COMSAE Phase 3-Style Practice
Examination: High-Yield Questions with
Answers and Detailed Rationales
Internal Medicine
,1. A 67-year-old man is postoperative day 2 after a hemicolectomy. He develops acute dyspnea,
pleuritic chest pain, tachycardia, and oxygen saturation of 86% on room air. What is the most likely
diagnosis?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Congestive heart failure
Answer: C. Pulmonary embolism
Rationale: Sudden dyspnea, pleuritic chest pain, hypoxemia, and tachycardia in a postoperative
patient strongly suggest pulmonary embolism. Surgery and immobility are major risk factors for
venous thromboembolism. The acute onset and pleuritic nature of the pain differentiate PE from
atelectasis or pneumonia, which typically present more gradually .
,2. A hospitalized patient with septic shock remains hypotensive despite adequate fluid
resuscitation. Which medication should be initiated first?
A. Dopamine
B. Norepinephrine
C. Dobutamine
D. Epinephrine
Answer: B. Norepinephrine
Rationale: Norepinephrine is the first-line vasopressor for septic shock after fluid resuscitation. It
increases mean arterial pressure through alpha-adrenergic vasoconstriction. Dopamine is a
second-line agent associated with more arrhythmias. Dobutamine is primarily an inotrope, not a
vasopressor, and epinephrine is typically reserved for refractory cases .
, 3. A patient with atrial fibrillation becomes hypotensive with altered mental status. The next best
step is:
A. IV diltiazem
B. Oral metoprolol
C. IV amiodarone
D. Immediate synchronized cardioversion
Answer: D. Immediate synchronized cardioversion
Rationale: Hemodynamically unstable atrial fibrillation with hypotension and altered mental status
requires immediate synchronized cardioversion. Pharmacologic rate control is appropriate for
stable patients. Delaying cardioversion in an unstable patient can lead to further hemodynamic
compromise and end-organ damage .
Examination: High-Yield Questions with
Answers and Detailed Rationales
Internal Medicine
,1. A 67-year-old man is postoperative day 2 after a hemicolectomy. He develops acute dyspnea,
pleuritic chest pain, tachycardia, and oxygen saturation of 86% on room air. What is the most likely
diagnosis?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Congestive heart failure
Answer: C. Pulmonary embolism
Rationale: Sudden dyspnea, pleuritic chest pain, hypoxemia, and tachycardia in a postoperative
patient strongly suggest pulmonary embolism. Surgery and immobility are major risk factors for
venous thromboembolism. The acute onset and pleuritic nature of the pain differentiate PE from
atelectasis or pneumonia, which typically present more gradually .
,2. A hospitalized patient with septic shock remains hypotensive despite adequate fluid
resuscitation. Which medication should be initiated first?
A. Dopamine
B. Norepinephrine
C. Dobutamine
D. Epinephrine
Answer: B. Norepinephrine
Rationale: Norepinephrine is the first-line vasopressor for septic shock after fluid resuscitation. It
increases mean arterial pressure through alpha-adrenergic vasoconstriction. Dopamine is a
second-line agent associated with more arrhythmias. Dobutamine is primarily an inotrope, not a
vasopressor, and epinephrine is typically reserved for refractory cases .
, 3. A patient with atrial fibrillation becomes hypotensive with altered mental status. The next best
step is:
A. IV diltiazem
B. Oral metoprolol
C. IV amiodarone
D. Immediate synchronized cardioversion
Answer: D. Immediate synchronized cardioversion
Rationale: Hemodynamically unstable atrial fibrillation with hypotension and altered mental status
requires immediate synchronized cardioversion. Pharmacologic rate control is appropriate for
stable patients. Delaying cardioversion in an unstable patient can lead to further hemodynamic
compromise and end-organ damage .
