Internal Medicine COMAT
Review Exam (Actual 2025/2026)
Questions with Correct Answers
Verified by Experts | Graded A+
CARDIOVASCULAR SYSTEM (Questions 1-25)
Question 1
A 68-year-old male presents with a 2-week history of progressive dyspnea on
exertion, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination
reveals jugular venous distention, bibasilar crackles, and an S3 gallop. What is the
most common cause of an S3 heart sound?
A. Aortic stenosis
B. Hypertrophic cardiomyopathy
C. Congestive heart failure
D. Mitral regurgitation
Correct Answer: C. Congestive heart failure
Rationale: An S3 gallop occurs during early diastole due to rapid ventricular filling
and is most commonly associated with congestive heart failure with reduced
ejection fraction. It results from increased atrial pressure and decreased
ventricular compliance. An S3 in an older adult is a hallmark of elevated
ventricular filling pressures and systolic heart failure .
Question 2
A 62-year-old woman with a history of hypertension presents with sudden onset
,of "tearing" chest pain radiating to the interscapular region. Her blood pressure is
180/100 mm Hg in the right arm and 100/60 mm Hg in the left arm. Which of the
following is the most appropriate initial diagnostic study?
A. Transthoracic echocardiogram
B. CT angiography of the chest
C. Chest x-ray
D. Cardiac catheterization
Correct Answer: B. CT angiography of the chest
Rationale: The presentation is classic for acute aortic dissection (sudden, severe
"tearing" chest pain radiating to the back with differential blood pressures in the
upper extremities). CT angiography of the chest is the preferred initial imaging
study due to its high sensitivity and specificity for detecting dissection, especially
of the descending aorta .
Question 3
A 55-year-old male with a history of myocardial infarction presents with an early
decrescendo diastolic murmur best heard at the left upper sternal border. The
murmur is most consistent with:
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Pulmonic stenosis
Correct Answer: B. Aortic regurgitation
Rationale: Aortic regurgitation produces an early decrescendo diastolic murmur. It
is best auscultated at the second left intercostal space (left upper sternal border)
with the patient leaning forward and breath held in expiration. The murmur occurs
because blood flows backward from the aorta into the left ventricle during
diastole .
Question 4
A 70-year-old male with known systolic heart failure (EF 30%) presents with
worsening dyspnea and a new S3 gallop. He is currently on lisinopril, metoprolol
,succinate, and furosemide. Which medication is most likely to reduce mortality
and should be initiated next?
A. Spironolactone
B. Hydralazine/isosorbide dinitrate
C. Digoxin
D. Amiodarone
Correct Answer: A. Spironolactone
Rationale: In patients with NYHA class II-IV heart failure with reduced ejection
fraction (HFrEF), spironolactone (or eplerenone) reduces mortality by blocking
aldosterone receptors, decreasing sodium reabsorption, and reducing cardiac
fibrosis. Hydralazine/isosorbide dinitrate is indicated primarily in African American
patients with persistent symptoms despite optimal therapy .
Question 5
A 65-year-old male presents with substernal chest pain that began 2 hours ago.
ECG shows ST elevation in leads II, III, and aVF. Blood pressure is 90/60 mm Hg,
and heart rate is 45 beats per minute with a first-degree AV block. The most likely
occluded artery is the:
A. Left anterior descending artery (LAD)
B. Left circumflex artery (LCx)
C. Right coronary artery (RCA)
D. Diagonal branch
Correct Answer: C. Right coronary artery (RCA)
*Rationale: An inferior wall MI (ST elevation in leads II, III, aVF) is often caused by
occlusion of the right coronary artery. The RCA supplies the sinoatrial (SA) node in
60% of individuals and the atrioventricular (AV) node in 80-90%. Thus, inferior MIs
frequently cause bradycardia, AV blocks (often transient), and hypotension due to
the Bezold-Jarisch reflex. The LAD usually produces anterior MIs (V1-V4) .*
Question 6
A patient is found to have a blood pressure of 210/120 mm Hg and is
asymptomatic. He has no evidence of end-organ damage. Which of the following
, is the most appropriate initial management?
A. Hospital admission for IV nitroprusside
B. Oral nifedipine
C. Oral antihypertensive therapy with close outpatient follow-up
D. Intravenous labetalol immediately
Correct Answer: C. Oral antihypertensive therapy with close outpatient follow-
up
Rationale: Asymptomatic severe hypertension (often called "hypertensive
urgency") is defined by severely elevated BP without acute end-organ damage.
These patients can be managed in an outpatient setting with oral
antihypertensives; rapid reduction in BP is not needed and may be harmful (risk of
ischemic stroke, MI, or renal injury). Hospital admission and IV agents are reserved
for hypertensive emergencies where acute end-organ damage is present .
Question 7
ECG leads V1-V4 represent which wall of the heart?
A. Inferior
B. Lateral
C. Septal/anterior
D. Posterior
Correct Answer: C. Septal/anterior
*Rationale: Leads V1-V4 reflect the septal and anterior wall of the left ventricle.
V1-V2 are septal leads, while V3-V4 are anterior leads. This territory is supplied by
the left anterior descending (LAD) coronary artery. Anterior wall MIs are often
larger and carry a worse prognosis than inferior MIs .*
Question 8
Which ECG leads are used to view the inferior wall of the heart?
A. I and aVL
B. V1 and V2
C. II, III, and aVF
D. V5 and V6
Review Exam (Actual 2025/2026)
Questions with Correct Answers
Verified by Experts | Graded A+
CARDIOVASCULAR SYSTEM (Questions 1-25)
Question 1
A 68-year-old male presents with a 2-week history of progressive dyspnea on
exertion, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination
reveals jugular venous distention, bibasilar crackles, and an S3 gallop. What is the
most common cause of an S3 heart sound?
A. Aortic stenosis
B. Hypertrophic cardiomyopathy
C. Congestive heart failure
D. Mitral regurgitation
Correct Answer: C. Congestive heart failure
Rationale: An S3 gallop occurs during early diastole due to rapid ventricular filling
and is most commonly associated with congestive heart failure with reduced
ejection fraction. It results from increased atrial pressure and decreased
ventricular compliance. An S3 in an older adult is a hallmark of elevated
ventricular filling pressures and systolic heart failure .
Question 2
A 62-year-old woman with a history of hypertension presents with sudden onset
,of "tearing" chest pain radiating to the interscapular region. Her blood pressure is
180/100 mm Hg in the right arm and 100/60 mm Hg in the left arm. Which of the
following is the most appropriate initial diagnostic study?
A. Transthoracic echocardiogram
B. CT angiography of the chest
C. Chest x-ray
D. Cardiac catheterization
Correct Answer: B. CT angiography of the chest
Rationale: The presentation is classic for acute aortic dissection (sudden, severe
"tearing" chest pain radiating to the back with differential blood pressures in the
upper extremities). CT angiography of the chest is the preferred initial imaging
study due to its high sensitivity and specificity for detecting dissection, especially
of the descending aorta .
Question 3
A 55-year-old male with a history of myocardial infarction presents with an early
decrescendo diastolic murmur best heard at the left upper sternal border. The
murmur is most consistent with:
A. Aortic stenosis
B. Aortic regurgitation
C. Mitral stenosis
D. Pulmonic stenosis
Correct Answer: B. Aortic regurgitation
Rationale: Aortic regurgitation produces an early decrescendo diastolic murmur. It
is best auscultated at the second left intercostal space (left upper sternal border)
with the patient leaning forward and breath held in expiration. The murmur occurs
because blood flows backward from the aorta into the left ventricle during
diastole .
Question 4
A 70-year-old male with known systolic heart failure (EF 30%) presents with
worsening dyspnea and a new S3 gallop. He is currently on lisinopril, metoprolol
,succinate, and furosemide. Which medication is most likely to reduce mortality
and should be initiated next?
A. Spironolactone
B. Hydralazine/isosorbide dinitrate
C. Digoxin
D. Amiodarone
Correct Answer: A. Spironolactone
Rationale: In patients with NYHA class II-IV heart failure with reduced ejection
fraction (HFrEF), spironolactone (or eplerenone) reduces mortality by blocking
aldosterone receptors, decreasing sodium reabsorption, and reducing cardiac
fibrosis. Hydralazine/isosorbide dinitrate is indicated primarily in African American
patients with persistent symptoms despite optimal therapy .
Question 5
A 65-year-old male presents with substernal chest pain that began 2 hours ago.
ECG shows ST elevation in leads II, III, and aVF. Blood pressure is 90/60 mm Hg,
and heart rate is 45 beats per minute with a first-degree AV block. The most likely
occluded artery is the:
A. Left anterior descending artery (LAD)
B. Left circumflex artery (LCx)
C. Right coronary artery (RCA)
D. Diagonal branch
Correct Answer: C. Right coronary artery (RCA)
*Rationale: An inferior wall MI (ST elevation in leads II, III, aVF) is often caused by
occlusion of the right coronary artery. The RCA supplies the sinoatrial (SA) node in
60% of individuals and the atrioventricular (AV) node in 80-90%. Thus, inferior MIs
frequently cause bradycardia, AV blocks (often transient), and hypotension due to
the Bezold-Jarisch reflex. The LAD usually produces anterior MIs (V1-V4) .*
Question 6
A patient is found to have a blood pressure of 210/120 mm Hg and is
asymptomatic. He has no evidence of end-organ damage. Which of the following
, is the most appropriate initial management?
A. Hospital admission for IV nitroprusside
B. Oral nifedipine
C. Oral antihypertensive therapy with close outpatient follow-up
D. Intravenous labetalol immediately
Correct Answer: C. Oral antihypertensive therapy with close outpatient follow-
up
Rationale: Asymptomatic severe hypertension (often called "hypertensive
urgency") is defined by severely elevated BP without acute end-organ damage.
These patients can be managed in an outpatient setting with oral
antihypertensives; rapid reduction in BP is not needed and may be harmful (risk of
ischemic stroke, MI, or renal injury). Hospital admission and IV agents are reserved
for hypertensive emergencies where acute end-organ damage is present .
Question 7
ECG leads V1-V4 represent which wall of the heart?
A. Inferior
B. Lateral
C. Septal/anterior
D. Posterior
Correct Answer: C. Septal/anterior
*Rationale: Leads V1-V4 reflect the septal and anterior wall of the left ventricle.
V1-V2 are septal leads, while V3-V4 are anterior leads. This territory is supplied by
the left anterior descending (LAD) coronary artery. Anterior wall MIs are often
larger and carry a worse prognosis than inferior MIs .*
Question 8
Which ECG leads are used to view the inferior wall of the heart?
A. I and aVL
B. V1 and V2
C. II, III, and aVF
D. V5 and V6
