COMSAE Phase 2 BSA Form 117 – Comprehensive
Exam with Questions, Answers and Rationales
2026/2027 Update
Question 1
A 62-year-old man with a 45-pack-year smoking history and chronic obstructive pulmonary
disease (COPD) presents with a 2-month history of a persistent cough, hemoptysis, and an 18-
pound weight loss. A chest radiograph demonstrates a large central mass in the right hilum with
post-obstructive pneumonitis.
Histological examination of a bronchoscopic biopsy is most likely to reveal which of the
following characteristics?
A. Glandular architecture with mucin production
B. Intercellular bridges and keratin pearls
C. Sheets of small, dark cells with scant cytoplasm
D. Large pleomorphic cells with abundant eosinophilic cytoplasm
Correct Answer: B. Intercellular bridges and keratin pearls
Rationale: The patient's presentation of a central lung mass in a heavy smoker is characteristic
of squamous cell carcinoma of the lung. Histologically, squamous cell carcinoma is marked by
the presence of intercellular bridges and keratin pearls. Small cell carcinoma typically presents as
sheets of small, dark cells with scant cytoplasm, while adenocarcinoma typically demonstrates
glandular architecture or mucin production and is more often peripheral.
Question 2
A 44-year-old woman presents to the clinic complaining of chronic fatigue, severe generalized
pruritus, and a 6-month history of right upper quadrant discomfort. Laboratory evaluation reveals
a marked elevation in alkaline phosphatase and gamma-glutamyl transferase, with a mildly
elevated total bilirubin. Anti-mitochondrial antibodies (AMA) are present at high titers.
Which of the following is the most likely diagnosis?
A. Primary sclerosing cholangitis
B. Primary biliary cholangitis
C. Autoimmune hepatitis
, D. Alcoholic liver disease
Correct Answer: B. Primary biliary cholangitis
Rationale: Primary biliary cholangitis (formerly primary biliary cirrhosis) is an autoimmune
disease characterized by progressive destruction of small intrahepatic bile ducts. It
predominantly affects middle-aged women and presents with fatigue, pruritus, elevated
cholestatic liver enzymes, and high titers of anti-mitochondrial antibodies (AMA), which are
highly specific for this condition.
Question 3
A 68-year-old man with a history of long-standing hypertension and chronic kidney disease
presents for evaluation of progressive weakness, lethargy, and generalized bone pain. Laboratory
studies show a serum calcium of 11.4 mg/dL, serum phosphate of 5.6 mg/dL, and an elevated
parathyroid hormone (PTH) level of 520 pg/mL.
Which of the following terms best describes the underlying physiological process driving the
elevated PTH level in this patient?
A. Primary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Tertiary hyperparathyroidism
D. Parathyroid carcinoma
Correct Answer: B. Secondary hyperparathyroidism
Rationale: Chronic kidney disease impairs phosphate excretion and active vitamin D synthesis,
leading to hyperphosphatemia and hypocalcemia. This persistent biochemical stimulus triggers
compensatory hyperplasia of all four parathyroid glands and elevated parathyroid hormone
secretion, known as secondary hyperparathyroidism.
Question 4
A 35-year-old man presents with intermittent episodes of severe, sharp headache localized
around his right eye, accompanied by ipsilateral lacrimation, rhinorrhea, and conjunctival
injection. Each attack lasts approximately 45 minutes and occurs multiple times a day over
several weeks.
Which of the following is the most appropriate acute abortive therapy?
A. Oral propranolol daily
, B. Subcutaneous sumatriptan and 100% oxygen
C. Intravenous valproate sodium
D. Oral topiramate daily
Correct Answer: B. Subcutaneous sumatriptan and 100% oxygen
Rationale: The clinical presentation is characteristic of cluster headache, a primary headache
disorder marked by severe unilateral periorbital pain paired with prominent autonomic
symptoms. Because attacks are short-lived and extremely painful, fast-acting acute therapies are
required. High-flow 100% oxygen via non-rebreather mask and subcutaneous sumatriptan are the
established first-line abortive treatments.
Question 5
A 58-year-old man is evaluated for progressive, painless jaundice, dark urine, and pale stools
over the past month, accompanied by a 15-pound weight loss. Physical examination reveals a
non-tender, palpable gallbladder in the right upper quadrant.
Obstruction of which anatomical structure is most directly responsible for this presentation?
A. Cystic duct
B. Common hepatic duct
C. Distal common bile duct
D. Ampulla of Vater
Correct Answer: C. Distal common bile duct
Rationale: Painless jaundice accompanied by a palpable, non-tender gallbladder (Courvoisier
law) strongly suggests malignant obstruction of the biliary tree, most commonly pancreatic head
adenocarcinoma compressing the distal common bile duct. The resulting obstruction leads to
conjugated hyperbilirubinemia, acholic stools, and dark urine.
Question 6
A 31-year-old primigravida at 39 weeks of gestation undergoes spontaneous rupture of
membranes. During the second stage of labor, fetal heart rate monitoring reveals persistent late
decelerations with minimal baseline variability. An immediate scalp stimulation test yields no
fetal heart rate acceleration.
Which of the following is the most immediate priority in managing this clinical scenario?
, A. Administer maternal intravenous fluids and reposition to the left lateral decubitus position
B. Proceed with immediate operative vaginal delivery or emergent cesarean section
C. Administer subcutaneous terbutaline to reduce uterine tachysystole
D. Perform an immediate artificial rupture of membranes to assess amniotic fluid color
Correct Answer: B. Proceed with immediate operative vaginal delivery or emergent cesarean
section
Rationale: Late decelerations reflect uteroplacental insufficiency and fetal hypoxia. When
persistent and accompanied by loss of variability and a non-reactive scalp stimulation, they
indicate significant fetal acidemia and compromise. If intrauterine resuscitative measures fail,
prompt delivery via operative vaginal delivery or emergency cesarean section is required to
prevent permanent neurological injury or demise.
Question 7
A 48-year-old man with a history of heavy tobacco use presents with a 3-month history of a
persistent cough, hemoptysis, and weight loss. A chest radiograph reveals a central lung mass.
Laboratory evaluation reveals a serum sodium level of 120 mEq/L, serum osmolality of 252
mOsm/kg, and a urine osmolality of 480 mOsm/kg. He is clinically euvolemic with no signs of
edema or dehydration.
Which of the following underlying pathophysiological processes caused this patient's electrolyte
disturbance?
A. Ectopic production of antidiuretic hormone by a tumor
B. Excessive renal loss of sodium due to primary adrenal insufficiency
C. Primary polydipsia overwhelming free water clearance capacity
D. Volume depletion triggering secondary aldosterone release
Correct Answer: A. Ectopic production of antidiuretic hormone by a tumor
Rationale: This patient presents with syndrome of inappropriate antidiuretic hormone secretion
(SIADH) secondary to small cell lung cancer. SIADH is characterized by euvolemic hypotonic
hyponatremia caused by unregulated, ectopic release of vasopressin (ADH) from tumor tissue,
leading to concentrated urine and impaired free water excretion despite low serum osmolarity.
Question 8
Exam with Questions, Answers and Rationales
2026/2027 Update
Question 1
A 62-year-old man with a 45-pack-year smoking history and chronic obstructive pulmonary
disease (COPD) presents with a 2-month history of a persistent cough, hemoptysis, and an 18-
pound weight loss. A chest radiograph demonstrates a large central mass in the right hilum with
post-obstructive pneumonitis.
Histological examination of a bronchoscopic biopsy is most likely to reveal which of the
following characteristics?
A. Glandular architecture with mucin production
B. Intercellular bridges and keratin pearls
C. Sheets of small, dark cells with scant cytoplasm
D. Large pleomorphic cells with abundant eosinophilic cytoplasm
Correct Answer: B. Intercellular bridges and keratin pearls
Rationale: The patient's presentation of a central lung mass in a heavy smoker is characteristic
of squamous cell carcinoma of the lung. Histologically, squamous cell carcinoma is marked by
the presence of intercellular bridges and keratin pearls. Small cell carcinoma typically presents as
sheets of small, dark cells with scant cytoplasm, while adenocarcinoma typically demonstrates
glandular architecture or mucin production and is more often peripheral.
Question 2
A 44-year-old woman presents to the clinic complaining of chronic fatigue, severe generalized
pruritus, and a 6-month history of right upper quadrant discomfort. Laboratory evaluation reveals
a marked elevation in alkaline phosphatase and gamma-glutamyl transferase, with a mildly
elevated total bilirubin. Anti-mitochondrial antibodies (AMA) are present at high titers.
Which of the following is the most likely diagnosis?
A. Primary sclerosing cholangitis
B. Primary biliary cholangitis
C. Autoimmune hepatitis
, D. Alcoholic liver disease
Correct Answer: B. Primary biliary cholangitis
Rationale: Primary biliary cholangitis (formerly primary biliary cirrhosis) is an autoimmune
disease characterized by progressive destruction of small intrahepatic bile ducts. It
predominantly affects middle-aged women and presents with fatigue, pruritus, elevated
cholestatic liver enzymes, and high titers of anti-mitochondrial antibodies (AMA), which are
highly specific for this condition.
Question 3
A 68-year-old man with a history of long-standing hypertension and chronic kidney disease
presents for evaluation of progressive weakness, lethargy, and generalized bone pain. Laboratory
studies show a serum calcium of 11.4 mg/dL, serum phosphate of 5.6 mg/dL, and an elevated
parathyroid hormone (PTH) level of 520 pg/mL.
Which of the following terms best describes the underlying physiological process driving the
elevated PTH level in this patient?
A. Primary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Tertiary hyperparathyroidism
D. Parathyroid carcinoma
Correct Answer: B. Secondary hyperparathyroidism
Rationale: Chronic kidney disease impairs phosphate excretion and active vitamin D synthesis,
leading to hyperphosphatemia and hypocalcemia. This persistent biochemical stimulus triggers
compensatory hyperplasia of all four parathyroid glands and elevated parathyroid hormone
secretion, known as secondary hyperparathyroidism.
Question 4
A 35-year-old man presents with intermittent episodes of severe, sharp headache localized
around his right eye, accompanied by ipsilateral lacrimation, rhinorrhea, and conjunctival
injection. Each attack lasts approximately 45 minutes and occurs multiple times a day over
several weeks.
Which of the following is the most appropriate acute abortive therapy?
A. Oral propranolol daily
, B. Subcutaneous sumatriptan and 100% oxygen
C. Intravenous valproate sodium
D. Oral topiramate daily
Correct Answer: B. Subcutaneous sumatriptan and 100% oxygen
Rationale: The clinical presentation is characteristic of cluster headache, a primary headache
disorder marked by severe unilateral periorbital pain paired with prominent autonomic
symptoms. Because attacks are short-lived and extremely painful, fast-acting acute therapies are
required. High-flow 100% oxygen via non-rebreather mask and subcutaneous sumatriptan are the
established first-line abortive treatments.
Question 5
A 58-year-old man is evaluated for progressive, painless jaundice, dark urine, and pale stools
over the past month, accompanied by a 15-pound weight loss. Physical examination reveals a
non-tender, palpable gallbladder in the right upper quadrant.
Obstruction of which anatomical structure is most directly responsible for this presentation?
A. Cystic duct
B. Common hepatic duct
C. Distal common bile duct
D. Ampulla of Vater
Correct Answer: C. Distal common bile duct
Rationale: Painless jaundice accompanied by a palpable, non-tender gallbladder (Courvoisier
law) strongly suggests malignant obstruction of the biliary tree, most commonly pancreatic head
adenocarcinoma compressing the distal common bile duct. The resulting obstruction leads to
conjugated hyperbilirubinemia, acholic stools, and dark urine.
Question 6
A 31-year-old primigravida at 39 weeks of gestation undergoes spontaneous rupture of
membranes. During the second stage of labor, fetal heart rate monitoring reveals persistent late
decelerations with minimal baseline variability. An immediate scalp stimulation test yields no
fetal heart rate acceleration.
Which of the following is the most immediate priority in managing this clinical scenario?
, A. Administer maternal intravenous fluids and reposition to the left lateral decubitus position
B. Proceed with immediate operative vaginal delivery or emergent cesarean section
C. Administer subcutaneous terbutaline to reduce uterine tachysystole
D. Perform an immediate artificial rupture of membranes to assess amniotic fluid color
Correct Answer: B. Proceed with immediate operative vaginal delivery or emergent cesarean
section
Rationale: Late decelerations reflect uteroplacental insufficiency and fetal hypoxia. When
persistent and accompanied by loss of variability and a non-reactive scalp stimulation, they
indicate significant fetal acidemia and compromise. If intrauterine resuscitative measures fail,
prompt delivery via operative vaginal delivery or emergency cesarean section is required to
prevent permanent neurological injury or demise.
Question 7
A 48-year-old man with a history of heavy tobacco use presents with a 3-month history of a
persistent cough, hemoptysis, and weight loss. A chest radiograph reveals a central lung mass.
Laboratory evaluation reveals a serum sodium level of 120 mEq/L, serum osmolality of 252
mOsm/kg, and a urine osmolality of 480 mOsm/kg. He is clinically euvolemic with no signs of
edema or dehydration.
Which of the following underlying pathophysiological processes caused this patient's electrolyte
disturbance?
A. Ectopic production of antidiuretic hormone by a tumor
B. Excessive renal loss of sodium due to primary adrenal insufficiency
C. Primary polydipsia overwhelming free water clearance capacity
D. Volume depletion triggering secondary aldosterone release
Correct Answer: A. Ectopic production of antidiuretic hormone by a tumor
Rationale: This patient presents with syndrome of inappropriate antidiuretic hormone secretion
(SIADH) secondary to small cell lung cancer. SIADH is characterized by euvolemic hypotonic
hyponatremia caused by unregulated, ectopic release of vasopressin (ADH) from tumor tissue,
leading to concentrated urine and impaired free water excretion despite low serum osmolarity.
Question 8
