2026 COMSAE Phase 2 – Assessment
Series B Form 114i High-Difficulty Practice
Examination | Verified Detailed Questions,
Rationales & Complete Answers
Question 1
A 64-year-old man presents with crushing substernal chest pain
for 45 minutes. Blood pressure is 86/54 mmHg. ECG
demonstrates ST elevations in leads II, III, and aVF with
reciprocal depressions in I and aVL. The lungs are clear.
Which intervention should be performed immediately before
administering nitroglycerin?
A. Administer IV furosemide
B. Obtain right-sided ECG leads
C. Begin metoprolol
D. Administer morphine
Answer: B. Obtain right-sided ECG leads
Rationale: Inferior STEMIs frequently involve the right ventricle.
Right ventricular infarction is preload dependent, and
nitroglycerin may cause profound hypotension. Right-sided ECG
,(especially V4R) should be obtained before nitrates. Clear lungs
and hypotension strongly suggest RV infarction.
Question 2
A 30-year-old woman develops fever, hypotension, diffuse
erythroderma, vomiting, and confusion during menstruation.
Laboratory testing reveals elevated creatinine and
thrombocytopenia.
Which organism is most likely responsible?
A. Streptococcus pneumoniae
B. Escherichia coli
C. Staphylococcus aureus
D. Neisseria meningitidis
Answer: C. Staphylococcus aureus
Rationale: Toxic shock syndrome is caused by TSST-1
superantigen-producing Staphylococcus aureus. The illness
presents with fever, diffuse rash, hypotension, multiorgan
dysfunction, and desquamation during recovery.
Question 3
,A 58-year-old smoker develops painless hematuria. CT
urography demonstrates a papillary bladder mass.
Which risk factor is most strongly associated with this
malignancy?
A. Phenacetin abuse
B. Cyclophosphamide exposure
C. Cigarette smoking
D. Recurrent nephrolithiasis
Answer: C. Cigarette smoking
Rationale: Smoking is the strongest risk factor for urothelial
carcinoma because urinary carcinogens concentrate in the
bladder.
Question 4
A trauma patient develops severe respiratory distress six hours
after multiple long-bone fractures. Petechiae appear over the
chest.
Which diagnosis is most likely?
A. Pulmonary embolism
B. Fat embolism syndrome
, C. Tension pneumothorax
D. Aspiration pneumonitis
Answer: B. Fat embolism syndrome
Rationale: The classic triad includes respiratory distress,
neurologic abnormalities, and petechial rash following long-
bone fractures.
Question 5
A hospitalized patient receiving unfractionated heparin
experiences a platelet count decline from 280,000/μL to
95,000/μL on day 7.
What is the best next step?
A. Continue heparin
B. Reduce heparin dose
C. Stop heparin and begin argatroban
D. Administer platelet transfusion
Answer: C. Stop heparin and begin argatroban
Rationale: Heparin-induced thrombocytopenia is immune
mediated and highly thrombotic. Immediate cessation of all
Series B Form 114i High-Difficulty Practice
Examination | Verified Detailed Questions,
Rationales & Complete Answers
Question 1
A 64-year-old man presents with crushing substernal chest pain
for 45 minutes. Blood pressure is 86/54 mmHg. ECG
demonstrates ST elevations in leads II, III, and aVF with
reciprocal depressions in I and aVL. The lungs are clear.
Which intervention should be performed immediately before
administering nitroglycerin?
A. Administer IV furosemide
B. Obtain right-sided ECG leads
C. Begin metoprolol
D. Administer morphine
Answer: B. Obtain right-sided ECG leads
Rationale: Inferior STEMIs frequently involve the right ventricle.
Right ventricular infarction is preload dependent, and
nitroglycerin may cause profound hypotension. Right-sided ECG
,(especially V4R) should be obtained before nitrates. Clear lungs
and hypotension strongly suggest RV infarction.
Question 2
A 30-year-old woman develops fever, hypotension, diffuse
erythroderma, vomiting, and confusion during menstruation.
Laboratory testing reveals elevated creatinine and
thrombocytopenia.
Which organism is most likely responsible?
A. Streptococcus pneumoniae
B. Escherichia coli
C. Staphylococcus aureus
D. Neisseria meningitidis
Answer: C. Staphylococcus aureus
Rationale: Toxic shock syndrome is caused by TSST-1
superantigen-producing Staphylococcus aureus. The illness
presents with fever, diffuse rash, hypotension, multiorgan
dysfunction, and desquamation during recovery.
Question 3
,A 58-year-old smoker develops painless hematuria. CT
urography demonstrates a papillary bladder mass.
Which risk factor is most strongly associated with this
malignancy?
A. Phenacetin abuse
B. Cyclophosphamide exposure
C. Cigarette smoking
D. Recurrent nephrolithiasis
Answer: C. Cigarette smoking
Rationale: Smoking is the strongest risk factor for urothelial
carcinoma because urinary carcinogens concentrate in the
bladder.
Question 4
A trauma patient develops severe respiratory distress six hours
after multiple long-bone fractures. Petechiae appear over the
chest.
Which diagnosis is most likely?
A. Pulmonary embolism
B. Fat embolism syndrome
, C. Tension pneumothorax
D. Aspiration pneumonitis
Answer: B. Fat embolism syndrome
Rationale: The classic triad includes respiratory distress,
neurologic abnormalities, and petechial rash following long-
bone fractures.
Question 5
A hospitalized patient receiving unfractionated heparin
experiences a platelet count decline from 280,000/μL to
95,000/μL on day 7.
What is the best next step?
A. Continue heparin
B. Reduce heparin dose
C. Stop heparin and begin argatroban
D. Administer platelet transfusion
Answer: C. Stop heparin and begin argatroban
Rationale: Heparin-induced thrombocytopenia is immune
mediated and highly thrombotic. Immediate cessation of all
