COMSAE Phase 2 BSA Form 114i – Comprehensive
Exam with Questions, Answers and Rationales
2026/2027 Update
Question 1: Cardiology / Emergency Medicine
A 64-year-old man presents to the emergency department with acute, crushing substernal chest
pain radiating to his neck and left arm. An electrocardiogram (ECG) demonstrates significant
ST-segment elevations in leads I, aVL, and V4 through V6.
Which coronary artery is most likely occluded?
A. Left anterior descending artery (proximal or mid portion)
B. Left circumflex artery
C. Posterior descending artery
D. Right coronary artery
Correct Answer: B. Left circumflex artery (or high lateral involvement, noting that extensive
anterolateral involvement includes the LCx/diagonal branches; classic lateral leads point toward
LCx).
Rationale: Electrocardiographic changes in leads I, aVL, and lateral chest leads (V5–V6)
localize ischemia or infarction to the lateral wall of the left ventricle, which is typically supplied
by the left circumflex (LCx) artery or its branches. Conversely, anterior leads (V1–V4) reflect
LAD occlusion, and inferior leads (II, III, aVF) reflect RCA or dominant LCx occlusion.
Question 2: Pulmonology / Critical Care
A 62-year-old woman with a history of severe chronic obstructive pulmonary disease (COPD) is
brought to the hospital with worsening dyspnea, confusion, and lethargy. Arterial blood gas
(ABG) analysis on room air reveals pH 7.28, PaCO₂ 68 mmHg, and PaO₂ 50 mmHg.
What is the most appropriate initial management step?
A. Immediate endotracheal intubation and mechanical ventilation
B. Noninvasive positive pressure ventilation (BiPAP)
C. High-flow nasal cannula oxygen therapy targeting 100% saturation
, D. Intravenous sodium bicarbonate administration
Correct Answer: B. Noninvasive positive pressure ventilation (BiPAP)
Rationale: This patient has acute-on-chronic hypercapnic respiratory failure with respiratory
acidosis (pH < 7.35, PaCO₂ > 45 mmHg). In the absence of absolute contraindications (such as
hemodynamic instability, facial trauma, or inability to protect the airway), trial of noninvasive
positive pressure ventilation (BiPAP) is first-line therapy to decrease the work of breathing,
correct acidosis, and avoid invasive intubation.
Question 3: Endocrinology
A 35-year-old woman is evaluated for a three-month history of unintended weight loss, heat
intolerance, tremors, and frequent bowel movements. Physical examination reveals a diffuse,
non-tender goiter and mild lid lag. Serum TSH is undetectable, and free T4 is markedly elevated.
What is the primary autoantibody responsible for this condition?
A. Anti-thyroid peroxidase (anti-TPO) antibodies
B. Thyroid-stimulating hormone receptor antibodies (TSI)
C. Anti-thyroglobulin antibodies
D. Islet cell autoantibodies
Correct Answer: B. Thyroid-stimulating hormone receptor antibodies (TSI)
Rationale: The clinical presentation is classic for Graves disease, the most common cause of
hyperthyroidism. It is an autoimmune disorder caused by circulating thyroid-stimulating
immunoglobulins (TSI) that bind to and activate TSH receptors on thyroid follicular cells,
leading to autonomous overproduction of thyroid hormones.
Question 4: Gastroenterology / Pediatrics
A 3-week-old male infant presents with non-bilious projectile vomiting that occurs immediately
after feeding. The infant is constantly hungry and eager to feed again. An olive-shaped, mobile
mass is palpated in the right upper quadrant.
What is the primary electrolyte and acid-base disturbance associated with this condition?
A. Hypochloremic, hypokalemic metabolic alkalosis
B. Hyperchloremic, hyperkalemic metabolic acidosis
C. Normal anion gap metabolic acidosis with hyperkalemia
, D. Respiratory alkalosis secondary to central compensation
Correct Answer: A. Hypochloremic, hypokalemic metabolic alkalosis
Rationale: Infantile hypertrophic pyloric stenosis causes gastric outlet obstruction, resulting in
frequent vomiting of hydrochloric acid. The loss of hydrogen and chloride ions leads to a
hypochloremic, hypokalemic metabolic alkalosis. Renal mechanisms attempt to preserve volume
by exchanging sodium for hydrogen ions in the distal tubules, worsening the alkalosis and
kaliuresis.
Question 5: Nephrology
A 54-year-old man with a history of poorly controlled hypertension and type 2 diabetes mellitus
is evaluated for progressive generalized edema and foamy urine. Laboratory workup reveals 24-
hour urine protein excretion of 6.2 grams, serum albumin of 2.1 g/dL, and hypercholesterolemia.
What is the pathognomonic renal histologic lesion associated with advanced diabetic
nephropathy?
A. Kimmelstiel-Wilson nodular glomerulosclerosis
B. Epimembranous spike-and-dome deposits
C. Crescents within Bowman space
D. Wire-loop glomerular capillary thickening
Correct Answer: A. Kimmelstiel-Wilson nodular glomerulosclerosis
Rationale: Nephrotic-range proteinuria (> 3.5 g/day), hypoalbuminemia, hyperlipidemia, and
edema define nephrotic syndrome. In diabetic nephropathy, the characteristic light microscopic
finding is Kimmelstiel-Wilson lesions, which are acellular, eosinophilic nodular mesangial
sclerosis deposits in the glomeruli.
Question 6: Urology
A 25-year-old man presents with sudden-onset severe pain in his left hemiscrotum accompanied
by nausea and lightheadedness. Physical examination reveals a high-riding left testicle with a
horizontal lie and absent cremasteric reflex. Doppler ultrasonography demonstrates complete
absence of blood flow to the testis.
What is the most appropriate management?
A. Immediate emergency surgical exploration and detorsion
B. Outpatient scrotal support and oral nonsteroidal anti-inflammatory drugs
, C. Empiric treatment with broad-spectrum oral antibiotics for epididymitis
D. Elective outpatient ultrasound follow-up in two weeks
Correct Answer: A. Immediate emergency surgical exploration and detorsion
Rationale: Testicular torsion is a surgical emergency caused by twisting of the spermatic cord,
leading to vascular compromise and ischemia. The classic presentation includes acute scrotal
pain, high-riding testis, abnormal orientation, and absent cremasteric reflex. Time is critical, as
testicular salvage rates drop sharply after 6 hours of ischemia.
Question 7: Rheumatology
A 28-year-old woman is evaluated for a photosensitive malar rash across her cheeks and bridge
of the nose, generalized fatigue, and painful swelling in her hands. Laboratory analysis reveals a
positive anti-nuclear antibody (ANA) titer of 1:1280, positive anti-double-stranded DNA (anti-
dsDNA) antibodies, and low serum complement levels.
Which organ system involvement is a leading cause of morbidity and mortality in this
condition?
A. Renal system (lupus nephritis)
B. Hepatic system (primary sclerosing cholangitis)
C. Gastrointestinal system (mesenteric ischemia)
D. Endocrine system (autoimmune hypophysitis)
Correct Answer: A. Renal system (lupus nephritis)
Rationale: The constellation of findings confirms systemic lupus erythematosus (SLE). Lupus
nephritis is one of the most serious organ manifestations of SLE, occurring in a significant
percentage of patients, and remains a primary determinant of long-term prognosis, morbidity,
and mortality.
Question 8: Psychiatry
A 32-year-old man is brought to the psychiatric emergency department by his family because he
has been uncharacteristically hyperactive, sleeping only 2 hours a night for the past 10 days,
speaking rapidly with flight of ideas, and making reckless business investments. He has no
history of prior depressive episodes.
What is the most accurate diagnosis?
A. Bipolar I disorder
Exam with Questions, Answers and Rationales
2026/2027 Update
Question 1: Cardiology / Emergency Medicine
A 64-year-old man presents to the emergency department with acute, crushing substernal chest
pain radiating to his neck and left arm. An electrocardiogram (ECG) demonstrates significant
ST-segment elevations in leads I, aVL, and V4 through V6.
Which coronary artery is most likely occluded?
A. Left anterior descending artery (proximal or mid portion)
B. Left circumflex artery
C. Posterior descending artery
D. Right coronary artery
Correct Answer: B. Left circumflex artery (or high lateral involvement, noting that extensive
anterolateral involvement includes the LCx/diagonal branches; classic lateral leads point toward
LCx).
Rationale: Electrocardiographic changes in leads I, aVL, and lateral chest leads (V5–V6)
localize ischemia or infarction to the lateral wall of the left ventricle, which is typically supplied
by the left circumflex (LCx) artery or its branches. Conversely, anterior leads (V1–V4) reflect
LAD occlusion, and inferior leads (II, III, aVF) reflect RCA or dominant LCx occlusion.
Question 2: Pulmonology / Critical Care
A 62-year-old woman with a history of severe chronic obstructive pulmonary disease (COPD) is
brought to the hospital with worsening dyspnea, confusion, and lethargy. Arterial blood gas
(ABG) analysis on room air reveals pH 7.28, PaCO₂ 68 mmHg, and PaO₂ 50 mmHg.
What is the most appropriate initial management step?
A. Immediate endotracheal intubation and mechanical ventilation
B. Noninvasive positive pressure ventilation (BiPAP)
C. High-flow nasal cannula oxygen therapy targeting 100% saturation
, D. Intravenous sodium bicarbonate administration
Correct Answer: B. Noninvasive positive pressure ventilation (BiPAP)
Rationale: This patient has acute-on-chronic hypercapnic respiratory failure with respiratory
acidosis (pH < 7.35, PaCO₂ > 45 mmHg). In the absence of absolute contraindications (such as
hemodynamic instability, facial trauma, or inability to protect the airway), trial of noninvasive
positive pressure ventilation (BiPAP) is first-line therapy to decrease the work of breathing,
correct acidosis, and avoid invasive intubation.
Question 3: Endocrinology
A 35-year-old woman is evaluated for a three-month history of unintended weight loss, heat
intolerance, tremors, and frequent bowel movements. Physical examination reveals a diffuse,
non-tender goiter and mild lid lag. Serum TSH is undetectable, and free T4 is markedly elevated.
What is the primary autoantibody responsible for this condition?
A. Anti-thyroid peroxidase (anti-TPO) antibodies
B. Thyroid-stimulating hormone receptor antibodies (TSI)
C. Anti-thyroglobulin antibodies
D. Islet cell autoantibodies
Correct Answer: B. Thyroid-stimulating hormone receptor antibodies (TSI)
Rationale: The clinical presentation is classic for Graves disease, the most common cause of
hyperthyroidism. It is an autoimmune disorder caused by circulating thyroid-stimulating
immunoglobulins (TSI) that bind to and activate TSH receptors on thyroid follicular cells,
leading to autonomous overproduction of thyroid hormones.
Question 4: Gastroenterology / Pediatrics
A 3-week-old male infant presents with non-bilious projectile vomiting that occurs immediately
after feeding. The infant is constantly hungry and eager to feed again. An olive-shaped, mobile
mass is palpated in the right upper quadrant.
What is the primary electrolyte and acid-base disturbance associated with this condition?
A. Hypochloremic, hypokalemic metabolic alkalosis
B. Hyperchloremic, hyperkalemic metabolic acidosis
C. Normal anion gap metabolic acidosis with hyperkalemia
, D. Respiratory alkalosis secondary to central compensation
Correct Answer: A. Hypochloremic, hypokalemic metabolic alkalosis
Rationale: Infantile hypertrophic pyloric stenosis causes gastric outlet obstruction, resulting in
frequent vomiting of hydrochloric acid. The loss of hydrogen and chloride ions leads to a
hypochloremic, hypokalemic metabolic alkalosis. Renal mechanisms attempt to preserve volume
by exchanging sodium for hydrogen ions in the distal tubules, worsening the alkalosis and
kaliuresis.
Question 5: Nephrology
A 54-year-old man with a history of poorly controlled hypertension and type 2 diabetes mellitus
is evaluated for progressive generalized edema and foamy urine. Laboratory workup reveals 24-
hour urine protein excretion of 6.2 grams, serum albumin of 2.1 g/dL, and hypercholesterolemia.
What is the pathognomonic renal histologic lesion associated with advanced diabetic
nephropathy?
A. Kimmelstiel-Wilson nodular glomerulosclerosis
B. Epimembranous spike-and-dome deposits
C. Crescents within Bowman space
D. Wire-loop glomerular capillary thickening
Correct Answer: A. Kimmelstiel-Wilson nodular glomerulosclerosis
Rationale: Nephrotic-range proteinuria (> 3.5 g/day), hypoalbuminemia, hyperlipidemia, and
edema define nephrotic syndrome. In diabetic nephropathy, the characteristic light microscopic
finding is Kimmelstiel-Wilson lesions, which are acellular, eosinophilic nodular mesangial
sclerosis deposits in the glomeruli.
Question 6: Urology
A 25-year-old man presents with sudden-onset severe pain in his left hemiscrotum accompanied
by nausea and lightheadedness. Physical examination reveals a high-riding left testicle with a
horizontal lie and absent cremasteric reflex. Doppler ultrasonography demonstrates complete
absence of blood flow to the testis.
What is the most appropriate management?
A. Immediate emergency surgical exploration and detorsion
B. Outpatient scrotal support and oral nonsteroidal anti-inflammatory drugs
, C. Empiric treatment with broad-spectrum oral antibiotics for epididymitis
D. Elective outpatient ultrasound follow-up in two weeks
Correct Answer: A. Immediate emergency surgical exploration and detorsion
Rationale: Testicular torsion is a surgical emergency caused by twisting of the spermatic cord,
leading to vascular compromise and ischemia. The classic presentation includes acute scrotal
pain, high-riding testis, abnormal orientation, and absent cremasteric reflex. Time is critical, as
testicular salvage rates drop sharply after 6 hours of ischemia.
Question 7: Rheumatology
A 28-year-old woman is evaluated for a photosensitive malar rash across her cheeks and bridge
of the nose, generalized fatigue, and painful swelling in her hands. Laboratory analysis reveals a
positive anti-nuclear antibody (ANA) titer of 1:1280, positive anti-double-stranded DNA (anti-
dsDNA) antibodies, and low serum complement levels.
Which organ system involvement is a leading cause of morbidity and mortality in this
condition?
A. Renal system (lupus nephritis)
B. Hepatic system (primary sclerosing cholangitis)
C. Gastrointestinal system (mesenteric ischemia)
D. Endocrine system (autoimmune hypophysitis)
Correct Answer: A. Renal system (lupus nephritis)
Rationale: The constellation of findings confirms systemic lupus erythematosus (SLE). Lupus
nephritis is one of the most serious organ manifestations of SLE, occurring in a significant
percentage of patients, and remains a primary determinant of long-term prognosis, morbidity,
and mortality.
Question 8: Psychiatry
A 32-year-old man is brought to the psychiatric emergency department by his family because he
has been uncharacteristically hyperactive, sleeping only 2 hours a night for the past 10 days,
speaking rapidly with flight of ideas, and making reckless business investments. He has no
history of prior depressive episodes.
What is the most accurate diagnosis?
A. Bipolar I disorder
