2026 EDITION COMSAE Phase 4 Clinical
Integration Practice Exam 2026 Edition
Questions with Correct Answers and
Detailed Rationales
1.
A 67-year-old man presents with sudden-onset right-sided
weakness and difficulty speaking that began 90 minutes ago.
He has atrial fibrillation but stopped taking his anticoagulant
several weeks ago. Blood pressure is 172/96 mm Hg.
Noncontrast CT of the head shows no hemorrhage.
Neurologic examination reveals expressive aphasia and right
face and arm weakness. Which of the following is the most
appropriate next step?
A. Administer aspirin and observe
B. Begin intravenous heparin
C. Administer intravenous alteplase
D. Perform carotid endarterectomy
Answer: C. Administer intravenous alteplase
Rationale: This patient has an acute ischemic stroke with
disabling neurologic deficits, no intracranial hemorrhage on
CT, and presentation within the therapeutic window for
intravenous thrombolysis. Blood pressure is below the usual
threshold of 185/110 mm Hg required before thrombolytic
,administration. Heparin is not routinely used acutely for
ischemic stroke, and carotid intervention is not the immediate
treatment.
2.
A 24-year-old woman presents with fatigue, weight loss, heat
intolerance, tremulousness, and palpitations. Examination
reveals a diffusely enlarged thyroid and bilateral
exophthalmos. Laboratory studies show suppressed TSH and
elevated free T4. Which antibody is most likely responsible
for her condition?
A. Anti-thyroid peroxidase antibody
B. Anti-thyroglobulin antibody
C. Thyroid-stimulating immunoglobulin
D. Anti-centromere antibody
Answer: C. Thyroid-stimulating immunoglobulin
Rationale: Graves disease results from thyroid-stimulating
immunoglobulins that bind and activate the TSH receptor,
causing diffuse thyroid enlargement and excess thyroid
hormone production. Ophthalmopathy is particularly
characteristic of Graves disease.
3.
A 59-year-old man with a 50-pack-year smoking history
presents with hemoptysis and weight loss. Chest imaging
reveals a central hilar mass. Laboratory testing shows serum
,sodium of 119 mEq/L, low serum osmolality, and
inappropriately concentrated urine. Which pulmonary
malignancy is most likely?
A. Adenocarcinoma
B. Squamous cell carcinoma
C. Small cell carcinoma
D. Large cell carcinoma
Answer: C. Small cell carcinoma
Rationale: Small cell carcinoma is strongly associated with
smoking and commonly arises centrally. It produces ectopic
ADH, leading to euvolemic hyponatremia with low serum
osmolality and concentrated urine.
4.
A 72-year-old woman develops fever, productive cough, and
pleuritic chest pain 4 days after hospitalization for a hip
fracture. She has received broad-spectrum antibiotics during
her admission. Chest radiography reveals a new right lower-
lobe infiltrate. Which pathogen is most likely responsible?
A. Mycoplasma pneumoniae
B. Streptococcus pneumoniae
C. Pseudomonas aeruginosa
D. Chlamydia pneumoniae
Answer: C. Pseudomonas aeruginosa
Rationale: Hospital-acquired pneumonia occurring after
recent hospitalization and antibiotic exposure raises concern
, for gram-negative organisms, including Pseudomonas
aeruginosa. The clinical setting is more important than the
radiographic location in identifying the likely pathogen.
5.
A 35-year-old woman presents with recurrent episodes of
painful swelling in her right knee. Joint aspiration reveals
needle-shaped, negatively birefringent crystals. Which
metabolic abnormality is most likely associated with this
condition?
A. Hypouricemia
B. Hyperuricemia
C. Hypocalcemia
D. Hyperphosphatemia
Answer: B. Hyperuricemia
Rationale: Negatively birefringent, needle-shaped
monosodium urate crystals indicate gout. Hyperuricemia
promotes urate crystal deposition in joints, producing acute
inflammatory arthritis.
6.
A 43-year-old man presents with severe epigastric pain
radiating to the back and repeated vomiting. Serum lipase is
markedly elevated. He has a history of heavy alcohol
consumption. Which complication is most likely to occur
during the acute phase?
Integration Practice Exam 2026 Edition
Questions with Correct Answers and
Detailed Rationales
1.
A 67-year-old man presents with sudden-onset right-sided
weakness and difficulty speaking that began 90 minutes ago.
He has atrial fibrillation but stopped taking his anticoagulant
several weeks ago. Blood pressure is 172/96 mm Hg.
Noncontrast CT of the head shows no hemorrhage.
Neurologic examination reveals expressive aphasia and right
face and arm weakness. Which of the following is the most
appropriate next step?
A. Administer aspirin and observe
B. Begin intravenous heparin
C. Administer intravenous alteplase
D. Perform carotid endarterectomy
Answer: C. Administer intravenous alteplase
Rationale: This patient has an acute ischemic stroke with
disabling neurologic deficits, no intracranial hemorrhage on
CT, and presentation within the therapeutic window for
intravenous thrombolysis. Blood pressure is below the usual
threshold of 185/110 mm Hg required before thrombolytic
,administration. Heparin is not routinely used acutely for
ischemic stroke, and carotid intervention is not the immediate
treatment.
2.
A 24-year-old woman presents with fatigue, weight loss, heat
intolerance, tremulousness, and palpitations. Examination
reveals a diffusely enlarged thyroid and bilateral
exophthalmos. Laboratory studies show suppressed TSH and
elevated free T4. Which antibody is most likely responsible
for her condition?
A. Anti-thyroid peroxidase antibody
B. Anti-thyroglobulin antibody
C. Thyroid-stimulating immunoglobulin
D. Anti-centromere antibody
Answer: C. Thyroid-stimulating immunoglobulin
Rationale: Graves disease results from thyroid-stimulating
immunoglobulins that bind and activate the TSH receptor,
causing diffuse thyroid enlargement and excess thyroid
hormone production. Ophthalmopathy is particularly
characteristic of Graves disease.
3.
A 59-year-old man with a 50-pack-year smoking history
presents with hemoptysis and weight loss. Chest imaging
reveals a central hilar mass. Laboratory testing shows serum
,sodium of 119 mEq/L, low serum osmolality, and
inappropriately concentrated urine. Which pulmonary
malignancy is most likely?
A. Adenocarcinoma
B. Squamous cell carcinoma
C. Small cell carcinoma
D. Large cell carcinoma
Answer: C. Small cell carcinoma
Rationale: Small cell carcinoma is strongly associated with
smoking and commonly arises centrally. It produces ectopic
ADH, leading to euvolemic hyponatremia with low serum
osmolality and concentrated urine.
4.
A 72-year-old woman develops fever, productive cough, and
pleuritic chest pain 4 days after hospitalization for a hip
fracture. She has received broad-spectrum antibiotics during
her admission. Chest radiography reveals a new right lower-
lobe infiltrate. Which pathogen is most likely responsible?
A. Mycoplasma pneumoniae
B. Streptococcus pneumoniae
C. Pseudomonas aeruginosa
D. Chlamydia pneumoniae
Answer: C. Pseudomonas aeruginosa
Rationale: Hospital-acquired pneumonia occurring after
recent hospitalization and antibiotic exposure raises concern
, for gram-negative organisms, including Pseudomonas
aeruginosa. The clinical setting is more important than the
radiographic location in identifying the likely pathogen.
5.
A 35-year-old woman presents with recurrent episodes of
painful swelling in her right knee. Joint aspiration reveals
needle-shaped, negatively birefringent crystals. Which
metabolic abnormality is most likely associated with this
condition?
A. Hypouricemia
B. Hyperuricemia
C. Hypocalcemia
D. Hyperphosphatemia
Answer: B. Hyperuricemia
Rationale: Negatively birefringent, needle-shaped
monosodium urate crystals indicate gout. Hyperuricemia
promotes urate crystal deposition in joints, producing acute
inflammatory arthritis.
6.
A 43-year-old man presents with severe epigastric pain
radiating to the back and repeated vomiting. Serum lipase is
markedly elevated. He has a history of heavy alcohol
consumption. Which complication is most likely to occur
during the acute phase?
