COMSAE PHASE 1 FORM 115 REAL QUESTIONS + DETAILED ANSWERS
- LATEST VERSION - TOP RATED | 2027/2027 PASS GUARANTEE
COMSAE 115
1. A 58-year-old man presents with crushing substernal chest pain radiating
to his left arm for the past 45 minutes. He is diaphoretic and dyspneic. ECG
shows ST elevation in leads II, III, and aVF. Which coronary artery is most
likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
ANSWER : C
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall MI.
The right coronary artery (RCA) supplies the inferior wall of the left
ventricle in the majority of patients (right-dominant circulation). Occlusion
of the RCA is the most common cause of inferior STEMI.
2. A 45-year-old woman is found to have a blood pressure of 168/104
mmHg on two separate office visits. She has no other medical problems.
Which of the following is the most appropriate initial antihypertensive
agent?
A. Hydrochlorothiazide
B. Amlodipine
C. Lisinopril
D. Metoprolol
ANSWER : A
Rationale: According to JNC guidelines and the ACC/AHA hypertension
guidelines, thiazide diuretics such as hydrochlorothiazide are considered
appropriate first-line agents for uncomplicated hypertension. They are cost-
,effective, well-tolerated, and have demonstrated reduction in cardiovascular
events.
3. A 72-year-old man with a history of atrial fibrillation presents with
sudden onset right-sided weakness and aphasia. Symptoms began 1.5 hours
ago. CT head without contrast is negative for hemorrhage. Which of the
following is the most appropriate next step?
A. Administer IV alteplase
B. Begin heparin infusion
C. Schedule carotid endarterectomy
D. Obtain MRI brain with diffusion-weighted imaging
ANSWER : A
Rationale: This patient presents within the 4.5-hour window for IV
thrombolytic therapy with alteplase. The absence of hemorrhage on CT,
onset within the treatment window, and ischemic etiology make IV tPA the
most appropriate intervention. Time is critical in acute ischemic stroke
management.
4. A 34-year-old woman presents with palpitations, heat intolerance, weight
loss despite increased appetite, and a fine tremor. TSH is undetectable and
free T4 is markedly elevated. Radioactive iodine uptake is diffusely
increased. Which of the following is the most likely diagnosis?
A. Toxic multinodular goiter
B. Graves disease
C. Subacute thyroiditis
D. Toxic adenoma
ANSWER : B
Rationale: Graves disease is the most common cause of hyperthyroidism in
young women. It is an autoimmune condition characterized by diffuse goiter,
ophthalmopathy, and diffusely increased radioactive iodine uptake. The
clinical presentation of heat intolerance, weight loss, tremor, and
palpitations is classic for hyperthyroidism.
5. A 65-year-old man with a 40 pack-year smoking history presents with
hemoptysis, a 15-pound weight loss over 3 months, and a persistent cough.
Chest X-ray reveals a 3 cm spiculated mass in the right upper lobe. Which of
,the following histological types of lung cancer is most commonly associated
with this location?
A. Small cell carcinoma
B. Adenocarcinoma
C. Squamous cell carcinoma
D. Large cell carcinoma
ANSWER : C
Rationale: Squamous cell carcinoma is classically associated with a central
location, though it can be peripheral. It is strongly associated with cigarette
smoking. However, squamous cell carcinoma has a predilection for the upper
lobes and is among the most common subtypes in heavy smokers with
central or upper lobe masses.
6. A 28-year-old woman presents with a butterfly-shaped rash across her
cheeks and nose, joint pain, fatigue, and oral ulcers. Lab work shows ANA
positive at 1:320, anti-dsDNA positive, and low complement levels. Which of
the following best explains the renal complications seen in this condition?
A. Direct invasion of renal parenchyma by activated T cells
B. Deposition of immune complexes in the glomerular basement
membrane
C. Antineutrophil cytoplasmic antibody-mediated destruction
D. Thrombotic microangiopathy due to complement activation
ANSWER : B
Rationale: In systemic lupus erythematosus (SLE), lupus nephritis results
from deposition of immune complexes (antigen-antibody complexes,
particularly anti-dsDNA) in the glomerular basement membrane and
mesangium. This triggers complement activation and inflammation, leading
to glomerulonephritis. The pattern is type III hypersensitivity.
7. A 55-year-old man with type 2 diabetes mellitus presents for a routine
visit. His HbA1c is 9.2%. He is currently on metformin 1000 mg twice daily.
His eGFR is 42 mL/min/1.73m². Which of the following medications is
contraindicated in this patient?
A. Empagliflozin
B. Sitagliptin
C. Insulin glargine
D. Pioglitazone
, ANSWER : A
Rationale: SGLT-2 inhibitors such as empagliflozin are generally not
recommended when eGFR falls below 45 mL/min/1.73m² (some agents have
a cutoff of 30) due to reduced efficacy and potential for adverse effects
including volume depletion and acute kidney injury. An eGFR of 42 is below
the threshold for empagliflozin.
8. A 50-year-old woman presents with progressive dysphagia to both solids
and liquids, regurgitation of undigested food, and weight loss. Esophageal
manometry shows absent peristalsis and failure of the lower esophageal
sphincter to relax. Which of the following is the most likely diagnosis?
A. Diffuse esophageal spasm
B. Achalasia
C. Scleroderma esophagus
D. Nutcracker esophagus
ANSWER : B
Rationale: Achalasia is characterized by failure of the lower esophageal
sphincter (LES) to relax and absence of normal peristalsis. The classic
manometric findings are elevated LES pressure with incomplete relaxation
and aperistalsis of the esophageal body. Dysphagia to both solids and liquids
from onset is a hallmark feature.
9. A 40-year-old man presents with fatigue, pallor, and jaundice. Lab work
shows hemoglobin of 7.8 g/dL, elevated indirect bilirubin, elevated LDH,
decreased haptoglobin, and a positive direct Coombs test. Which of the
following is the most likely diagnosis?
A. Iron deficiency anemia
B. Warm autoimmune hemolytic anemia
C. Hereditary spherocytosis
D. G6PD deficiency
ANSWER : B
Rationale: Warm autoimmune hemolytic anemia (AIHA) is characterized by
hemolytic anemia with a positive direct Coombs test (direct antiglobulin
test), elevated indirect bilirubin, elevated LDH, and decreased haptoglobin.
Warm AIHA is mediated by IgG antibodies that react at 37°C and cause
extravascular hemolysis in the spleen.
- LATEST VERSION - TOP RATED | 2027/2027 PASS GUARANTEE
COMSAE 115
1. A 58-year-old man presents with crushing substernal chest pain radiating
to his left arm for the past 45 minutes. He is diaphoretic and dyspneic. ECG
shows ST elevation in leads II, III, and aVF. Which coronary artery is most
likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
ANSWER : C
Rationale: ST elevation in leads II, III, and aVF indicates an inferior wall MI.
The right coronary artery (RCA) supplies the inferior wall of the left
ventricle in the majority of patients (right-dominant circulation). Occlusion
of the RCA is the most common cause of inferior STEMI.
2. A 45-year-old woman is found to have a blood pressure of 168/104
mmHg on two separate office visits. She has no other medical problems.
Which of the following is the most appropriate initial antihypertensive
agent?
A. Hydrochlorothiazide
B. Amlodipine
C. Lisinopril
D. Metoprolol
ANSWER : A
Rationale: According to JNC guidelines and the ACC/AHA hypertension
guidelines, thiazide diuretics such as hydrochlorothiazide are considered
appropriate first-line agents for uncomplicated hypertension. They are cost-
,effective, well-tolerated, and have demonstrated reduction in cardiovascular
events.
3. A 72-year-old man with a history of atrial fibrillation presents with
sudden onset right-sided weakness and aphasia. Symptoms began 1.5 hours
ago. CT head without contrast is negative for hemorrhage. Which of the
following is the most appropriate next step?
A. Administer IV alteplase
B. Begin heparin infusion
C. Schedule carotid endarterectomy
D. Obtain MRI brain with diffusion-weighted imaging
ANSWER : A
Rationale: This patient presents within the 4.5-hour window for IV
thrombolytic therapy with alteplase. The absence of hemorrhage on CT,
onset within the treatment window, and ischemic etiology make IV tPA the
most appropriate intervention. Time is critical in acute ischemic stroke
management.
4. A 34-year-old woman presents with palpitations, heat intolerance, weight
loss despite increased appetite, and a fine tremor. TSH is undetectable and
free T4 is markedly elevated. Radioactive iodine uptake is diffusely
increased. Which of the following is the most likely diagnosis?
A. Toxic multinodular goiter
B. Graves disease
C. Subacute thyroiditis
D. Toxic adenoma
ANSWER : B
Rationale: Graves disease is the most common cause of hyperthyroidism in
young women. It is an autoimmune condition characterized by diffuse goiter,
ophthalmopathy, and diffusely increased radioactive iodine uptake. The
clinical presentation of heat intolerance, weight loss, tremor, and
palpitations is classic for hyperthyroidism.
5. A 65-year-old man with a 40 pack-year smoking history presents with
hemoptysis, a 15-pound weight loss over 3 months, and a persistent cough.
Chest X-ray reveals a 3 cm spiculated mass in the right upper lobe. Which of
,the following histological types of lung cancer is most commonly associated
with this location?
A. Small cell carcinoma
B. Adenocarcinoma
C. Squamous cell carcinoma
D. Large cell carcinoma
ANSWER : C
Rationale: Squamous cell carcinoma is classically associated with a central
location, though it can be peripheral. It is strongly associated with cigarette
smoking. However, squamous cell carcinoma has a predilection for the upper
lobes and is among the most common subtypes in heavy smokers with
central or upper lobe masses.
6. A 28-year-old woman presents with a butterfly-shaped rash across her
cheeks and nose, joint pain, fatigue, and oral ulcers. Lab work shows ANA
positive at 1:320, anti-dsDNA positive, and low complement levels. Which of
the following best explains the renal complications seen in this condition?
A. Direct invasion of renal parenchyma by activated T cells
B. Deposition of immune complexes in the glomerular basement
membrane
C. Antineutrophil cytoplasmic antibody-mediated destruction
D. Thrombotic microangiopathy due to complement activation
ANSWER : B
Rationale: In systemic lupus erythematosus (SLE), lupus nephritis results
from deposition of immune complexes (antigen-antibody complexes,
particularly anti-dsDNA) in the glomerular basement membrane and
mesangium. This triggers complement activation and inflammation, leading
to glomerulonephritis. The pattern is type III hypersensitivity.
7. A 55-year-old man with type 2 diabetes mellitus presents for a routine
visit. His HbA1c is 9.2%. He is currently on metformin 1000 mg twice daily.
His eGFR is 42 mL/min/1.73m². Which of the following medications is
contraindicated in this patient?
A. Empagliflozin
B. Sitagliptin
C. Insulin glargine
D. Pioglitazone
, ANSWER : A
Rationale: SGLT-2 inhibitors such as empagliflozin are generally not
recommended when eGFR falls below 45 mL/min/1.73m² (some agents have
a cutoff of 30) due to reduced efficacy and potential for adverse effects
including volume depletion and acute kidney injury. An eGFR of 42 is below
the threshold for empagliflozin.
8. A 50-year-old woman presents with progressive dysphagia to both solids
and liquids, regurgitation of undigested food, and weight loss. Esophageal
manometry shows absent peristalsis and failure of the lower esophageal
sphincter to relax. Which of the following is the most likely diagnosis?
A. Diffuse esophageal spasm
B. Achalasia
C. Scleroderma esophagus
D. Nutcracker esophagus
ANSWER : B
Rationale: Achalasia is characterized by failure of the lower esophageal
sphincter (LES) to relax and absence of normal peristalsis. The classic
manometric findings are elevated LES pressure with incomplete relaxation
and aperistalsis of the esophageal body. Dysphagia to both solids and liquids
from onset is a hallmark feature.
9. A 40-year-old man presents with fatigue, pallor, and jaundice. Lab work
shows hemoglobin of 7.8 g/dL, elevated indirect bilirubin, elevated LDH,
decreased haptoglobin, and a positive direct Coombs test. Which of the
following is the most likely diagnosis?
A. Iron deficiency anemia
B. Warm autoimmune hemolytic anemia
C. Hereditary spherocytosis
D. G6PD deficiency
ANSWER : B
Rationale: Warm autoimmune hemolytic anemia (AIHA) is characterized by
hemolytic anemia with a positive direct Coombs test (direct antiglobulin
test), elevated indirect bilirubin, elevated LDH, and decreased haptoglobin.
Warm AIHA is mediated by IgG antibodies that react at 37°C and cause
extravascular hemolysis in the spleen.
