COMSAE Phase 2 Form 109 Practice Exam | 100% Complete
Q&A Board Review Bundle/ COMLEX Level 2 CE &
COMSAE Form 109 Prep | Questions & Answers with High-
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Internal Medicine & Cardiology
1. A 64-year-old male presents to the emergency department reporting sudden-onset,
crushing substernal chest pain that radiates to his left jaw and back. He has a history
of type 2 diabetes mellitus, hypertension, and hyperlipidemia. His vital signs are: BP
142/88 mmHg, HR 92/min, RR 20/min, and SpO2 94% on room air. An
electrocardiogram (ECG) demonstrates 2.5-mm ST-segment elevation in leads V1
through V4. While preparing for immediate cardiac catheterization, which of the
following mechanisms explains the therapeutic action of the first-line medication that
should be chewed by the patient immediately?
A) Direct inhibition of thrombin (Factor IIa)
B) Irreversible acetylation of cyclooxygenase-1 (COX-1)
C) Antagonism of adenosine diphosphate (ADP) P2Y12 receptors
D) Blockade of glycoprotein IIb/IIIa surface receptors
This patient is experiencing an acute anterior ST-elevation myocardial infarction
(STEMI). The initial management requires the immediate administration of non-
enteric-coated aspirin (162–325 mg), which should be chewed to achieve rapid
systemic absorption. Aspirin works by irreversibly acetylating and inhibiting
cyclooxygenase-1 (COX-1), preventing the synthesis of thromboxane A2, a potent
inducer of platelet aggregation and vasoconstriction.
2. A 58-year-old female presents for a routine follow-up. She has a history of chronic
heart failure with reduced ejection fraction (HFEF, left ventricular ejection fraction of
, 32%). She reports mild dyspnea when climbing two flights of stairs but denies
orthopnea or paroxysmal nocturnal dyspnea. Her current daily medications include
lisinopril and furosemide. Her vitals are: BP 118/74 mmHg, HR 68/min, and regular
rhythm. Physical examination reveals no jugular venous distention and trace pedal
edema. Which of the following medications should be added next to her regimen to
reduce long-term mortality?
A) Digoxin
B) Isosorbide dinitrate
C) Carvedilol
D) Amlodipine
Beta-blockers (specifically carvedilol, metoprolol succinate, or bisoprolol) are
indicated for all patients with stable heart failure with reduced ejection fraction
(HFrEF) to improve survival and decrease hospitalization rates. They work by
mitigating the cardiotoxic effects of chronic sympathetic nervous system
upregulation. Digoxin and loop diuretics improve symptoms but do not decrease
long-term mortality.
3. A 45-year-old male with a history of alcohol use disorder presents with worsening
fatigue, abdominal distention, and confusion over the past 3 days. On examination,
he is disoriented to time and place, has scleral icterus, a distended abdomen with a
positive fluid wave, and a flapping tremor of his hands when his wrists are extended.
Laboratory evaluation demonstrates an elevated serum ammonia level. Which of the
following treatments is the primary first-line therapy to promote the fecal excretion of
the toxin causing his confusion?
A) Neomycin
B) Rifaximin
C) Lactulose
, D) Intravenous sodium bicarbonate
The patient has hepatic encephalopathy secondary to liver cirrhosis, characterized
by cognitive deficits and asterixis due to elevated serum ammonia levels. Lactulose
is the primary first-line therapy. In the colon, gut bacteria convert lactulose into lactic
acid and acetic acid, acidifying the colon contents. This converts diffusible ammonia
(NH3) into non-diffusible ammonium (NH4+), trapping it in the gut lumen and
facilitating its fecal evacuation via osmotic laxative effects.
4. A 72-year-old female is admitted to the hospital with a severe urinary tract infection.
On day 2 of admission, she becomes acutely confused, agitated, and starts
visualising insects on her hospital bed sheets. Her vital signs are stable, and she has
no focal neurological deficits. Her baseline mental status was completely intact prior
to admission. Which of the following terms best characterizes her acute
neurobehavioral condition?
A) Major neurocognitive disorder (Alzheimer's disease)
B) Delirium
C) Acute schizophrenia flare
D) Vascular dementia
Delirium is an acute, fluctuating change in mental status characterized by
inattention, disorganized thinking, and altered levels of consciousness, often
accompanied by hallucinations. It is commonly triggered by underlying systemic
infections, metabolic derangements, or medications in elderly, hospitalized patients.
Unlike dementia, delirium develops acutely and is potentially completely reversible
once the underlying trigger is resolved.
5. A 34-year-old male presents with a persistent cough, hemoptysis, and recurrent
epistaxis over the past two months. Urinalysis demonstrates hematuria and
dysmorphic red blood cells. Laboratory evaluation reveals a positive c-ANCA (PR3-
, ANCA) antibody titer. A renal biopsy shows crescentic glomerulonephritis. What is
the most likely diagnosis?
A) Goodpasture syndrome
B) Granulomatosis with polyangiitis
C) Microscopic polyangiitis
D) Henoch-Schönlein purpura
Granulomatosis with polyangiitis (formerly Wegener's) is a systemic necrotizing
vasculitis affecting small-to-medium vessels. It characteristically involves the upper
respiratory tract (epistaxis, nasal septal perforation), lower respiratory tract
(hemoptysis, cough), and kidneys (pauci-immune crescentic glomerulonephritis).
The highly specific serological marker is c-ANCA (anti-proteinase 3).
General & Trauma Surgery
6. A 24-year-old male is brought to the emergency department by emergency medical
services after sustaining a stab wound to the right mid-axillary line at the level of the
5th intercostal space. His vital signs are: BP 86/52 mmHg, HR 128/min, RR 26/min,
and SpO2 88% on a non-rebreather mask. Physical examination reveals absent
breath sounds and hyperresonance on the right side of the chest, along with jugular
venous distention. What is the immediate next step in the management of this
patient?
A) Order an urgent portable chest X-ray
B) Perform immediate needle thoracostomy in the second intercostal space at
the midclavicular line
C) Endotracheal intubation and mechanical ventilation
D) Obtain a stat computed tomography (CT) angiogram of the chest
This patient presents with a life-threatening tension pneumothorax, as evidenced by
Q&A Board Review Bundle/ COMLEX Level 2 CE &
COMSAE Form 109 Prep | Questions & Answers with High-
Yield OMM Rationales
Internal Medicine & Cardiology
1. A 64-year-old male presents to the emergency department reporting sudden-onset,
crushing substernal chest pain that radiates to his left jaw and back. He has a history
of type 2 diabetes mellitus, hypertension, and hyperlipidemia. His vital signs are: BP
142/88 mmHg, HR 92/min, RR 20/min, and SpO2 94% on room air. An
electrocardiogram (ECG) demonstrates 2.5-mm ST-segment elevation in leads V1
through V4. While preparing for immediate cardiac catheterization, which of the
following mechanisms explains the therapeutic action of the first-line medication that
should be chewed by the patient immediately?
A) Direct inhibition of thrombin (Factor IIa)
B) Irreversible acetylation of cyclooxygenase-1 (COX-1)
C) Antagonism of adenosine diphosphate (ADP) P2Y12 receptors
D) Blockade of glycoprotein IIb/IIIa surface receptors
This patient is experiencing an acute anterior ST-elevation myocardial infarction
(STEMI). The initial management requires the immediate administration of non-
enteric-coated aspirin (162–325 mg), which should be chewed to achieve rapid
systemic absorption. Aspirin works by irreversibly acetylating and inhibiting
cyclooxygenase-1 (COX-1), preventing the synthesis of thromboxane A2, a potent
inducer of platelet aggregation and vasoconstriction.
2. A 58-year-old female presents for a routine follow-up. She has a history of chronic
heart failure with reduced ejection fraction (HFEF, left ventricular ejection fraction of
, 32%). She reports mild dyspnea when climbing two flights of stairs but denies
orthopnea or paroxysmal nocturnal dyspnea. Her current daily medications include
lisinopril and furosemide. Her vitals are: BP 118/74 mmHg, HR 68/min, and regular
rhythm. Physical examination reveals no jugular venous distention and trace pedal
edema. Which of the following medications should be added next to her regimen to
reduce long-term mortality?
A) Digoxin
B) Isosorbide dinitrate
C) Carvedilol
D) Amlodipine
Beta-blockers (specifically carvedilol, metoprolol succinate, or bisoprolol) are
indicated for all patients with stable heart failure with reduced ejection fraction
(HFrEF) to improve survival and decrease hospitalization rates. They work by
mitigating the cardiotoxic effects of chronic sympathetic nervous system
upregulation. Digoxin and loop diuretics improve symptoms but do not decrease
long-term mortality.
3. A 45-year-old male with a history of alcohol use disorder presents with worsening
fatigue, abdominal distention, and confusion over the past 3 days. On examination,
he is disoriented to time and place, has scleral icterus, a distended abdomen with a
positive fluid wave, and a flapping tremor of his hands when his wrists are extended.
Laboratory evaluation demonstrates an elevated serum ammonia level. Which of the
following treatments is the primary first-line therapy to promote the fecal excretion of
the toxin causing his confusion?
A) Neomycin
B) Rifaximin
C) Lactulose
, D) Intravenous sodium bicarbonate
The patient has hepatic encephalopathy secondary to liver cirrhosis, characterized
by cognitive deficits and asterixis due to elevated serum ammonia levels. Lactulose
is the primary first-line therapy. In the colon, gut bacteria convert lactulose into lactic
acid and acetic acid, acidifying the colon contents. This converts diffusible ammonia
(NH3) into non-diffusible ammonium (NH4+), trapping it in the gut lumen and
facilitating its fecal evacuation via osmotic laxative effects.
4. A 72-year-old female is admitted to the hospital with a severe urinary tract infection.
On day 2 of admission, she becomes acutely confused, agitated, and starts
visualising insects on her hospital bed sheets. Her vital signs are stable, and she has
no focal neurological deficits. Her baseline mental status was completely intact prior
to admission. Which of the following terms best characterizes her acute
neurobehavioral condition?
A) Major neurocognitive disorder (Alzheimer's disease)
B) Delirium
C) Acute schizophrenia flare
D) Vascular dementia
Delirium is an acute, fluctuating change in mental status characterized by
inattention, disorganized thinking, and altered levels of consciousness, often
accompanied by hallucinations. It is commonly triggered by underlying systemic
infections, metabolic derangements, or medications in elderly, hospitalized patients.
Unlike dementia, delirium develops acutely and is potentially completely reversible
once the underlying trigger is resolved.
5. A 34-year-old male presents with a persistent cough, hemoptysis, and recurrent
epistaxis over the past two months. Urinalysis demonstrates hematuria and
dysmorphic red blood cells. Laboratory evaluation reveals a positive c-ANCA (PR3-
, ANCA) antibody titer. A renal biopsy shows crescentic glomerulonephritis. What is
the most likely diagnosis?
A) Goodpasture syndrome
B) Granulomatosis with polyangiitis
C) Microscopic polyangiitis
D) Henoch-Schönlein purpura
Granulomatosis with polyangiitis (formerly Wegener's) is a systemic necrotizing
vasculitis affecting small-to-medium vessels. It characteristically involves the upper
respiratory tract (epistaxis, nasal septal perforation), lower respiratory tract
(hemoptysis, cough), and kidneys (pauci-immune crescentic glomerulonephritis).
The highly specific serological marker is c-ANCA (anti-proteinase 3).
General & Trauma Surgery
6. A 24-year-old male is brought to the emergency department by emergency medical
services after sustaining a stab wound to the right mid-axillary line at the level of the
5th intercostal space. His vital signs are: BP 86/52 mmHg, HR 128/min, RR 26/min,
and SpO2 88% on a non-rebreather mask. Physical examination reveals absent
breath sounds and hyperresonance on the right side of the chest, along with jugular
venous distention. What is the immediate next step in the management of this
patient?
A) Order an urgent portable chest X-ray
B) Perform immediate needle thoracostomy in the second intercostal space at
the midclavicular line
C) Endotracheal intubation and mechanical ventilation
D) Obtain a stat computed tomography (CT) angiogram of the chest
This patient presents with a life-threatening tension pneumothorax, as evidenced by
