COMSAE Phase 2 BSA Form 119 – Comprehensive Exam with
Questions, Answers and Rationales 2026/2027 Update
Question 1
A 55-year-old man comes to the clinic for a routine follow-up. He has a
10-year history of essential hypertension, well-controlled on
hydrochlorothiazide. His blood pressure today is 132/82 mm Hg, and his
pulse is 72/min. Laboratory studies show a fasting blood glucose of 104
mg/dL and a serum creatinine of 1.1 mg/dL. Urinalysis reveals 2+
proteinuria. Which of the following is the most appropriate next step in
pharmacological management?
A. Continue hydrochlorothiazide monotherapy
B. Add an ACE inhibitor or angiotensin receptor blocker (ARB)
C. Add a non-dihydropyridine calcium channel blocker
D. Switch hydrochlorothiazide to a loop diuretic
Correct Answer: B. Add an ACE inhibitor or angiotensin receptor blocker
(ARB)
Detailed Rationale: The presence of persistent proteinuria (2+) in a
patient with hypertension suggests early diabetic nephropathy or
hypertensive nephrosclerosis. ACE inhibitors or ARBs are first-line
therapy for patients with hypertension and proteinuria/albuminuria
because they reduce intraglomerular pressure, slow the progression of
renal disease, and provide cardiovascular protection.
Question 2
,A 68-year-old man is brought to the emergency department by his
daughter due to acute-onset shortness of breath and right-sided
pleuritic chest pain that started 2 hours ago. He underwent a total knee
arthroplasty 5 days ago. His temperature is 37.0°C (98.6°F), blood
pressure is 108/72 mm Hg, pulse is 115/min, and respiration rate is
26/min. Pulse oximetry shows an oxygen saturation of 88% on room air.
An electrocardiogram shows sinus tachycardia with an S1Q3T3 pattern.
Which of the following is the most appropriate initial diagnostic imaging
study?
A. Ventilation-perfusion (V/Q) scan
B. Computed tomography angiography (CTA) of the chest
C. Lower extremity duplex ultrasonography
D. Transthoracic echocardiogram
Correct Answer: B. Computed tomography angiography (CTA) of the
chest
Detailed Rationale: This patient has classic signs, symptoms, and risk
factors (recent major orthopedic surgery) for an acute pulmonary
embolism (PE). Computed tomography angiography (CTA) of the chest is
the gold standard and initial diagnostic imaging study of choice for
stable patients with suspected PE to visualize thrombi in the pulmonary
vasculature.
Question 3
A 45-year-old woman comes to the physician complaining of fatigue,
weight gain of 15 lbs over the past 6 months, constipation, and cold
intolerance. Physical examination reveals delayed relaxation of deep
,tendon reflexes and dry skin. Laboratory evaluation shows a TSH of 12.5
mIU/L (normal 0.4–4.0) and a free T4 of 0.6 ng/dL (normal 0.8–1.8).
Which of the following is the most common cause of this condition in
the United States?
A. Iodine deficiency
B. Hashimoto thyroiditis
C. Subacute granulomatous thyroiditis
D. Pituitary adenoma
Correct Answer: B. Hashimoto thyroiditis
Detailed Rationale: The patient has classic clinical and laboratory
findings of primary hypothyroidism (elevated TSH, low free T4).
Hashimoto thyroiditis is an autoimmune disorder and the most
common cause of hypothyroidism in iodine-sufficient regions like the
United States, characterized by anti-thyroid peroxidase (anti-TPO)
antibodies.
Question 4
A 32-year-old man is brought to the emergency department after being
found unresponsive in an alley. His friends report he uses heroin. His
temperature is 35.8°C (96.4°F), blood pressure is 90/60 mm Hg, pulse is
58/min, and respiration rate is 6/min. Physical examination shows
pinpoint pupils and decreased bowel sounds. Arterial blood gas analysis
on room air shows pH 7.22, PaCO2 65 mm Hg, PaO2 55 mm Hg, and
HCO3 26 mEq/L. Which of the following is the most appropriate
immediate intervention?
A. Administration of intravenous sodium bicarbonate
, B. Administration of intravenous naloxone
C. Endotracheal intubation and mechanical ventilation alone
D. Administration of intravenous flumazenil
Correct Answer: B. Administration of intravenous naloxone
Detailed Rationale: This patient presents with opioid overdose
characterized by the classic triad of central nervous system depression
(unresponsiveness), respiratory depression (respiratory rate of 6/min,
hypercapnic respiratory acidosis), and miosis (pinpoint pupils).
Naloxone is a competitive opioid receptor antagonist used to rapidly
reverse opioid-induced respiratory depression.
Question 5
A 72-year-old man with a 40 pack-year smoking history comes to the
office for a routine health maintenance visit. He reports a chronic
productive cough for the past 4 months that occurs daily, persisting for
over two consecutive years. He has mild dyspnea on exertion.
Spirometry reveals an FEV1/FVC ratio of 65% and an FEV1 of 60% of
predicted value, which does not significantly improve after
administration of an inhaled bronchodilator. Which of the following is
the most accurate diagnosis?
A. Asthma
B. Chronic bronchitis
C. Emphysema
D. Bronchiectasis
Correct Answer: B. Chronic bronchitis
Questions, Answers and Rationales 2026/2027 Update
Question 1
A 55-year-old man comes to the clinic for a routine follow-up. He has a
10-year history of essential hypertension, well-controlled on
hydrochlorothiazide. His blood pressure today is 132/82 mm Hg, and his
pulse is 72/min. Laboratory studies show a fasting blood glucose of 104
mg/dL and a serum creatinine of 1.1 mg/dL. Urinalysis reveals 2+
proteinuria. Which of the following is the most appropriate next step in
pharmacological management?
A. Continue hydrochlorothiazide monotherapy
B. Add an ACE inhibitor or angiotensin receptor blocker (ARB)
C. Add a non-dihydropyridine calcium channel blocker
D. Switch hydrochlorothiazide to a loop diuretic
Correct Answer: B. Add an ACE inhibitor or angiotensin receptor blocker
(ARB)
Detailed Rationale: The presence of persistent proteinuria (2+) in a
patient with hypertension suggests early diabetic nephropathy or
hypertensive nephrosclerosis. ACE inhibitors or ARBs are first-line
therapy for patients with hypertension and proteinuria/albuminuria
because they reduce intraglomerular pressure, slow the progression of
renal disease, and provide cardiovascular protection.
Question 2
,A 68-year-old man is brought to the emergency department by his
daughter due to acute-onset shortness of breath and right-sided
pleuritic chest pain that started 2 hours ago. He underwent a total knee
arthroplasty 5 days ago. His temperature is 37.0°C (98.6°F), blood
pressure is 108/72 mm Hg, pulse is 115/min, and respiration rate is
26/min. Pulse oximetry shows an oxygen saturation of 88% on room air.
An electrocardiogram shows sinus tachycardia with an S1Q3T3 pattern.
Which of the following is the most appropriate initial diagnostic imaging
study?
A. Ventilation-perfusion (V/Q) scan
B. Computed tomography angiography (CTA) of the chest
C. Lower extremity duplex ultrasonography
D. Transthoracic echocardiogram
Correct Answer: B. Computed tomography angiography (CTA) of the
chest
Detailed Rationale: This patient has classic signs, symptoms, and risk
factors (recent major orthopedic surgery) for an acute pulmonary
embolism (PE). Computed tomography angiography (CTA) of the chest is
the gold standard and initial diagnostic imaging study of choice for
stable patients with suspected PE to visualize thrombi in the pulmonary
vasculature.
Question 3
A 45-year-old woman comes to the physician complaining of fatigue,
weight gain of 15 lbs over the past 6 months, constipation, and cold
intolerance. Physical examination reveals delayed relaxation of deep
,tendon reflexes and dry skin. Laboratory evaluation shows a TSH of 12.5
mIU/L (normal 0.4–4.0) and a free T4 of 0.6 ng/dL (normal 0.8–1.8).
Which of the following is the most common cause of this condition in
the United States?
A. Iodine deficiency
B. Hashimoto thyroiditis
C. Subacute granulomatous thyroiditis
D. Pituitary adenoma
Correct Answer: B. Hashimoto thyroiditis
Detailed Rationale: The patient has classic clinical and laboratory
findings of primary hypothyroidism (elevated TSH, low free T4).
Hashimoto thyroiditis is an autoimmune disorder and the most
common cause of hypothyroidism in iodine-sufficient regions like the
United States, characterized by anti-thyroid peroxidase (anti-TPO)
antibodies.
Question 4
A 32-year-old man is brought to the emergency department after being
found unresponsive in an alley. His friends report he uses heroin. His
temperature is 35.8°C (96.4°F), blood pressure is 90/60 mm Hg, pulse is
58/min, and respiration rate is 6/min. Physical examination shows
pinpoint pupils and decreased bowel sounds. Arterial blood gas analysis
on room air shows pH 7.22, PaCO2 65 mm Hg, PaO2 55 mm Hg, and
HCO3 26 mEq/L. Which of the following is the most appropriate
immediate intervention?
A. Administration of intravenous sodium bicarbonate
, B. Administration of intravenous naloxone
C. Endotracheal intubation and mechanical ventilation alone
D. Administration of intravenous flumazenil
Correct Answer: B. Administration of intravenous naloxone
Detailed Rationale: This patient presents with opioid overdose
characterized by the classic triad of central nervous system depression
(unresponsiveness), respiratory depression (respiratory rate of 6/min,
hypercapnic respiratory acidosis), and miosis (pinpoint pupils).
Naloxone is a competitive opioid receptor antagonist used to rapidly
reverse opioid-induced respiratory depression.
Question 5
A 72-year-old man with a 40 pack-year smoking history comes to the
office for a routine health maintenance visit. He reports a chronic
productive cough for the past 4 months that occurs daily, persisting for
over two consecutive years. He has mild dyspnea on exertion.
Spirometry reveals an FEV1/FVC ratio of 65% and an FEV1 of 60% of
predicted value, which does not significantly improve after
administration of an inhaled bronchodilator. Which of the following is
the most accurate diagnosis?
A. Asthma
B. Chronic bronchitis
C. Emphysema
D. Bronchiectasis
Correct Answer: B. Chronic bronchitis
