COMSAE Phase 3 Form CSA 104 Advanced
Clinical Synthesis Exam Practice Questions
& [Verified Answers], Plus Explained
Rationales|2026 Latest Update| Instant
Download PDF
1. A 68-year-old man with a history of hypertension, diabetes
mellitus, chronic kidney disease stage 3, and atrial fibrillation
presents with sudden onset right-sided weakness and aphasia
that began 45 minutes ago. Blood pressure is 188/104 mm Hg.
Noncontrast CT of the head shows no hemorrhage. Which is the
most appropriate next step?
A. Begin aspirin therapy immediately
B. Administer intravenous alteplase after eligibility confirmation
C. Lower blood pressure to less than 120/80 mm Hg before treatment
D. Start therapeutic heparin infusion
Answer: B. Administer intravenous alteplase after eligibility
confirmation
Rationale: The patient presents within the thrombolytic window for
acute ischemic stroke. CT excludes hemorrhage, making IV alteplase
appropriate if no contraindications exist. Aspirin is generally delayed
after thrombolysis. Aggressive BP reduction is not recommended prior
to thrombolysis; BP should be below 185/110 mm Hg. Heparin is not
routinely indicated in acute ischemic stroke.
2. A 27-year-old woman presents with fever, hypotension, diffuse
erythematous rash, and multiorgan dysfunction 3 days after
, prolonged tampon use. Which organism is most likely
responsible?
A. Streptococcus pneumoniae
B. Neisseria meningitidis
C. Staphylococcus aureus
D. Haemophilus influenzae
Answer: C. Staphylococcus aureus
Rationale: Toxic shock syndrome is classically caused by toxin-
producing Staphylococcus aureus. TSST-1 acts as a superantigen,
leading to massive cytokine release, fever, rash, hypotension, and
multisystem involvement.
3. A 72-year-old man develops crushing substernal chest pain. ECG
demonstrates ST-segment 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. Posterior descending artery
Answer: C. Right coronary artery
Rationale: Inferior wall myocardial infarctions involving leads II, III,
and aVF most commonly result from right coronary artery occlusion.
Associated findings may include bradycardia and AV nodal
dysfunction.
4. A patient in septic shock remains hypotensive despite adequate
fluid resuscitation. Which vasopressor is considered first-line
therapy?
,A. Dopamine
B. Epinephrine
C. Vasopressin
D. Norepinephrine
Answer: D. Norepinephrine
Rationale: Norepinephrine is the preferred initial vasopressor in septic
shock due to potent alpha-adrenergic effects and relatively lower
arrhythmogenic potential compared with dopamine.
5. A 35-year-old woman develops progressive ascending weakness
following a gastrointestinal illness. Examination reveals areflexia.
CSF analysis demonstrates elevated protein with normal cell
count. What is the diagnosis?
A. Myasthenia gravis
B. Guillain-Barré syndrome
C. Multiple sclerosis
D. Lambert-Eaton syndrome
Answer: B. Guillain-Barré syndrome
Rationale: Guillain-Barré syndrome classically presents with ascending
paralysis, areflexia, and albuminocytologic dissociation (elevated CSF
protein with normal WBC count), often following Campylobacter
infection.
6. A 58-year-old smoker presents with hematuria. CT imaging reveals
a renal mass. Which paraneoplastic syndrome is most associated
with renal cell carcinoma?
A. Hyperparathyroidism
B. SIADH
, C. Polycythemia
D. Hypothyroidism
Answer: C. Polycythemia
Rationale: Renal cell carcinoma can produce erythropoietin
ectopically, resulting in secondary polycythemia. Other paraneoplastic
manifestations include hypercalcemia and hypertension.
7. A patient with cirrhosis presents with confusion, asterixis, and
elevated ammonia levels. What is the most appropriate initial
treatment?
A. Metronidazole
B. Lactulose
C. Prednisone
D. Furosemide
Answer: B. Lactulose
Rationale: Hepatic encephalopathy results from ammonia
accumulation. Lactulose acidifies the colon, converting ammonia to
ammonium and promoting excretion.
8. A 22-year-old man presents with fever, neck stiffness, and
photophobia. CSF analysis shows elevated neutrophils, decreased
glucose, and increased protein. What is the most likely diagnosis?
A. Viral meningitis
B. Tuberculous meningitis
C. Bacterial meningitis
D. Fungal meningitis
Answer: C. Bacterial meningitis
Clinical Synthesis Exam Practice Questions
& [Verified Answers], Plus Explained
Rationales|2026 Latest Update| Instant
Download PDF
1. A 68-year-old man with a history of hypertension, diabetes
mellitus, chronic kidney disease stage 3, and atrial fibrillation
presents with sudden onset right-sided weakness and aphasia
that began 45 minutes ago. Blood pressure is 188/104 mm Hg.
Noncontrast CT of the head shows no hemorrhage. Which is the
most appropriate next step?
A. Begin aspirin therapy immediately
B. Administer intravenous alteplase after eligibility confirmation
C. Lower blood pressure to less than 120/80 mm Hg before treatment
D. Start therapeutic heparin infusion
Answer: B. Administer intravenous alteplase after eligibility
confirmation
Rationale: The patient presents within the thrombolytic window for
acute ischemic stroke. CT excludes hemorrhage, making IV alteplase
appropriate if no contraindications exist. Aspirin is generally delayed
after thrombolysis. Aggressive BP reduction is not recommended prior
to thrombolysis; BP should be below 185/110 mm Hg. Heparin is not
routinely indicated in acute ischemic stroke.
2. A 27-year-old woman presents with fever, hypotension, diffuse
erythematous rash, and multiorgan dysfunction 3 days after
, prolonged tampon use. Which organism is most likely
responsible?
A. Streptococcus pneumoniae
B. Neisseria meningitidis
C. Staphylococcus aureus
D. Haemophilus influenzae
Answer: C. Staphylococcus aureus
Rationale: Toxic shock syndrome is classically caused by toxin-
producing Staphylococcus aureus. TSST-1 acts as a superantigen,
leading to massive cytokine release, fever, rash, hypotension, and
multisystem involvement.
3. A 72-year-old man develops crushing substernal chest pain. ECG
demonstrates ST-segment 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. Posterior descending artery
Answer: C. Right coronary artery
Rationale: Inferior wall myocardial infarctions involving leads II, III,
and aVF most commonly result from right coronary artery occlusion.
Associated findings may include bradycardia and AV nodal
dysfunction.
4. A patient in septic shock remains hypotensive despite adequate
fluid resuscitation. Which vasopressor is considered first-line
therapy?
,A. Dopamine
B. Epinephrine
C. Vasopressin
D. Norepinephrine
Answer: D. Norepinephrine
Rationale: Norepinephrine is the preferred initial vasopressor in septic
shock due to potent alpha-adrenergic effects and relatively lower
arrhythmogenic potential compared with dopamine.
5. A 35-year-old woman develops progressive ascending weakness
following a gastrointestinal illness. Examination reveals areflexia.
CSF analysis demonstrates elevated protein with normal cell
count. What is the diagnosis?
A. Myasthenia gravis
B. Guillain-Barré syndrome
C. Multiple sclerosis
D. Lambert-Eaton syndrome
Answer: B. Guillain-Barré syndrome
Rationale: Guillain-Barré syndrome classically presents with ascending
paralysis, areflexia, and albuminocytologic dissociation (elevated CSF
protein with normal WBC count), often following Campylobacter
infection.
6. A 58-year-old smoker presents with hematuria. CT imaging reveals
a renal mass. Which paraneoplastic syndrome is most associated
with renal cell carcinoma?
A. Hyperparathyroidism
B. SIADH
, C. Polycythemia
D. Hypothyroidism
Answer: C. Polycythemia
Rationale: Renal cell carcinoma can produce erythropoietin
ectopically, resulting in secondary polycythemia. Other paraneoplastic
manifestations include hypercalcemia and hypertension.
7. A patient with cirrhosis presents with confusion, asterixis, and
elevated ammonia levels. What is the most appropriate initial
treatment?
A. Metronidazole
B. Lactulose
C. Prednisone
D. Furosemide
Answer: B. Lactulose
Rationale: Hepatic encephalopathy results from ammonia
accumulation. Lactulose acidifies the colon, converting ammonia to
ammonium and promoting excretion.
8. A 22-year-old man presents with fever, neck stiffness, and
photophobia. CSF analysis shows elevated neutrophils, decreased
glucose, and increased protein. What is the most likely diagnosis?
A. Viral meningitis
B. Tuberculous meningitis
C. Bacterial meningitis
D. Fungal meningitis
Answer: C. Bacterial meningitis
