COMSAE Phase 1 Form 115 Real Exam 2026: High-Yield
Questions with Answers & Detailed Rationales — Complete
NBOME Osteopathic Board Review for Cardiology, Pulmonology,
Neurology, OMM, Microbiology & Endocrinology | COMLEX-USA
Level 1 Prep
Question 1
A 62-year-old male with a history of hypertension presents with progressive dyspnea on
exertion. Echocardiogram shows left ventricular hypertrophy with a small cavity and diastolic
dysfunction. Which of the following is the most appropriate first-line medication?
A) Metoprolol
B) Furosemide
C) Digoxin
D) Spironolactone
E) Dobutamine
Answer: A) Metoprolol
Rationale: The patient has heart failure with preserved ejection fraction (HFpEF) with
hypertensive cardiomyopathy. Beta-blockers (metoprolol) and ACE inhibitors are first-line
for rate control and blood pressure management. Furosemide treats volume overload but is
not first-line. Digoxin does not improve outcomes in HFpEF.
,Question 2
A 55-year-old male presents with acute-onset substernal chest pain radiating to the left arm.
ECG shows ST elevations in leads V1–V4. Which coronary artery is most likely occluded?
A) Right coronary artery (RCA)
B) Left circumflex (LCx)
C) Left anterior descending (LAD)
D) Left main coronary artery
E) Posterior descending artery (PDA)
Answer: C) Left anterior descending (LAD)
Rationale: ST elevations in V1–V4 indicate an anterior wall STEMI, which is caused by
occlusion of the left anterior descending (LAD) artery, often called the "widowmaker." RCA
causes inferior MI (II, III, aVF). LCx causes lateral MI (I, aVL, V5-V6).
Question 3
A 68-year-old female presents with palpitations. ECG shows an irregularly irregular rhythm
with no discernible P waves and a ventricular rate of 150 bpm. She is hemodynamically
stable. Which medication is most appropriate for acute rate control?
A) Amiodarone
B) Diltiazem
C) Digoxin
D) Adenosine
E) Lidocaine
Answer: B) Diltiazem
Rationale: This is atrial fibrillation with rapid ventricular response. In hemodynamically
stable patients, rate control with a calcium channel blocker (diltiazem or verapamil) or beta-
blocker is first-line. Adenosine is for narrow complex tachycardias like AVNRT. Digoxin is
second-line.
Question 4
A 72-year-old male with a history of heart failure with reduced ejection fraction (HFrEF)
presents with worsening dyspnea. He is on lisinopril, carvedilol, and furosemide. His
ejection fraction is 30%. Which additional medication has been shown to reduce mortality?
A) Hydralazine
B) Digoxin
C) Sacubitril/valsartan
,D) Metolazone
E) Spironolactone
Answer: C) Sacubitril/valsartan
Rationale: Sacubitril/valsartan (ARNI) reduces mortality and hospitalizations in HFrEF
compared to ACE inhibitors. Spironolactone also reduces mortality but is typically added
after ARNI/ACEi. Hydralazine/nitrates are for African Americans with persistent symptoms.
Question 5
A 45-year-old male presents with syncope during exercise. A harsh crescendo-decrescendo
systolic murmur at the right upper sternal border radiates to the carotids. What is the most
common cause of this condition in a patient of this age?
A) Calcific degeneration of trileaflet valve
B) Bicuspid aortic valve
C) Rheumatic heart disease
D) Hypertrophic cardiomyopathy
E) Infective endocarditis
Answer: B) Bicuspid aortic valve
Rationale: In patients aged 50-70 years, bicuspid aortic valve is the most common cause of
aortic stenosis. Calcific degeneration of trileaflet valve is most common in patients >70
years. Rheumatic heart disease is less common and usually involves mitral valve.
Question 6
A 58-year-old female presents with acute chest pain and dyspnea. ECG shows ST
elevations in leads II, III, and aVF with reciprocal changes in I and aVL. Which physical
exam finding may be present if there is right ventricular involvement?
A) Kussmaul sign
B) Pulsus paradoxus
C) De Musset's sign
D) Opening snap
E) Holosystolic murmur at apex
Answer: A) Kussmaul sign
Rationale: Right ventricular infarction occurs in 30-50% of inferior STEMIs. Kussmaul sign
(increased JVP with inspiration) is classic for RV infarction. Pulsus paradoxus is seen in
cardiac tamponade or severe asthma. De Musset's sign is for aortic regurgitation.
, Question 7
A 65-year-old male presents with chronic dyspnea. Echocardiogram shows a thickened,
calcified aortic valve with a peak gradient of 50 mmHg and valve area of 0.8 cm². He is
symptomatic. What is the most appropriate next step?
A) Medical management with beta-blockers
B) Aortic valve replacement
C) Balloon valvuloplasty
D) Observation with annual echocardiogram
E) Antibiotic prophylaxis
Answer: B) Aortic valve replacement
Rationale: Symptomatic severe aortic stenosis (valve area <1.0 cm², mean gradient >40
mmHg) requires aortic valve replacement (surgical or transcatheter). Balloon valvuloplasty
is a bridge to surgery in unstable patients. Medical management does not improve survival.
Question 8
A 52-year-old male with hypertension presents with acute-onset tearing chest pain radiating
to the back. BP is 200/110 in the right arm and 140/80 in the left arm. What is the most
appropriate immediate medical management?
A) Aspirin and clopidogrel
B) IV nitroglycerin and furosemide
C) IV beta-blocker (esmolol) followed by nitroprusside
D) IV alteplase (tPA)
E) Heparin drip
Answer: C) IV beta-blocker (esmolol) followed by nitroprusside
Rationale: This is aortic dissection. Immediate management includes IV beta-blockers to
reduce dP/dt (shear force), followed by vasodilators (nitroprusside) if needed. Thrombolytics
and anticoagulation are contraindicated. Emergent surgical consultation is also required.
Question 9
A 48-year-old female presents with palpitations and lightheadedness. ECG shows a narrow
complex tachycardia at 190 bpm with no visible P waves. Vagal maneuvers terminate the
rhythm. What is the diagnosis?
A) Atrial fibrillation
B) Atrial flutter
C) AV nodal reentrant tachycardia (AVNRT)
Questions with Answers & Detailed Rationales — Complete
NBOME Osteopathic Board Review for Cardiology, Pulmonology,
Neurology, OMM, Microbiology & Endocrinology | COMLEX-USA
Level 1 Prep
Question 1
A 62-year-old male with a history of hypertension presents with progressive dyspnea on
exertion. Echocardiogram shows left ventricular hypertrophy with a small cavity and diastolic
dysfunction. Which of the following is the most appropriate first-line medication?
A) Metoprolol
B) Furosemide
C) Digoxin
D) Spironolactone
E) Dobutamine
Answer: A) Metoprolol
Rationale: The patient has heart failure with preserved ejection fraction (HFpEF) with
hypertensive cardiomyopathy. Beta-blockers (metoprolol) and ACE inhibitors are first-line
for rate control and blood pressure management. Furosemide treats volume overload but is
not first-line. Digoxin does not improve outcomes in HFpEF.
,Question 2
A 55-year-old male presents with acute-onset substernal chest pain radiating to the left arm.
ECG shows ST elevations in leads V1–V4. Which coronary artery is most likely occluded?
A) Right coronary artery (RCA)
B) Left circumflex (LCx)
C) Left anterior descending (LAD)
D) Left main coronary artery
E) Posterior descending artery (PDA)
Answer: C) Left anterior descending (LAD)
Rationale: ST elevations in V1–V4 indicate an anterior wall STEMI, which is caused by
occlusion of the left anterior descending (LAD) artery, often called the "widowmaker." RCA
causes inferior MI (II, III, aVF). LCx causes lateral MI (I, aVL, V5-V6).
Question 3
A 68-year-old female presents with palpitations. ECG shows an irregularly irregular rhythm
with no discernible P waves and a ventricular rate of 150 bpm. She is hemodynamically
stable. Which medication is most appropriate for acute rate control?
A) Amiodarone
B) Diltiazem
C) Digoxin
D) Adenosine
E) Lidocaine
Answer: B) Diltiazem
Rationale: This is atrial fibrillation with rapid ventricular response. In hemodynamically
stable patients, rate control with a calcium channel blocker (diltiazem or verapamil) or beta-
blocker is first-line. Adenosine is for narrow complex tachycardias like AVNRT. Digoxin is
second-line.
Question 4
A 72-year-old male with a history of heart failure with reduced ejection fraction (HFrEF)
presents with worsening dyspnea. He is on lisinopril, carvedilol, and furosemide. His
ejection fraction is 30%. Which additional medication has been shown to reduce mortality?
A) Hydralazine
B) Digoxin
C) Sacubitril/valsartan
,D) Metolazone
E) Spironolactone
Answer: C) Sacubitril/valsartan
Rationale: Sacubitril/valsartan (ARNI) reduces mortality and hospitalizations in HFrEF
compared to ACE inhibitors. Spironolactone also reduces mortality but is typically added
after ARNI/ACEi. Hydralazine/nitrates are for African Americans with persistent symptoms.
Question 5
A 45-year-old male presents with syncope during exercise. A harsh crescendo-decrescendo
systolic murmur at the right upper sternal border radiates to the carotids. What is the most
common cause of this condition in a patient of this age?
A) Calcific degeneration of trileaflet valve
B) Bicuspid aortic valve
C) Rheumatic heart disease
D) Hypertrophic cardiomyopathy
E) Infective endocarditis
Answer: B) Bicuspid aortic valve
Rationale: In patients aged 50-70 years, bicuspid aortic valve is the most common cause of
aortic stenosis. Calcific degeneration of trileaflet valve is most common in patients >70
years. Rheumatic heart disease is less common and usually involves mitral valve.
Question 6
A 58-year-old female presents with acute chest pain and dyspnea. ECG shows ST
elevations in leads II, III, and aVF with reciprocal changes in I and aVL. Which physical
exam finding may be present if there is right ventricular involvement?
A) Kussmaul sign
B) Pulsus paradoxus
C) De Musset's sign
D) Opening snap
E) Holosystolic murmur at apex
Answer: A) Kussmaul sign
Rationale: Right ventricular infarction occurs in 30-50% of inferior STEMIs. Kussmaul sign
(increased JVP with inspiration) is classic for RV infarction. Pulsus paradoxus is seen in
cardiac tamponade or severe asthma. De Musset's sign is for aortic regurgitation.
, Question 7
A 65-year-old male presents with chronic dyspnea. Echocardiogram shows a thickened,
calcified aortic valve with a peak gradient of 50 mmHg and valve area of 0.8 cm². He is
symptomatic. What is the most appropriate next step?
A) Medical management with beta-blockers
B) Aortic valve replacement
C) Balloon valvuloplasty
D) Observation with annual echocardiogram
E) Antibiotic prophylaxis
Answer: B) Aortic valve replacement
Rationale: Symptomatic severe aortic stenosis (valve area <1.0 cm², mean gradient >40
mmHg) requires aortic valve replacement (surgical or transcatheter). Balloon valvuloplasty
is a bridge to surgery in unstable patients. Medical management does not improve survival.
Question 8
A 52-year-old male with hypertension presents with acute-onset tearing chest pain radiating
to the back. BP is 200/110 in the right arm and 140/80 in the left arm. What is the most
appropriate immediate medical management?
A) Aspirin and clopidogrel
B) IV nitroglycerin and furosemide
C) IV beta-blocker (esmolol) followed by nitroprusside
D) IV alteplase (tPA)
E) Heparin drip
Answer: C) IV beta-blocker (esmolol) followed by nitroprusside
Rationale: This is aortic dissection. Immediate management includes IV beta-blockers to
reduce dP/dt (shear force), followed by vasodilators (nitroprusside) if needed. Thrombolytics
and anticoagulation are contraindicated. Emergent surgical consultation is also required.
Question 9
A 48-year-old female presents with palpitations and lightheadedness. ECG shows a narrow
complex tachycardia at 190 bpm with no visible P waves. Vagal maneuvers terminate the
rhythm. What is the diagnosis?
A) Atrial fibrillation
B) Atrial flutter
C) AV nodal reentrant tachycardia (AVNRT)
