COMSAE Phase 1 (ASA 110i) Level 1 Exam
Latest 2026/2027 Edition
Question 1
A 45-year-old male presents with sudden onset of severe, tearing chest pain radiating to the back. Blood
pressure is 160/90 in the right arm and 110/70 in the left arm. What is the most likely diagnosis?
A) Acute myocardial infarction
Rationale: While AMI can cause chest pain, it typically presents with pressure-like pain, not tearing, and
does not cause blood pressure differentials between arms. ST-segment changes and elevated cardiac
enzymes would be expected.
B) Pulmonary embolism
Rationale: PE typically presents with sudden dyspnea, pleuritic chest pain, and hypoxia. The tearing
nature of pain and blood pressure differential are not characteristic of PE.
C) Aortic dissectionANSWER✔
Rationale: Aortic dissection presents with sudden, severe tearing chest pain radiating to the back. Blood
pressure differential between arms (≥20 mmHg) is a classic sign due to involvement of the subclavian
artery. This is a life-threatening emergency requiring immediate imaging and surgical consultation.
D) Pericarditis
Rationale: Pericarditis presents with sharp, pleuritic chest pain that improves with leaning forward. It
does not cause tearing pain or blood pressure differentials between extremities.
Question 2
,A 65-year-old with chronic obstructive pulmonary disease (COPD) presents with worsening dyspnea and
a new right-sided pneumothorax. Which physical examination finding is expected on the right side?
A) Hyperresonance to percussionANSWER✔
Rationale: Hyperresonance to percussion is a classic finding in pneumothorax due to air accumulation in
the pleural space. The increased air content alters the percussion tone, making it more resonant than
normal lung tissue.
B) Egophony
Rationale: Egophony is a finding of lung consolidation, typically associated with pneumonia, not
pneumothorax. It is characterized by a nasal or bleating quality to the voice during auscultation.
C) Bronchial breath sounds
Rationale: Bronchial breath sounds over peripheral lung fields suggest consolidation (e.g., pneumonia)
or compression of lung tissue. In pneumothorax, breath sounds are typically decreased or absent.
D) Dullness to percussion
Rationale: Dullness to percussion indicates fluid or solid tissue (pleural effusion, consolidation, tumor),
not air. Pneumothorax produces hyperresonance, not dullness.
Question 3
Which of the following is the most common causative agent of community-acquired pneumonia in a
previously healthy 22-year-old?
A) Mycoplasma pneumoniaeANSWER✔
Rationale: Mycoplasma pneumoniae is the most common cause of community-acquired pneumonia in
young, healthy adults (ages 5-35). It is an atypical pathogen that causes "walking pneumonia" with
symptoms like dry cough, sore throat, and extrapulmonary manifestations.
B) Klebsiella pneumoniae
,Rationale: Klebsiella is more commonly associated with pneumonia in patients with underlying
conditions like alcoholism, diabetes, or chronic lung disease. It causes necrotizing pneumonia with
currant jelly sputum.
C) Staphylococcus aureus
Rationale: S. aureus is a less common cause of community-acquired pneumonia in healthy individuals. It
is more frequently seen post-influenza infection, in hospitalized patients, or in intravenous drug users.
D) Moraxella catarrhalis
Rationale: M. catarrhalis is more common in elderly patients with COPD and in children. It is not the
most common cause of pneumonia in young healthy adults.
Question 4
A 72-year-old female presents with progressive shortness of breath, orthopnea, and paroxysmal
nocturnal dyspnea. She has a history of hypertension and diabetes. On examination, she has jugular
venous distension, crackles in both lung bases, and pedal edema. Which medication should be initiated
first?
A) Metoprolol succinate
Rationale: Beta-blockers are beneficial in heart failure with reduced ejection fraction but are typically
initiated after stabilization of acute decompensation due to their negative inotropic effects.
B) FurosemideANSWER✔
Rationale: The patient has signs of acute decompensated heart failure with volume overload (JVD,
crackles, edema). Loop diuretics like furosemide are the first-line treatment to reduce preload and
alleviate pulmonary congestion.
C) Lisinopril
Rationale: ACE inhibitors are important in chronic HF management but are not the first medication for
acute decompensation. They are started after initial diuresis to help with long-term remodeling.
D) Digoxin
, Rationale: Digoxin is used in heart failure, particularly with concurrent atrial fibrillation, but does not
address acute volume overload and is not first-line for acute management.
Question 5
A 34-year-old male presents with acute-onset right lower quadrant abdominal pain associated with
fever and nausea. On examination, there is rebound tenderness at McBurney's point. Which of the
following is the most appropriate next step?
A) CT scan of the abdomenANSWER✔
Rationale: CT scan with contrast is the most sensitive and specific imaging modality for diagnosing acute
appendicitis. It provides definitive diagnosis and helps rule out other causes of right lower quadrant
pain.
B) Exploratory laparotomy
Rationale: Surgery without imaging may lead to unnecessary procedures if the diagnosis is not
confirmed. Imaging should be obtained first unless there are signs of peritonitis requiring immediate
intervention.
C) Abdominal ultrasound
Rationale: Ultrasound is useful, particularly in children and pregnant women, but has lower sensitivity
than CT (especially in adults with high body mass index) and is operator-dependent.
D) Observation with serial examinations
Rationale: Observation may be appropriate in some cases but carries risk of perforation. Given classic
findings, imaging should be pursued to confirm diagnosis and plan management.
Question 6
A 58-year-old male with a history of peptic ulcer disease presents with sudden onset of severe, sharp
epigastric pain that radiates to the back. He is lying still and appears in distress. On examination, his
abdomen is rigid and board-like. What is the most likely diagnosis?
A) Acute pancreatitis
Latest 2026/2027 Edition
Question 1
A 45-year-old male presents with sudden onset of severe, tearing chest pain radiating to the back. Blood
pressure is 160/90 in the right arm and 110/70 in the left arm. What is the most likely diagnosis?
A) Acute myocardial infarction
Rationale: While AMI can cause chest pain, it typically presents with pressure-like pain, not tearing, and
does not cause blood pressure differentials between arms. ST-segment changes and elevated cardiac
enzymes would be expected.
B) Pulmonary embolism
Rationale: PE typically presents with sudden dyspnea, pleuritic chest pain, and hypoxia. The tearing
nature of pain and blood pressure differential are not characteristic of PE.
C) Aortic dissectionANSWER✔
Rationale: Aortic dissection presents with sudden, severe tearing chest pain radiating to the back. Blood
pressure differential between arms (≥20 mmHg) is a classic sign due to involvement of the subclavian
artery. This is a life-threatening emergency requiring immediate imaging and surgical consultation.
D) Pericarditis
Rationale: Pericarditis presents with sharp, pleuritic chest pain that improves with leaning forward. It
does not cause tearing pain or blood pressure differentials between extremities.
Question 2
,A 65-year-old with chronic obstructive pulmonary disease (COPD) presents with worsening dyspnea and
a new right-sided pneumothorax. Which physical examination finding is expected on the right side?
A) Hyperresonance to percussionANSWER✔
Rationale: Hyperresonance to percussion is a classic finding in pneumothorax due to air accumulation in
the pleural space. The increased air content alters the percussion tone, making it more resonant than
normal lung tissue.
B) Egophony
Rationale: Egophony is a finding of lung consolidation, typically associated with pneumonia, not
pneumothorax. It is characterized by a nasal or bleating quality to the voice during auscultation.
C) Bronchial breath sounds
Rationale: Bronchial breath sounds over peripheral lung fields suggest consolidation (e.g., pneumonia)
or compression of lung tissue. In pneumothorax, breath sounds are typically decreased or absent.
D) Dullness to percussion
Rationale: Dullness to percussion indicates fluid or solid tissue (pleural effusion, consolidation, tumor),
not air. Pneumothorax produces hyperresonance, not dullness.
Question 3
Which of the following is the most common causative agent of community-acquired pneumonia in a
previously healthy 22-year-old?
A) Mycoplasma pneumoniaeANSWER✔
Rationale: Mycoplasma pneumoniae is the most common cause of community-acquired pneumonia in
young, healthy adults (ages 5-35). It is an atypical pathogen that causes "walking pneumonia" with
symptoms like dry cough, sore throat, and extrapulmonary manifestations.
B) Klebsiella pneumoniae
,Rationale: Klebsiella is more commonly associated with pneumonia in patients with underlying
conditions like alcoholism, diabetes, or chronic lung disease. It causes necrotizing pneumonia with
currant jelly sputum.
C) Staphylococcus aureus
Rationale: S. aureus is a less common cause of community-acquired pneumonia in healthy individuals. It
is more frequently seen post-influenza infection, in hospitalized patients, or in intravenous drug users.
D) Moraxella catarrhalis
Rationale: M. catarrhalis is more common in elderly patients with COPD and in children. It is not the
most common cause of pneumonia in young healthy adults.
Question 4
A 72-year-old female presents with progressive shortness of breath, orthopnea, and paroxysmal
nocturnal dyspnea. She has a history of hypertension and diabetes. On examination, she has jugular
venous distension, crackles in both lung bases, and pedal edema. Which medication should be initiated
first?
A) Metoprolol succinate
Rationale: Beta-blockers are beneficial in heart failure with reduced ejection fraction but are typically
initiated after stabilization of acute decompensation due to their negative inotropic effects.
B) FurosemideANSWER✔
Rationale: The patient has signs of acute decompensated heart failure with volume overload (JVD,
crackles, edema). Loop diuretics like furosemide are the first-line treatment to reduce preload and
alleviate pulmonary congestion.
C) Lisinopril
Rationale: ACE inhibitors are important in chronic HF management but are not the first medication for
acute decompensation. They are started after initial diuresis to help with long-term remodeling.
D) Digoxin
, Rationale: Digoxin is used in heart failure, particularly with concurrent atrial fibrillation, but does not
address acute volume overload and is not first-line for acute management.
Question 5
A 34-year-old male presents with acute-onset right lower quadrant abdominal pain associated with
fever and nausea. On examination, there is rebound tenderness at McBurney's point. Which of the
following is the most appropriate next step?
A) CT scan of the abdomenANSWER✔
Rationale: CT scan with contrast is the most sensitive and specific imaging modality for diagnosing acute
appendicitis. It provides definitive diagnosis and helps rule out other causes of right lower quadrant
pain.
B) Exploratory laparotomy
Rationale: Surgery without imaging may lead to unnecessary procedures if the diagnosis is not
confirmed. Imaging should be obtained first unless there are signs of peritonitis requiring immediate
intervention.
C) Abdominal ultrasound
Rationale: Ultrasound is useful, particularly in children and pregnant women, but has lower sensitivity
than CT (especially in adults with high body mass index) and is operator-dependent.
D) Observation with serial examinations
Rationale: Observation may be appropriate in some cases but carries risk of perforation. Given classic
findings, imaging should be pursued to confirm diagnosis and plan management.
Question 6
A 58-year-old male with a history of peptic ulcer disease presents with sudden onset of severe, sharp
epigastric pain that radiates to the back. He is lying still and appears in distress. On examination, his
abdomen is rigid and board-like. What is the most likely diagnosis?
A) Acute pancreatitis
