Page 1 of 287
COMSAE Phase 2 Form 116 EXAM PRACTICE
QUESTIONS AND VERIFIED ANSWERS WITH
RATIONALES JUST RELEASED
COMSAE Phase 2 Form 116 EXAM
Comprehensive Question Bank with Answers and Rationales
EXAM COVERAGE AREAS (BOLD POINTS)
Advanced Clinical Medicine, Osteopathic Principles & Practice, Clinical Reasoning, Patient
Management & COMLEX-USA Level 2-CE Competencies (Core Exam Area)
Internal Medicine
Family Medicine & Preventive Care
Pediatrics
Obstetrics & Gynecology
General Surgery & Surgical Care
Emergency Medicine & Critical Care
Psychiatry & Behavioral Health
Neurology
Osteopathic Principles & Osteopathic Manipulative Medicine (OPP/OMM)
Clinical Reasoning, Ethics & Professionalism
EXAMINATION QUESTIONS WITH ANSWERS AND RATIONALES
QUESTION 1
A 58-year-old male with a history of hypertension and type 2 diabetes presents to the
emergency department with sudden onset of severe substernal chest pain radiating to his left
arm and jaw that began approximately 45 minutes ago while he was shoveling snow. His vital
signs reveal a heart rate of 98 beats per minute, blood pressure of 165/95 mmHg, respiratory
rate of 22 breaths per minute, and oxygen saturation of 96% on room air. An electrocardiogram
demonstrates ST-segment elevation of 3 mm in leads V1 through V4 with reciprocal changes in
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the inferior leads. Which of the following is the MOST appropriate immediate management for
this patient?
A) Administer sublingual nitroglycerin and schedule a stress test for the following day
B) Transfer to the cardiac catheterization laboratory for urgent percutaneous coronary
intervention
C) Administer intravenous heparin and admit to the telemetry floor for observation
D) Administer intravenous tissue plasminogen activator (tPA) and admit to the intensive care
unit
Answer: B) Transfer to the cardiac catheterization laboratory for urgent percutaneous
coronary intervention
Rationale: This patient is presenting with an acute anterior ST-segment elevation myocardial
infarction (STEMI) as evidenced by ST elevation in leads V1 through V4, which corresponds to
the anterior wall of the heart. The presence of reciprocal changes in the inferior leads further
supports the diagnosis of an acute STEMI. The standard of care for STEMI is urgent reperfusion
therapy, with percutaneous coronary intervention (PCI) being the preferred method if it can be
performed within 90 minutes of arrival. The patient has classic cardiac risk factors and a typical
presentation. PCI is superior to thrombolytic therapy for STEMI when available in a timely
manner.
QUESTION 2
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A 45-year-old female presents to the outpatient clinic with complaints of progressive fatigue,
weight gain of 15 pounds over the past 6 months, cold intolerance, constipation, and dry skin.
Her past medical history is significant for autoimmune thyroiditis. On physical examination, she
has a bradycardia at 52 beats per minute, mild periorbital edema, and a delayed relaxation
phase of the deep tendon reflexes. Laboratory evaluation reveals a markedly elevated thyroid-
stimulating hormone (TSH) of 45 mIU/L with a low free thyroxine (T4) level. What is the MOST
appropriate initial management for this patient's condition?
A) Start levothyroxine 25 mcg daily and recheck TSH in 6 weeks
B) Start levothyroxine 100 mcg daily and recheck TSH in 4 weeks
C) Start liothyronine 25 mcg daily and recheck TSH in 6 weeks
D) Start levothyroxine 50 mcg daily and recheck TSH in 8 weeks
Answer: A) Start levothyroxine 25 mcg daily and recheck TSH in 6 weeks
Rationale: This patient has primary hypothyroidism as evidenced by an elevated TSH and low
free T4 in the setting of classic symptoms of hypothyroidism. The standard initial management
for hypothyroidism is levothyroxine replacement therapy. For elderly patients or those with
cardiovascular disease, a lower starting dose of 25 mcg is recommended, but for a relatively
healthy 45-year-old, an initial dose of 50 to 100 mcg may be appropriate. However, many
clinicians start with a conservative dose to avoid precipitating cardiac issues. The TSH should be
rechecked in 6 weeks to allow steady-state levels to be achieved. Liothyronine (T3) is not
routinely used as initial therapy due to potential toxicity.
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QUESTION 3
A 67-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents to
the emergency department with worsening shortness of breath, increased sputum production
that is now purulent, and a fever of 101.2°F. He has been using his home bronchodilators more
frequently. On examination, he is tachypneic with a respiratory rate of 28 breaths per minute,
using accessory muscles of respiration, and has diffuse expiratory wheezing. His oxygen
saturation is 88% on room air. Chest radiography reveals hyperinflation and no evidence of
infiltrate. Which of the following is the MOST appropriate initial management for this patient?
A) Start oral prednisone 40 mg daily and discharge home with antibiotics
B) Administer nebulized albuterol and ipratropium, start oral corticosteroids, and initiate
antibiotics
C) Administer intravenous antibiotics and admit to the intensive care unit
D) Start oxygen therapy and arrange for pulmonary rehabilitation
Answer: B) Administer nebulized albuterol and ipratropium, start oral corticosteroids, and
initiate antibiotics
Rationale: This patient is experiencing an acute exacerbation of COPD characterized by
worsening dyspnea, increased sputum production with purulence, and fever. The exacerbation
is likely infectious in nature given the fever and purulent sputum. The initial management of
COPD exacerbation includes bronchodilators (nebulized albuterol and ipratropium), systemic
COMSAE Phase 2 Form 116 EXAM PRACTICE
QUESTIONS AND VERIFIED ANSWERS WITH
RATIONALES JUST RELEASED
COMSAE Phase 2 Form 116 EXAM
Comprehensive Question Bank with Answers and Rationales
EXAM COVERAGE AREAS (BOLD POINTS)
Advanced Clinical Medicine, Osteopathic Principles & Practice, Clinical Reasoning, Patient
Management & COMLEX-USA Level 2-CE Competencies (Core Exam Area)
Internal Medicine
Family Medicine & Preventive Care
Pediatrics
Obstetrics & Gynecology
General Surgery & Surgical Care
Emergency Medicine & Critical Care
Psychiatry & Behavioral Health
Neurology
Osteopathic Principles & Osteopathic Manipulative Medicine (OPP/OMM)
Clinical Reasoning, Ethics & Professionalism
EXAMINATION QUESTIONS WITH ANSWERS AND RATIONALES
QUESTION 1
A 58-year-old male with a history of hypertension and type 2 diabetes presents to the
emergency department with sudden onset of severe substernal chest pain radiating to his left
arm and jaw that began approximately 45 minutes ago while he was shoveling snow. His vital
signs reveal a heart rate of 98 beats per minute, blood pressure of 165/95 mmHg, respiratory
rate of 22 breaths per minute, and oxygen saturation of 96% on room air. An electrocardiogram
demonstrates ST-segment elevation of 3 mm in leads V1 through V4 with reciprocal changes in
, Page 2 of 287
the inferior leads. Which of the following is the MOST appropriate immediate management for
this patient?
A) Administer sublingual nitroglycerin and schedule a stress test for the following day
B) Transfer to the cardiac catheterization laboratory for urgent percutaneous coronary
intervention
C) Administer intravenous heparin and admit to the telemetry floor for observation
D) Administer intravenous tissue plasminogen activator (tPA) and admit to the intensive care
unit
Answer: B) Transfer to the cardiac catheterization laboratory for urgent percutaneous
coronary intervention
Rationale: This patient is presenting with an acute anterior ST-segment elevation myocardial
infarction (STEMI) as evidenced by ST elevation in leads V1 through V4, which corresponds to
the anterior wall of the heart. The presence of reciprocal changes in the inferior leads further
supports the diagnosis of an acute STEMI. The standard of care for STEMI is urgent reperfusion
therapy, with percutaneous coronary intervention (PCI) being the preferred method if it can be
performed within 90 minutes of arrival. The patient has classic cardiac risk factors and a typical
presentation. PCI is superior to thrombolytic therapy for STEMI when available in a timely
manner.
QUESTION 2
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A 45-year-old female presents to the outpatient clinic with complaints of progressive fatigue,
weight gain of 15 pounds over the past 6 months, cold intolerance, constipation, and dry skin.
Her past medical history is significant for autoimmune thyroiditis. On physical examination, she
has a bradycardia at 52 beats per minute, mild periorbital edema, and a delayed relaxation
phase of the deep tendon reflexes. Laboratory evaluation reveals a markedly elevated thyroid-
stimulating hormone (TSH) of 45 mIU/L with a low free thyroxine (T4) level. What is the MOST
appropriate initial management for this patient's condition?
A) Start levothyroxine 25 mcg daily and recheck TSH in 6 weeks
B) Start levothyroxine 100 mcg daily and recheck TSH in 4 weeks
C) Start liothyronine 25 mcg daily and recheck TSH in 6 weeks
D) Start levothyroxine 50 mcg daily and recheck TSH in 8 weeks
Answer: A) Start levothyroxine 25 mcg daily and recheck TSH in 6 weeks
Rationale: This patient has primary hypothyroidism as evidenced by an elevated TSH and low
free T4 in the setting of classic symptoms of hypothyroidism. The standard initial management
for hypothyroidism is levothyroxine replacement therapy. For elderly patients or those with
cardiovascular disease, a lower starting dose of 25 mcg is recommended, but for a relatively
healthy 45-year-old, an initial dose of 50 to 100 mcg may be appropriate. However, many
clinicians start with a conservative dose to avoid precipitating cardiac issues. The TSH should be
rechecked in 6 weeks to allow steady-state levels to be achieved. Liothyronine (T3) is not
routinely used as initial therapy due to potential toxicity.
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QUESTION 3
A 67-year-old male with a history of chronic obstructive pulmonary disease (COPD) presents to
the emergency department with worsening shortness of breath, increased sputum production
that is now purulent, and a fever of 101.2°F. He has been using his home bronchodilators more
frequently. On examination, he is tachypneic with a respiratory rate of 28 breaths per minute,
using accessory muscles of respiration, and has diffuse expiratory wheezing. His oxygen
saturation is 88% on room air. Chest radiography reveals hyperinflation and no evidence of
infiltrate. Which of the following is the MOST appropriate initial management for this patient?
A) Start oral prednisone 40 mg daily and discharge home with antibiotics
B) Administer nebulized albuterol and ipratropium, start oral corticosteroids, and initiate
antibiotics
C) Administer intravenous antibiotics and admit to the intensive care unit
D) Start oxygen therapy and arrange for pulmonary rehabilitation
Answer: B) Administer nebulized albuterol and ipratropium, start oral corticosteroids, and
initiate antibiotics
Rationale: This patient is experiencing an acute exacerbation of COPD characterized by
worsening dyspnea, increased sputum production with purulence, and fever. The exacerbation
is likely infectious in nature given the fever and purulent sputum. The initial management of
COPD exacerbation includes bronchodilators (nebulized albuterol and ipratropium), systemic
