COMSAE Phase 2 – Form BSA 103 (Legacy Surgical
and Internal Medicine Metrics) (2026 Edition):
Comprehensive Multiple-Choice Questions,
Answers, and Detailed Rationales
Question 1
A 67-year-old man presents with crushing substernal chest
pain radiating to the left arm for 45 minutes. ECG
demonstrates ST-segment elevations in leads II, III, and aVF.
Which coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Obtuse marginal artery
E. Posterior interventricular vein
Rationale: Inferior wall myocardial infarctions are classically
associated with occlusion of the right coronary artery. ST
elevations in leads II, III, and aVF localize ischemia to the
inferior wall of the heart.
Question 2
A 72-year-old woman develops sudden abdominal pain out of
proportion to physical examination findings. She has a history
of atrial fibrillation. Which diagnosis is most likely?
,A. Diverticulitis
B. Acute appendicitis
C. Small bowel obstruction
D. Acute mesenteric ischemia
E. Cholecystitis
Rationale: Acute mesenteric ischemia presents with severe
abdominal pain disproportionate to exam findings.
Embolization from atrial fibrillation is a major risk factor.
Question 3
A hospitalized patient develops fever, hypotension, and
leukocytosis 2 days after surgery. Which physiologic change is
most likely present in septic shock?
A. Increased systemic vascular resistance
B. Decreased cardiac output
C. Decreased systemic vascular resistance
D. Increased pulmonary wedge pressure
E. Reduced capillary permeability
Rationale: Septic shock is characterized by widespread
vasodilation, resulting in decreased systemic vascular
resistance and distributive shock.
Question 4
A 55-year-old man with cirrhosis presents with hematemesis.
Initial management should include:
,A. Emergent surgery
B. Colonoscopy
C. Oral antibiotics only
D. Airway stabilization and hemodynamic resuscitation
E. Immediate TIPS placement
Rationale: The first priority in upper gastrointestinal bleeding
is stabilization of airway, breathing, and circulation before
definitive diagnosis and therapy.
Question 5
A patient develops sudden dyspnea and pleuritic chest pain
three days after hip replacement surgery. Which test is most
useful for confirming the diagnosis?
A. Abdominal ultrasound
B. Echocardiography alone
C. CT pulmonary angiography
D. Colonoscopy
E. MRI brain
Rationale: Postoperative pulmonary embolism is best
confirmed with CT pulmonary angiography in a
hemodynamically stable patient.
Question 6
A patient presents with right upper quadrant pain, fever, and
jaundice. What condition is suggested by Charcot triad?
, A. Acute hepatitis
B. Pancreatitis
C. Ascending cholangitis
D. Gastric ulcer disease
E. Crohn disease
Rationale: Charcot triad consists of fever, jaundice, and right
upper quadrant pain and is classic for ascending cholangitis.
Question 7
A 65-year-old smoker has a pulsatile abdominal mass. Which
diagnosis is most likely?
A. Renal cell carcinoma
B. Diverticulosis
C. Pancreatic pseudocyst
D. Abdominal aortic aneurysm
E. Crohn disease
Rationale: A pulsatile abdominal mass in an older smoker
strongly suggests abdominal aortic aneurysm.
Question 8
A patient develops calf swelling after prolonged
immobilization. Which finding is most suggestive of deep
venous thrombosis?
A. Bilateral leg edema
B. Hyperactive bowel sounds
C. Unilateral leg swelling and tenderness
and Internal Medicine Metrics) (2026 Edition):
Comprehensive Multiple-Choice Questions,
Answers, and Detailed Rationales
Question 1
A 67-year-old man presents with crushing substernal chest
pain radiating to the left arm for 45 minutes. ECG
demonstrates ST-segment elevations in leads II, III, and aVF.
Which coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Obtuse marginal artery
E. Posterior interventricular vein
Rationale: Inferior wall myocardial infarctions are classically
associated with occlusion of the right coronary artery. ST
elevations in leads II, III, and aVF localize ischemia to the
inferior wall of the heart.
Question 2
A 72-year-old woman develops sudden abdominal pain out of
proportion to physical examination findings. She has a history
of atrial fibrillation. Which diagnosis is most likely?
,A. Diverticulitis
B. Acute appendicitis
C. Small bowel obstruction
D. Acute mesenteric ischemia
E. Cholecystitis
Rationale: Acute mesenteric ischemia presents with severe
abdominal pain disproportionate to exam findings.
Embolization from atrial fibrillation is a major risk factor.
Question 3
A hospitalized patient develops fever, hypotension, and
leukocytosis 2 days after surgery. Which physiologic change is
most likely present in septic shock?
A. Increased systemic vascular resistance
B. Decreased cardiac output
C. Decreased systemic vascular resistance
D. Increased pulmonary wedge pressure
E. Reduced capillary permeability
Rationale: Septic shock is characterized by widespread
vasodilation, resulting in decreased systemic vascular
resistance and distributive shock.
Question 4
A 55-year-old man with cirrhosis presents with hematemesis.
Initial management should include:
,A. Emergent surgery
B. Colonoscopy
C. Oral antibiotics only
D. Airway stabilization and hemodynamic resuscitation
E. Immediate TIPS placement
Rationale: The first priority in upper gastrointestinal bleeding
is stabilization of airway, breathing, and circulation before
definitive diagnosis and therapy.
Question 5
A patient develops sudden dyspnea and pleuritic chest pain
three days after hip replacement surgery. Which test is most
useful for confirming the diagnosis?
A. Abdominal ultrasound
B. Echocardiography alone
C. CT pulmonary angiography
D. Colonoscopy
E. MRI brain
Rationale: Postoperative pulmonary embolism is best
confirmed with CT pulmonary angiography in a
hemodynamically stable patient.
Question 6
A patient presents with right upper quadrant pain, fever, and
jaundice. What condition is suggested by Charcot triad?
, A. Acute hepatitis
B. Pancreatitis
C. Ascending cholangitis
D. Gastric ulcer disease
E. Crohn disease
Rationale: Charcot triad consists of fever, jaundice, and right
upper quadrant pain and is classic for ascending cholangitis.
Question 7
A 65-year-old smoker has a pulsatile abdominal mass. Which
diagnosis is most likely?
A. Renal cell carcinoma
B. Diverticulosis
C. Pancreatic pseudocyst
D. Abdominal aortic aneurysm
E. Crohn disease
Rationale: A pulsatile abdominal mass in an older smoker
strongly suggests abdominal aortic aneurysm.
Question 8
A patient develops calf swelling after prolonged
immobilization. Which finding is most suggestive of deep
venous thrombosis?
A. Bilateral leg edema
B. Hyperactive bowel sounds
C. Unilateral leg swelling and tenderness
