COMSAE Phase 2 Form 109 Comprehensive
Practice Exam: Questions, Answers, and
Rationales
SECTION 1: CARDIOVASCULAR & EMERGENCY MEDICINE
,Question 1
A 72-year-old man with hypertension and type 2 diabetes presents with acute onset of severe, tearing chest pain
radiating to the back. Blood pressure is 100/60 mmHg in the right arm and 140/80 mmHg in the left arm. Which
diagnostic study should be ordered first?
A) Transthoracic echocardiogram
B) CT angiography of the chest
C) Electrocardiogram
D) Chest X-ray
Correct Answer: B) CT angiography of the chest
Rationale: The presentation of tearing chest pain with unequal blood pressures between arms is classic for
acute aortic dissection. CT angiography is the definitive diagnostic study for aortic dissection, providing rapid
visualization of the aorta and its branches. ECG may show nonspecific changes but is not diagnostic. Chest X-
ray may show a widened mediastinum but is insensitive. Echocardiogram is useful but CT angiography is more
comprehensive and readily available in emergency settings .
Question 2
,A 45-year-old man presents with sudden-onset chest pain radiating to his left arm. He is diaphoretic and
nauseated. ECG shows ST-segment elevation in leads II, III, and aVF. Which is the most likely diagnosis?
A) Pulmonary embolism
B) Acute inferior myocardial infarction
C) Aortic dissection
D) Pericarditis
Correct Answer: B) Acute inferior myocardial infarction
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall myocardial infarction. The right coronary
artery (RCA) typically supplies this territory. The symptoms of chest pain radiating to the arm, diaphoresis, and
nausea support an acute coronary syndrome .
Question 3
A 65-year-old man presents with progressive dyspnea on exertion, orthopnea, and peripheral edema.
Echocardiogram shows a reduced ejection fraction of 30%. Which of the following is the most likely diagnosis?
A) Heart failure with preserved ejection fraction
, B) Heart failure with reduced ejection fraction
C) Pulmonary hypertension
D) Constrictive pericarditis
Correct Answer: B) Heart failure with reduced ejection fraction
Rationale: Dyspnea, orthopnea, and peripheral edema with a reduced ejection fraction indicate heart failure with
reduced ejection fraction (systolic heart failure). Heart failure with preserved ejection fraction has normal ejection
fraction. Pulmonary hypertension presents with right heart failure. Constrictive pericarditis presents with
constrictive physiology .
Question 4
A 50-year-old man presents with acute onset of right lower quadrant pain, nausea, and vomiting. He has a
history of atrial fibrillation. Which of the following is the most likely diagnosis?
A) Acute appendicitis
B) Ovarian torsion
C) Mesenteric ischemia
D) Diverticulitis
Practice Exam: Questions, Answers, and
Rationales
SECTION 1: CARDIOVASCULAR & EMERGENCY MEDICINE
,Question 1
A 72-year-old man with hypertension and type 2 diabetes presents with acute onset of severe, tearing chest pain
radiating to the back. Blood pressure is 100/60 mmHg in the right arm and 140/80 mmHg in the left arm. Which
diagnostic study should be ordered first?
A) Transthoracic echocardiogram
B) CT angiography of the chest
C) Electrocardiogram
D) Chest X-ray
Correct Answer: B) CT angiography of the chest
Rationale: The presentation of tearing chest pain with unequal blood pressures between arms is classic for
acute aortic dissection. CT angiography is the definitive diagnostic study for aortic dissection, providing rapid
visualization of the aorta and its branches. ECG may show nonspecific changes but is not diagnostic. Chest X-
ray may show a widened mediastinum but is insensitive. Echocardiogram is useful but CT angiography is more
comprehensive and readily available in emergency settings .
Question 2
,A 45-year-old man presents with sudden-onset chest pain radiating to his left arm. He is diaphoretic and
nauseated. ECG shows ST-segment elevation in leads II, III, and aVF. Which is the most likely diagnosis?
A) Pulmonary embolism
B) Acute inferior myocardial infarction
C) Aortic dissection
D) Pericarditis
Correct Answer: B) Acute inferior myocardial infarction
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall myocardial infarction. The right coronary
artery (RCA) typically supplies this territory. The symptoms of chest pain radiating to the arm, diaphoresis, and
nausea support an acute coronary syndrome .
Question 3
A 65-year-old man presents with progressive dyspnea on exertion, orthopnea, and peripheral edema.
Echocardiogram shows a reduced ejection fraction of 30%. Which of the following is the most likely diagnosis?
A) Heart failure with preserved ejection fraction
, B) Heart failure with reduced ejection fraction
C) Pulmonary hypertension
D) Constrictive pericarditis
Correct Answer: B) Heart failure with reduced ejection fraction
Rationale: Dyspnea, orthopnea, and peripheral edema with a reduced ejection fraction indicate heart failure with
reduced ejection fraction (systolic heart failure). Heart failure with preserved ejection fraction has normal ejection
fraction. Pulmonary hypertension presents with right heart failure. Constrictive pericarditis presents with
constrictive physiology .
Question 4
A 50-year-old man presents with acute onset of right lower quadrant pain, nausea, and vomiting. He has a
history of atrial fibrillation. Which of the following is the most likely diagnosis?
A) Acute appendicitis
B) Ovarian torsion
C) Mesenteric ischemia
D) Diverticulitis
