper quadrant pain. BP is 170/110 mmHg, urine dipstick shows 3+
protein. What is the most appropriate initial medication?
A) Labetalol IV
B) Magnesium sulfate IV
C) Hydralazine IV
D) Nifedipine PO
E) Furosemide IV
Answer: B) Magnesium sulfate IV
This patient has severe preeclampsia with severe features (severe hypertension, headache,
visual changes, RUQ pain). Magnesium sulfate is the first-line agent for seizure prophylaxis
in severe preeclampsia. Antihypertensives (labetalol, hydralazine, nifedipine) are used to
control severe hypertension but do not prevent eclampsia.
Q4. A 72-year-old man with BPH presents with acute urinary retention. A foley catheter is
placed. What is the most appropriate next step in management?
,A) Start an alpha-blocker and re-attempt voiding trial in 3 days
B) Immediate transurethral resection of the prostate
C) Discontinue catheter and observe
D) Start a 5-alpha-reductase inhibitor and remove catheter
E) Perform urodynamic studies
Answer: A) Start an alpha-blocker and re-attempt voiding trial in 3 days
Acute urinary retention in BPH is managed initially with catheterization and an alpha-blocker
(e.g., tamsulosin) to relax the prostatic smooth muscle. A voiding trial is attempted after 3-7
days. 5-alpha-reductase inhibitors take weeks to months for effect. Surgery is reserved for
recurrent or refractory cases.
Q5. A 25-year-old man presents with low back pain and morning stiffness that improves with
exercise and worsens with rest. Schober test is positive. What is the most likely diagnosis?
A) Lumbar disc herniation
B) Ankylosing spondylitis
C) Lumbar spinal stenosis
D) Mechanical low back pain
E) Sacroiliac joint dysfunction
Answer: B) Ankylosing spondylitis
Ankylosing spondylitis presents with inflammatory low back pain (improves with activity,
worsens with rest), morning stiffness, and a positive Schober test (limited lumbar flexion).
Sacroiliitis is the hallmark finding. HLA-B27 is strongly associated. OMT can provide
symptomatic relief but does not alter disease progression.
, Q6. A 45-year-old woman with asthma presents with acute dyspnea and wheezing. Her
peak expiratory flow is 40% of predicted. She has used her albuterol inhaler every 2 hours
without relief. What is the most appropriate next step?
A) Inhaled corticosteroid
B) Oral prednisone
C) IV methylprednisolone
D) IV magnesium sulfate
E) Continuous nebulized albuterol and ipratropium
Answer: E) Continuous nebulized albuterol and ipratropium
This patient is in a severe asthma exacerbation (PEF <50%). Initial treatment is continuous
inhaled beta-agonists (albuterol) plus ipratropium. Systemic corticosteroids (oral or IV)
should be administered within 1 hour but are not the immediate next step. Rib raising to T2-
T6 can be used as adjunctive OMT.
Q7. A 60-year-old man presents with progressive dysphagia to solids, weight loss, and
hoarseness. Barium swallow shows an irregular filling defect in the mid-esophagus. What is
the most likely diagnosis?
A) Achalasia
B) Esophageal carcinoma
C) Esophageal web
D) Zenker diverticulum
E) Diffuse esophageal spasm
Answer: B) Esophageal carcinoma
Progressive dysphagia to solids, weight loss, and hoarseness (recurrent laryngeal nerve
involvement) with an irregular filling defect is classic for esophageal carcinoma (squamous
