2026 Version COMSAE Phase 2 Form 119
Practice Exam Questions And Verified
Answers with Rationales
Question 1
A 67-year-old man with a 50-pack-year smoking history
presents with progressive dyspnea, chronic productive cough,
and worsening exercise intolerance. Pulmonary function
testing shows an FEV₁ of 42% predicted, FEV₁/FVC ratio of
0.48, and minimal reversibility after inhaled albuterol. He has
had two exacerbations requiring oral corticosteroids in the
past year. Which of the following is the most appropriate
long-term pharmacologic strategy?
A. Inhaled corticosteroid monotherapy
B. Short-acting β₂-agonist monotherapy
C. Long-acting muscarinic antagonist plus long-acting β₂-
agonist
D. Oral prednisone maintenance therapy
Rationale: This patient has COPD with significant airflow
obstruction and recurrent exacerbations. Long-acting
bronchodilator therapy with a LAMA/LABA combination
provides sustained bronchodilation and improves symptoms
and lung function. Inhaled corticosteroids are generally added
when exacerbations persist despite optimized
bronchodilation, particularly in patients with elevated
,eosinophils or asthma features. Chronic systemic
corticosteroids are avoided because of substantial adverse
effects.
Question 2
A 24-year-old woman presents with fatigue, weight loss, heat
intolerance, tremor, and palpitations. Examination reveals
diffuse thyroid enlargement and bilateral exophthalmos.
Laboratory studies show elevated free T₄ and suppressed
TSH. Which of the following mechanisms best explains her
thyroid disease?
A. Destruction of thyroid follicles by cytotoxic T cells
B. Autonomous thyroid hormone production by a toxic
adenoma
C. Autoantibody stimulation of the TSH receptor
D. Excessive secretion of TSH by a pituitary adenoma
Rationale: Graves disease results from thyroid-stimulating
immunoglobulins that bind and activate the TSH receptor,
causing diffuse thyroid hyperplasia and increased thyroid
hormone synthesis. Ophthalmopathy is particularly
characteristic of Graves disease. A toxic adenoma causes
focal rather than diffuse thyroid overactivity and does not
typically produce ophthalmopathy.
Question 3
,A 58-year-old man with hypertension and chronic kidney
disease presents with muscle weakness. Laboratory studies
reveal potassium 6.8 mEq/L. ECG demonstrates peaked T
waves followed by QRS widening. Which of the following
should be administered first?
A. Intravenous insulin with glucose
B. Sodium zirconium cyclosilicate
C. Furosemide
D. Intravenous calcium gluconate
Rationale: Severe hyperkalemia with ECG changes is an
immediate cardiac emergency. IV calcium stabilizes the
cardiac membrane and reduces the risk of fatal arrhythmias
but does not lower serum potassium. Insulin with glucose
shifts potassium intracellularly and should follow membrane
stabilization. Potassium-removing therapies are also required
but act more slowly.
Question 4
A 72-year-old woman develops sudden right-sided weakness
and expressive aphasia 90 minutes after symptom onset. CT
of the head shows no hemorrhage. Blood pressure is 168/94
mm Hg. She is not taking anticoagulants. Which of the
following is the most appropriate next step?
A. Immediate aspirin administration without further
intervention
B. Intravenous heparin
C. Intravenous thrombolytic therapy after confirming
, eligibility
D. Lower blood pressure to less than 120/80 mm Hg before
treatment
Rationale: This patient has an acute ischemic stroke within
the therapeutic window for IV thrombolysis and has no
evidence of intracranial hemorrhage. Her blood pressure is
below the threshold that would preclude thrombolysis.
Aspirin is appropriate when thrombolysis is not given or after
the appropriate post-thrombolysis interval, whereas routine
acute anticoagulation is not recommended.
Question 5
A 35-year-old woman presents with episodic headaches,
palpitations, diaphoresis, and severe hypertension. CT reveals
a 4-cm adrenal mass. Biochemical testing confirms excess
catecholamine production. Which of the following is the most
appropriate preoperative management?
A. β-blocker therapy followed by α-blocker therapy
B. Calcium channel blocker followed by β-blocker therapy
C. α-Blockade followed by β-blockade
D. Immediate surgical resection without medical preparation
Rationale: Pheochromocytoma requires adequate α-
adrenergic blockade before β-blockade. Giving a β-blocker
first can cause unopposed α-mediated vasoconstriction and
precipitate a hypertensive crisis. Once α-blockade is
established, β-blockade may be added to control tachycardia.
Practice Exam Questions And Verified
Answers with Rationales
Question 1
A 67-year-old man with a 50-pack-year smoking history
presents with progressive dyspnea, chronic productive cough,
and worsening exercise intolerance. Pulmonary function
testing shows an FEV₁ of 42% predicted, FEV₁/FVC ratio of
0.48, and minimal reversibility after inhaled albuterol. He has
had two exacerbations requiring oral corticosteroids in the
past year. Which of the following is the most appropriate
long-term pharmacologic strategy?
A. Inhaled corticosteroid monotherapy
B. Short-acting β₂-agonist monotherapy
C. Long-acting muscarinic antagonist plus long-acting β₂-
agonist
D. Oral prednisone maintenance therapy
Rationale: This patient has COPD with significant airflow
obstruction and recurrent exacerbations. Long-acting
bronchodilator therapy with a LAMA/LABA combination
provides sustained bronchodilation and improves symptoms
and lung function. Inhaled corticosteroids are generally added
when exacerbations persist despite optimized
bronchodilation, particularly in patients with elevated
,eosinophils or asthma features. Chronic systemic
corticosteroids are avoided because of substantial adverse
effects.
Question 2
A 24-year-old woman presents with fatigue, weight loss, heat
intolerance, tremor, and palpitations. Examination reveals
diffuse thyroid enlargement and bilateral exophthalmos.
Laboratory studies show elevated free T₄ and suppressed
TSH. Which of the following mechanisms best explains her
thyroid disease?
A. Destruction of thyroid follicles by cytotoxic T cells
B. Autonomous thyroid hormone production by a toxic
adenoma
C. Autoantibody stimulation of the TSH receptor
D. Excessive secretion of TSH by a pituitary adenoma
Rationale: Graves disease results from thyroid-stimulating
immunoglobulins that bind and activate the TSH receptor,
causing diffuse thyroid hyperplasia and increased thyroid
hormone synthesis. Ophthalmopathy is particularly
characteristic of Graves disease. A toxic adenoma causes
focal rather than diffuse thyroid overactivity and does not
typically produce ophthalmopathy.
Question 3
,A 58-year-old man with hypertension and chronic kidney
disease presents with muscle weakness. Laboratory studies
reveal potassium 6.8 mEq/L. ECG demonstrates peaked T
waves followed by QRS widening. Which of the following
should be administered first?
A. Intravenous insulin with glucose
B. Sodium zirconium cyclosilicate
C. Furosemide
D. Intravenous calcium gluconate
Rationale: Severe hyperkalemia with ECG changes is an
immediate cardiac emergency. IV calcium stabilizes the
cardiac membrane and reduces the risk of fatal arrhythmias
but does not lower serum potassium. Insulin with glucose
shifts potassium intracellularly and should follow membrane
stabilization. Potassium-removing therapies are also required
but act more slowly.
Question 4
A 72-year-old woman develops sudden right-sided weakness
and expressive aphasia 90 minutes after symptom onset. CT
of the head shows no hemorrhage. Blood pressure is 168/94
mm Hg. She is not taking anticoagulants. Which of the
following is the most appropriate next step?
A. Immediate aspirin administration without further
intervention
B. Intravenous heparin
C. Intravenous thrombolytic therapy after confirming
, eligibility
D. Lower blood pressure to less than 120/80 mm Hg before
treatment
Rationale: This patient has an acute ischemic stroke within
the therapeutic window for IV thrombolysis and has no
evidence of intracranial hemorrhage. Her blood pressure is
below the threshold that would preclude thrombolysis.
Aspirin is appropriate when thrombolysis is not given or after
the appropriate post-thrombolysis interval, whereas routine
acute anticoagulation is not recommended.
Question 5
A 35-year-old woman presents with episodic headaches,
palpitations, diaphoresis, and severe hypertension. CT reveals
a 4-cm adrenal mass. Biochemical testing confirms excess
catecholamine production. Which of the following is the most
appropriate preoperative management?
A. β-blocker therapy followed by α-blocker therapy
B. Calcium channel blocker followed by β-blocker therapy
C. α-Blockade followed by β-blockade
D. Immediate surgical resection without medical preparation
Rationale: Pheochromocytoma requires adequate α-
adrenergic blockade before β-blockade. Giving a β-blocker
first can cause unopposed α-mediated vasoconstriction and
precipitate a hypertensive crisis. Once α-blockade is
established, β-blockade may be added to control tachycardia.
