ASA 114 COMSAE PHASE 1 LEVEL 1 NEWEST EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS A NEW
UPDATED VERSION LATEST 2026-2027/COMSAE PHASE 1
ASA 114 EXAM (100%CORRECT VERIFIED ANSWERS)
ALREADY GRADED A+
Question 1
A 24-year-old woman presents with acute-onset severe headache, fever, and neck stiffness. CSF shows 2000
WBC/μL (95% neutrophils), glucose 20 mg/dL (serum 100), protein 150 mg/dL. Gram stain shows
gram-negative diplococci. Which is the most appropriate empiric antibiotic?
A) Ceftriaxone
B) Vancomycin
C) Ampicillin
D) Metronidazole
Answer. A
Rationale: The CSF findings of high neutrophil count, low glucose, and elevated protein indicate acute
bacterial meningitis. Gram-negative diplococci strongly suggest Neisseria meningitidis. A third-generation
cephalosporin such as ceftriaxone is the empiric antibiotic of choice for meningococcal meningitis, as it
provides excellent CNS penetration and covers the most common pathogens. Vancomycin is added for
penicillin-resistant Streptococcus pneumoniae but is not sufficient alone .
Question 2
A 58-year-old man with type 2 diabetes presents with a 2-week history of progressive right-sided weakness
and headache. MRI shows a ring-enhancing lesion in the left frontal lobe. Which additional finding would most
suggest a brain abscess rather than a primary tumor?
A) Solitary lesion
B) Diffusion restriction on DWI
C) Surrounding vasogenic edema
D) Contrast enhancement
Answer: B
Rationale:Brain abscesses characteristically show restricted diffusion on diffusion-weighted imaging (DWI) due
to the presence of pus and cellular debris. While both abscesses and tumors can be solitary, ring-enhancing,
and have surrounding edema, restricted diffusion is highly specific for abscess. This finding represents the
high viscosity of necrotic material within the abscess cavity .
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Question 3
A 35-year-old woman presents with fatigue, dyspnea on exertion, and palpitations. Labs: hemoglobin 7 g/dL,
MCV 65 fL, RDW elevated. Ferritin is 8 ng/mL. Which is the most appropriate next step?
,A) Oral ferrous sulfate
B) IV iron
C) Bone marrow biopsy
D) RBC transfusion
Answer: A
Rationale: Iron deficiency anemia is confirmed by low ferritin with microcytic, hypochromic indices. Oral ferrous
sulfate is first-line treatment for uncomplicated iron deficiency anemia unless the patient is symptomatic with
severe anemia. IV iron is reserved for patients with malabsorption, intolerance to oral iron, or severe
symptomatic anemia. Bone marrow biopsy is unnecessary for straightforward iron deficiency .
Question 4
A 3-year-old child presents with a barking cough, inspiratory stridor, and low-grade fever. Symptoms are worse
at night. Which is the most likely diagnosis?
A) Epiglottitis
B) Croup
C) Bacterial tracheitis
D) Foreign body aspiration
Answer: B
Rationale:Croup (laryngotracheobronchitis) is a viral infection causing subglottic swelling and is characterized
by a barking cough, inspiratory stridor, and hoarseness. Symptoms typically worsen at night. It is most
common in children aged 6 months to 3 years and is usually caused by parainfluenza virus. Epiglottitis
presents with high fever, drooling, and a toxic appearance without barking cough .
Question 5
A 28-year-old man presents with acute scrotal pain and nausea. On exam, the left testis is high-riding and
horizontal, with absent cremasteric reflex. What is the most appropriate next step?
A) Scrotal ultrasound
B) Urinalysis
C) Surgical exploration
D) Empiric antibiotics
Answer: C
Rationale:Testicular torsion is a surgical emergency. The classic presentation includes acute scrotal pain,
nausea, vomiting, high-riding testis, horizontal lie, and absent cremasteric reflex. Surgical exploration should
be performed emergently to salvage the testis. Imaging (ultrasound with Doppler) may delay treatment and
should not be obtained if the clinical suspicion is high. Antibiotics would be appropriate for epididymitis, which
typically presents with a positive cremasteric reflex .
Question 6
,A 52-year-old woman presents with painless jaundice, weight loss, and a palpable gallbladder. Which is the
most likely underlying diagnosis?
A) Choledocholithiasis
B) Pancreatic head cancer
C) Gallbladder cancer
D) Primary sclerosing cholangitis
Answer: B
Rationale: Courvoisier sign—jaundice with a palpable, non-tender gallbladder—classically indicates malignant
obstruction of the biliary tree, most commonly due to pancreatic head cancer. The gallbladder becomes
distended because the obstruction is distal to the cystic duct junction. Choledocholithiasis typically presents
with a non-palpable gallbladder (due to scarring and inflammation) and often with pain and fever .
Question 7
A 2-month-old infant presents with poor feeding, vomiting, and failure to thrive. Labs: Na 125, K 6.8, glucose
45. Which is the most likely diagnosis?
A) Pyloric stenosis
B) Congenital adrenal hyperplasia
C) Sepsis
D) Dehydration
Answer: B
Rationale: Salt-wasting crisis from 21-hydroxylase deficiency (the most common form of congenital adrenal
hyperplasia) presents with hyponatremia, hyperkalemia, and hypoglycemia in a newborn or young infant.
Pyloric stenosis causes metabolic alkalosis with hypochloremia, not hyperkalemia. Dehydration may cause
hypernatremia, and sepsis is less likely to cause this specific electrolyte pattern .
Question 8
A 45-year-old man presents with episodic headache, palpitations, and diaphoresis. Blood pressure during an
episode is 210/110 mmHg. Which test is most specific for diagnosis?
A) 24-hour urine metanephrines
B) Plasma fractionated metanephrines
C) Serum chromogranin A
D) CT abdomen
Answer: B
Rationale: Plasma fractionated metanephrines have the highest sensitivity and specificity for diagnosing
pheochromocytoma. This catecholamine-secreting tumor of the adrenal medulla presents with paroxysmal
hypertension, headache, palpitations, and diaphoresis. While 24-hour urine metanephrines and VMA are also
used, plasma fractionated metanephrines are considered the most sensitive biochemical test .
Question 9
, A 45-year-old man with alcohol use disorder presents with confusion, ataxia, and nystagmus. Which vitamin
deficiency is most likely?
A) Vitamin B2
B) Thiamine
C) Folate
D) Vitamin D
**Answer:** B
**Rationale:** Wernicke encephalopathy results from thiamine (vitamin B1) deficiency, most commonly seen in
alcohol use disorder. The classic triad includes confusion (or altered mental status), ataxia, and
ophthalmoplegia (nystagmus). Thiamine is a cofactor for several enzymes including pyruvate dehydrogenase
and transketolase. Immediate IV thiamine replacement is essential .
Question 10
A 70-year-old man with atrial fibrillation on warfarin presents with a sudden severe headache. INR is 4.2.
Noncontrast CT shows left frontal intraparenchymal hemorrhage. Which is the most appropriate immediate
treatment?
A) Vitamin K 10 mg IV
B) Fresh frozen plasma
C) Prothrombin complex concentrate
D) Hold warfarin and observe
**Answer:** C
**Rationale:** For intracranial hemorrhage in a patient on warfarin, prothrombin complex concentrate (PCC) is
preferred because it rapidly reverses the anticoagulant effect (within minutes). FFP is slower and requires
large volumes. Vitamin K alone takes hours to reverse. PCC contains factors II, VII, IX, and X, providing
complete reversal. Holding warfarin alone is insufficient for active intracranial bleeding .
**Question 11**
A 32-year-old pregnant woman at 30 weeks presents with BP 160/100 and proteinuria 2+. She has no
headache or visual changes. Which is the most appropriate management?
A) Immediate delivery
B) Labetalol and expectant management until 34 weeks
C) Magnesium sulfate for seizure prophylaxis
D) Outpatient monitoring with methyldopa
**Answer:** B
**Rationale:** Severe preeclampsia before 34 weeks gestation is managed with expectant management:
antihypertensives (labetalol, nifedipine, or methyldopa) and fetal monitoring. Corticosteroids are given for fetal
lung maturity. Magnesium sulfate is indicated for seizure prophylaxis in severe preeclampsia regardless of
gestational age, but expectant management is preferred until 34 weeks unless maternal or fetal compromise
develops .
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QUESTIONS AND CORRECT DETAILED ANSWERS A NEW
UPDATED VERSION LATEST 2026-2027/COMSAE PHASE 1
ASA 114 EXAM (100%CORRECT VERIFIED ANSWERS)
ALREADY GRADED A+
Question 1
A 24-year-old woman presents with acute-onset severe headache, fever, and neck stiffness. CSF shows 2000
WBC/μL (95% neutrophils), glucose 20 mg/dL (serum 100), protein 150 mg/dL. Gram stain shows
gram-negative diplococci. Which is the most appropriate empiric antibiotic?
A) Ceftriaxone
B) Vancomycin
C) Ampicillin
D) Metronidazole
Answer. A
Rationale: The CSF findings of high neutrophil count, low glucose, and elevated protein indicate acute
bacterial meningitis. Gram-negative diplococci strongly suggest Neisseria meningitidis. A third-generation
cephalosporin such as ceftriaxone is the empiric antibiotic of choice for meningococcal meningitis, as it
provides excellent CNS penetration and covers the most common pathogens. Vancomycin is added for
penicillin-resistant Streptococcus pneumoniae but is not sufficient alone .
Question 2
A 58-year-old man with type 2 diabetes presents with a 2-week history of progressive right-sided weakness
and headache. MRI shows a ring-enhancing lesion in the left frontal lobe. Which additional finding would most
suggest a brain abscess rather than a primary tumor?
A) Solitary lesion
B) Diffusion restriction on DWI
C) Surrounding vasogenic edema
D) Contrast enhancement
Answer: B
Rationale:Brain abscesses characteristically show restricted diffusion on diffusion-weighted imaging (DWI) due
to the presence of pus and cellular debris. While both abscesses and tumors can be solitary, ring-enhancing,
and have surrounding edema, restricted diffusion is highly specific for abscess. This finding represents the
high viscosity of necrotic material within the abscess cavity .
---
Question 3
A 35-year-old woman presents with fatigue, dyspnea on exertion, and palpitations. Labs: hemoglobin 7 g/dL,
MCV 65 fL, RDW elevated. Ferritin is 8 ng/mL. Which is the most appropriate next step?
,A) Oral ferrous sulfate
B) IV iron
C) Bone marrow biopsy
D) RBC transfusion
Answer: A
Rationale: Iron deficiency anemia is confirmed by low ferritin with microcytic, hypochromic indices. Oral ferrous
sulfate is first-line treatment for uncomplicated iron deficiency anemia unless the patient is symptomatic with
severe anemia. IV iron is reserved for patients with malabsorption, intolerance to oral iron, or severe
symptomatic anemia. Bone marrow biopsy is unnecessary for straightforward iron deficiency .
Question 4
A 3-year-old child presents with a barking cough, inspiratory stridor, and low-grade fever. Symptoms are worse
at night. Which is the most likely diagnosis?
A) Epiglottitis
B) Croup
C) Bacterial tracheitis
D) Foreign body aspiration
Answer: B
Rationale:Croup (laryngotracheobronchitis) is a viral infection causing subglottic swelling and is characterized
by a barking cough, inspiratory stridor, and hoarseness. Symptoms typically worsen at night. It is most
common in children aged 6 months to 3 years and is usually caused by parainfluenza virus. Epiglottitis
presents with high fever, drooling, and a toxic appearance without barking cough .
Question 5
A 28-year-old man presents with acute scrotal pain and nausea. On exam, the left testis is high-riding and
horizontal, with absent cremasteric reflex. What is the most appropriate next step?
A) Scrotal ultrasound
B) Urinalysis
C) Surgical exploration
D) Empiric antibiotics
Answer: C
Rationale:Testicular torsion is a surgical emergency. The classic presentation includes acute scrotal pain,
nausea, vomiting, high-riding testis, horizontal lie, and absent cremasteric reflex. Surgical exploration should
be performed emergently to salvage the testis. Imaging (ultrasound with Doppler) may delay treatment and
should not be obtained if the clinical suspicion is high. Antibiotics would be appropriate for epididymitis, which
typically presents with a positive cremasteric reflex .
Question 6
,A 52-year-old woman presents with painless jaundice, weight loss, and a palpable gallbladder. Which is the
most likely underlying diagnosis?
A) Choledocholithiasis
B) Pancreatic head cancer
C) Gallbladder cancer
D) Primary sclerosing cholangitis
Answer: B
Rationale: Courvoisier sign—jaundice with a palpable, non-tender gallbladder—classically indicates malignant
obstruction of the biliary tree, most commonly due to pancreatic head cancer. The gallbladder becomes
distended because the obstruction is distal to the cystic duct junction. Choledocholithiasis typically presents
with a non-palpable gallbladder (due to scarring and inflammation) and often with pain and fever .
Question 7
A 2-month-old infant presents with poor feeding, vomiting, and failure to thrive. Labs: Na 125, K 6.8, glucose
45. Which is the most likely diagnosis?
A) Pyloric stenosis
B) Congenital adrenal hyperplasia
C) Sepsis
D) Dehydration
Answer: B
Rationale: Salt-wasting crisis from 21-hydroxylase deficiency (the most common form of congenital adrenal
hyperplasia) presents with hyponatremia, hyperkalemia, and hypoglycemia in a newborn or young infant.
Pyloric stenosis causes metabolic alkalosis with hypochloremia, not hyperkalemia. Dehydration may cause
hypernatremia, and sepsis is less likely to cause this specific electrolyte pattern .
Question 8
A 45-year-old man presents with episodic headache, palpitations, and diaphoresis. Blood pressure during an
episode is 210/110 mmHg. Which test is most specific for diagnosis?
A) 24-hour urine metanephrines
B) Plasma fractionated metanephrines
C) Serum chromogranin A
D) CT abdomen
Answer: B
Rationale: Plasma fractionated metanephrines have the highest sensitivity and specificity for diagnosing
pheochromocytoma. This catecholamine-secreting tumor of the adrenal medulla presents with paroxysmal
hypertension, headache, palpitations, and diaphoresis. While 24-hour urine metanephrines and VMA are also
used, plasma fractionated metanephrines are considered the most sensitive biochemical test .
Question 9
, A 45-year-old man with alcohol use disorder presents with confusion, ataxia, and nystagmus. Which vitamin
deficiency is most likely?
A) Vitamin B2
B) Thiamine
C) Folate
D) Vitamin D
**Answer:** B
**Rationale:** Wernicke encephalopathy results from thiamine (vitamin B1) deficiency, most commonly seen in
alcohol use disorder. The classic triad includes confusion (or altered mental status), ataxia, and
ophthalmoplegia (nystagmus). Thiamine is a cofactor for several enzymes including pyruvate dehydrogenase
and transketolase. Immediate IV thiamine replacement is essential .
Question 10
A 70-year-old man with atrial fibrillation on warfarin presents with a sudden severe headache. INR is 4.2.
Noncontrast CT shows left frontal intraparenchymal hemorrhage. Which is the most appropriate immediate
treatment?
A) Vitamin K 10 mg IV
B) Fresh frozen plasma
C) Prothrombin complex concentrate
D) Hold warfarin and observe
**Answer:** C
**Rationale:** For intracranial hemorrhage in a patient on warfarin, prothrombin complex concentrate (PCC) is
preferred because it rapidly reverses the anticoagulant effect (within minutes). FFP is slower and requires
large volumes. Vitamin K alone takes hours to reverse. PCC contains factors II, VII, IX, and X, providing
complete reversal. Holding warfarin alone is insufficient for active intracranial bleeding .
**Question 11**
A 32-year-old pregnant woman at 30 weeks presents with BP 160/100 and proteinuria 2+. She has no
headache or visual changes. Which is the most appropriate management?
A) Immediate delivery
B) Labetalol and expectant management until 34 weeks
C) Magnesium sulfate for seizure prophylaxis
D) Outpatient monitoring with methyldopa
**Answer:** B
**Rationale:** Severe preeclampsia before 34 weeks gestation is managed with expectant management:
antihypertensives (labetalol, nifedipine, or methyldopa) and fetal monitoring. Corticosteroids are given for fetal
lung maturity. Magnesium sulfate is indicated for seizure prophylaxis in severe preeclampsia regardless of
gestational age, but expectant management is preferred until 34 weeks unless maternal or fetal compromise
develops .
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