COMSAE Phase 2 BSA Form 116 – Comprehensive
Exam with Questions, Answers and Rationales
2026/2027 Update
Question 1
A 55-year-old man is evaluated in the clinic for a three-month history of progressive shortness of
breath and a persistent dry cough. He has a 40-pack-year smoking history. High-resolution
computed tomography of the chest reveals subpleural reticular opacities, honeycombing, and
traction bronchiectasis predominantly distributed in the lower lung lobes. Surgical lung biopsy
demonstrates patchy interstitial fibrosis with fibroblastic foci and normal intervening lung
parenchyma.
Which of the following is the most likely diagnosis?
A. Idiopathic pulmonary fibrosis
B. Hypersensitivity pneumonitis
C. Sarcoidosis
D. Desquamative interstitial pneumonia
E. Asbestosis
Correct Answer: A. Idiopathic pulmonary fibrosis
Rationale: Idiopathic pulmonary fibrosis is a chronic, progressive fibrosing interstitial
pneumonia of unknown etiology. Histologically, it is characterized by the usual interstitial
pneumonia pattern, featuring temporal heterogeneity with fibroblastic foci, alternating areas of
fibrosis, and normal lung architecture.
Question 2
A 48-year-old woman is evaluated for a two-month history of intermittent right upper quadrant
abdominal pain, particularly after eating fatty meals. She is afebrile and has no jaundice.
Abdominal ultrasonography reveals multiple small gallstones within the gallbladder without
thickening of the gallbladder wall or dilation of the common bile duct.
What is the most appropriate next step in management?
A. Elective laparoscopic cholecystectomy
, B. Immediate endoscopic retrograde cholangiopancreatography
C. Observation with outpatient dietary fat restriction
D. Long-term oral ursodeoxycholic acid dissolution therapy
E. Emergent open cholecystectomy
Correct Answer: A. Elective laparoscopic cholecystectomy
Rationale: Symptomatic cholelithiasis presenting with recurrent biliary colic in the absence of
acute inflammation or ductal obstruction is best managed with elective laparoscopic
cholecystectomy to prevent future complications such as acute cholecystitis, gallstone
pancreatitis, or choledocholithiasis.
Question 3
A 35-year-old woman presents to the clinic complaining of chronic fatigue, widespread
musculoskeletal pain, and tenderness at multiple specific anatomical sites for the past ten
months. She reports that her sleep is unrefreshing and experiences cognitive difficulties often
referred to as fibro fog. Routine laboratory evaluations, including complete blood count, thyroid-
stimulating hormone, and inflammatory markers, are completely normal.
What is the primary pathophysiological mechanism underlying this disorder?
A. Central nervous system amplification of pain perception and abnormal central pain
processing
B. Autoimmune destruction of skeletal muscle microvasculature and endomysial fibrosis
C. Chronic bacterial infection of the fascial planes surrounding skeletal muscles
D. Primary degeneration of peripheral sensory nerve fibers due to metabolic dysfunction
E. Localized synovial inflammation and cartilage degradation within peripheral joints
Correct Answer: A. Central nervous system amplification of pain perception and abnormal
central pain processing
Rationale: Fibromyalgia is characterized by widespread chronic pain and tenderness resulting
from central sensitization, an amplification of neural signaling within the central nervous system
that alters pain perception. Laboratory markers and muscle histology remain normal because
there is no peripheral tissue inflammation or muscle pathology.
Question 4
,A 55-year-old man with a 30-pack-year smoking history is evaluated for persistent hoarseness
and a foreign body sensation in his throat. Laryngoscopy reveals an exophytic mass involving
the true vocal cord. Biopsy confirms squamous cell carcinoma.
Which of the following anatomical characteristics of the true vocal cords accounts for the early
clinical manifestation of hoarseness and the relatively low incidence of early regional lymph
node metastasis?
A. Sparse lymphatic drainage of the true vocal cords
B. Rich vascular supply prone to early hemorrhage
C. Thick stratified columnar epithelial lining
D. Absence of an underlying basement membrane
E. Direct innervation by the sympathetic nervous system
Correct Answer: A. Sparse lymphatic drainage of the true vocal cords
Rationale: The true vocal cords possess a remarkably sparse lymphatic drainage network
compared to surrounding structures like the supraglottis. Consequently, glottic squamous cell
carcinomas produce hoarseness very early by disrupting cord vibration, yet they tend to have a
low rate of early cervical lymph node metastasis.
Question 5
A 60-year-old man with a history of hypertension and hyperlipidemia is evaluated for a three-
month history of cramping pain in his right calf that consistently occurs after walking a distance
of two blocks and is promptly relieved by resting for a few minutes.
Which of the following is the most appropriate initial diagnostic study to confirm the diagnosis?
A. Measurement of resting and post-exercise ankle-brachial indices
B. Contrast-enhanced magnetic resonance angiography of the lower extremities
C. Invasive catheter-based digital subtraction angiography
D. Venous duplex ultrasonography of the lower extremities
E. Computed tomography angiography of the abdominal aorta and pelvis
Correct Answer: A. Measurement of resting and post-exercise ankle-brachial indices
, Rationale: The clinical history of reproducible exercise-induced calf pain relieved by rest is
classic for intermittent claudication secondary to peripheral artery disease. The non-invasive
ankle-brachial index measurement is the primary diagnostic test of choice for screening and
confirming lower extremity arterial insufficiency.
Question 6
A 3-year-old boy is brought to the pediatric emergency department by his parents because he
swallowed a small metallic coin approximately two hours ago. He is currently drooling, unable
to swallow his saliva, and experiencing mild stridor.
Which of the following anatomical locations is the most common site for ingested foreign bodies
to become lodged in the pediatric esophagus?
A. Cricopharyngeus muscle at the upper esophageal sphincter
B. Crossing of the aortic arch in the midesophagus
C. Compression point of the left main stem bronchus
D. Lower esophageal sphincter at the diaphragmatic hiatus
E. Pyloric sphincter of the stomach
Correct Answer: A. Cricopharyngeus muscle at the upper esophageal sphincter
Rationale: The narrowest region of the pediatric esophagus is at the level of the upper
esophageal sphincter, formed by the cricopharyngeus muscle. This is the most frequent site
where ingested foreign bodies, such as coins, become lodged, necessitating prompt endoscopic
removal if symptomatic.
Question 7
A 26-year-old woman presents to the clinic for preconception counseling. She has a history of
type 1 diabetes mellitus diagnosed at age 10. Her most recent hemoglobin level is elevated. She
reports occasional mild episodes of hypoglycemia but no severe events.
Which of the following fetal anomalies is most classically associated with poor glycemic control
during early organogenesis in diabetic pregnancies?
A. Caudal regression syndrome and neural tube defects
B. Achondroplasia and skeletal dysplasias
C. Congenital hypothyroidism and goiter
Exam with Questions, Answers and Rationales
2026/2027 Update
Question 1
A 55-year-old man is evaluated in the clinic for a three-month history of progressive shortness of
breath and a persistent dry cough. He has a 40-pack-year smoking history. High-resolution
computed tomography of the chest reveals subpleural reticular opacities, honeycombing, and
traction bronchiectasis predominantly distributed in the lower lung lobes. Surgical lung biopsy
demonstrates patchy interstitial fibrosis with fibroblastic foci and normal intervening lung
parenchyma.
Which of the following is the most likely diagnosis?
A. Idiopathic pulmonary fibrosis
B. Hypersensitivity pneumonitis
C. Sarcoidosis
D. Desquamative interstitial pneumonia
E. Asbestosis
Correct Answer: A. Idiopathic pulmonary fibrosis
Rationale: Idiopathic pulmonary fibrosis is a chronic, progressive fibrosing interstitial
pneumonia of unknown etiology. Histologically, it is characterized by the usual interstitial
pneumonia pattern, featuring temporal heterogeneity with fibroblastic foci, alternating areas of
fibrosis, and normal lung architecture.
Question 2
A 48-year-old woman is evaluated for a two-month history of intermittent right upper quadrant
abdominal pain, particularly after eating fatty meals. She is afebrile and has no jaundice.
Abdominal ultrasonography reveals multiple small gallstones within the gallbladder without
thickening of the gallbladder wall or dilation of the common bile duct.
What is the most appropriate next step in management?
A. Elective laparoscopic cholecystectomy
, B. Immediate endoscopic retrograde cholangiopancreatography
C. Observation with outpatient dietary fat restriction
D. Long-term oral ursodeoxycholic acid dissolution therapy
E. Emergent open cholecystectomy
Correct Answer: A. Elective laparoscopic cholecystectomy
Rationale: Symptomatic cholelithiasis presenting with recurrent biliary colic in the absence of
acute inflammation or ductal obstruction is best managed with elective laparoscopic
cholecystectomy to prevent future complications such as acute cholecystitis, gallstone
pancreatitis, or choledocholithiasis.
Question 3
A 35-year-old woman presents to the clinic complaining of chronic fatigue, widespread
musculoskeletal pain, and tenderness at multiple specific anatomical sites for the past ten
months. She reports that her sleep is unrefreshing and experiences cognitive difficulties often
referred to as fibro fog. Routine laboratory evaluations, including complete blood count, thyroid-
stimulating hormone, and inflammatory markers, are completely normal.
What is the primary pathophysiological mechanism underlying this disorder?
A. Central nervous system amplification of pain perception and abnormal central pain
processing
B. Autoimmune destruction of skeletal muscle microvasculature and endomysial fibrosis
C. Chronic bacterial infection of the fascial planes surrounding skeletal muscles
D. Primary degeneration of peripheral sensory nerve fibers due to metabolic dysfunction
E. Localized synovial inflammation and cartilage degradation within peripheral joints
Correct Answer: A. Central nervous system amplification of pain perception and abnormal
central pain processing
Rationale: Fibromyalgia is characterized by widespread chronic pain and tenderness resulting
from central sensitization, an amplification of neural signaling within the central nervous system
that alters pain perception. Laboratory markers and muscle histology remain normal because
there is no peripheral tissue inflammation or muscle pathology.
Question 4
,A 55-year-old man with a 30-pack-year smoking history is evaluated for persistent hoarseness
and a foreign body sensation in his throat. Laryngoscopy reveals an exophytic mass involving
the true vocal cord. Biopsy confirms squamous cell carcinoma.
Which of the following anatomical characteristics of the true vocal cords accounts for the early
clinical manifestation of hoarseness and the relatively low incidence of early regional lymph
node metastasis?
A. Sparse lymphatic drainage of the true vocal cords
B. Rich vascular supply prone to early hemorrhage
C. Thick stratified columnar epithelial lining
D. Absence of an underlying basement membrane
E. Direct innervation by the sympathetic nervous system
Correct Answer: A. Sparse lymphatic drainage of the true vocal cords
Rationale: The true vocal cords possess a remarkably sparse lymphatic drainage network
compared to surrounding structures like the supraglottis. Consequently, glottic squamous cell
carcinomas produce hoarseness very early by disrupting cord vibration, yet they tend to have a
low rate of early cervical lymph node metastasis.
Question 5
A 60-year-old man with a history of hypertension and hyperlipidemia is evaluated for a three-
month history of cramping pain in his right calf that consistently occurs after walking a distance
of two blocks and is promptly relieved by resting for a few minutes.
Which of the following is the most appropriate initial diagnostic study to confirm the diagnosis?
A. Measurement of resting and post-exercise ankle-brachial indices
B. Contrast-enhanced magnetic resonance angiography of the lower extremities
C. Invasive catheter-based digital subtraction angiography
D. Venous duplex ultrasonography of the lower extremities
E. Computed tomography angiography of the abdominal aorta and pelvis
Correct Answer: A. Measurement of resting and post-exercise ankle-brachial indices
, Rationale: The clinical history of reproducible exercise-induced calf pain relieved by rest is
classic for intermittent claudication secondary to peripheral artery disease. The non-invasive
ankle-brachial index measurement is the primary diagnostic test of choice for screening and
confirming lower extremity arterial insufficiency.
Question 6
A 3-year-old boy is brought to the pediatric emergency department by his parents because he
swallowed a small metallic coin approximately two hours ago. He is currently drooling, unable
to swallow his saliva, and experiencing mild stridor.
Which of the following anatomical locations is the most common site for ingested foreign bodies
to become lodged in the pediatric esophagus?
A. Cricopharyngeus muscle at the upper esophageal sphincter
B. Crossing of the aortic arch in the midesophagus
C. Compression point of the left main stem bronchus
D. Lower esophageal sphincter at the diaphragmatic hiatus
E. Pyloric sphincter of the stomach
Correct Answer: A. Cricopharyngeus muscle at the upper esophageal sphincter
Rationale: The narrowest region of the pediatric esophagus is at the level of the upper
esophageal sphincter, formed by the cricopharyngeus muscle. This is the most frequent site
where ingested foreign bodies, such as coins, become lodged, necessitating prompt endoscopic
removal if symptomatic.
Question 7
A 26-year-old woman presents to the clinic for preconception counseling. She has a history of
type 1 diabetes mellitus diagnosed at age 10. Her most recent hemoglobin level is elevated. She
reports occasional mild episodes of hypoglycemia but no severe events.
Which of the following fetal anomalies is most classically associated with poor glycemic control
during early organogenesis in diabetic pregnancies?
A. Caudal regression syndrome and neural tube defects
B. Achondroplasia and skeletal dysplasias
C. Congenital hypothyroidism and goiter
