2026 VERSION COMSAE Phase 2 B
Form 115i Practice Exam Questions
Answers and Verified Rationales
Question 1 — Cardiology
A 68-year-old man with hypertension and hyperlipidemia
develops sudden substernal chest pain radiating to his left
arm. ECG shows ST-segment elevations in leads II, III, and aVF.
Blood pressure is 86/58 mm Hg, jugular venous pressure is
elevated, and the lungs are clear. Which of the following is
the most appropriate immediate management?
A. Intravenous furosemide
B. Sublingual nitroglycerin
C. Intravenous isotonic crystalloid
D. Intravenous metoprolol
Rationale: Inferior myocardial infarction with hypotension,
elevated JVP, and clear lungs suggests right ventricular
infarction due to right coronary artery occlusion. The right
ventricle is preload dependent, so cautious IV fluid
administration improves right-sided filling and cardiac output.
Nitrates and diuretics decrease preload and may worsen
hypotension.
Question 2 — Pulmonology
,A 27-year-old woman presents with acute dyspnea and
pleuritic chest pain 5 days after returning from a long-haul
flight. She is tachycardic and mildly hypoxemic. CT
angiography demonstrates bilateral pulmonary emboli.
Which finding would most strongly indicate a massive, high-
risk pulmonary embolism requiring urgent reperfusion
therapy?
A. Mild pleuritic chest pain
B. Elevated D-dimer
C. Right ventricular dilation on CT
D. Persistent hypotension despite adequate fluid
resuscitation
Rationale: Hemodynamic instability, defined by sustained
hypotension or shock, indicates high-risk pulmonary
embolism with significant right ventricular failure. These
patients may require systemic thrombolysis or catheter-
based/surgical reperfusion. RV dilation alone indicates strain
but does not necessarily establish high-risk PE.
Question 3 — Nephrology
A 72-year-old man develops oliguria after receiving contrast
for coronary angiography. Two days later, serum creatinine
rises from 1.0 to 2.4 mg/dL. Urinalysis shows muddy brown
granular casts. Which renal process is most likely responsible?
A. Acute interstitial nephritis
B. Prerenal azotemia
,C. Acute tubular injury with tubular epithelial necrosis
D. Rapidly progressive glomerulonephritis
Rationale: Contrast-associated acute kidney injury commonly
produces acute tubular injury. Muddy brown granular casts
are characteristic of tubular epithelial injury and necrosis.
Prerenal disease typically has bland sediment, whereas
interstitial nephritis produces pyuria and WBC casts.
Question 4 — Endocrinology
A 34-year-old woman presents with fatigue, weight loss,
hyperpigmentation, hypotension, hyponatremia, and
hyperkalemia. Laboratory testing reveals low cortisol and
elevated ACTH. Which additional finding is most likely?
A. Low renin activity
B. Hypercalcemia due to PTH excess
C. Elevated plasma renin activity with low aldosterone
D. Increased cortisol after ACTH administration
Rationale: Primary adrenal insufficiency causes destruction or
dysfunction of the adrenal cortex, resulting in low cortisol,
low aldosterone, and elevated ACTH. Loss of aldosterone
causes sodium loss, hyperkalemia, hypovolemia, and
increased renin activity. ACTH stimulation produces an
inadequate cortisol response.
Question 5 — Infectious Disease
, A 63-year-old man with diabetes presents with fever,
hypotension, confusion, and rapidly progressive pain in his
lower leg. The skin is erythematous with bullae and crepitus.
Which is the most appropriate next step?
A. Oral clindamycin and outpatient follow-up
B. MRI before initiating treatment
C. Needle aspiration followed by observation
D. Immediate surgical exploration and debridement with
broad-spectrum IV antibiotics
Rationale: Severe pain out of proportion, systemic toxicity,
bullae, crepitus, and rapid progression strongly suggest
necrotizing fasciitis. Treatment requires immediate surgical
debridement and empiric broad-spectrum antibiotics.
Imaging should not delay definitive surgical management in a
clinically unstable patient.
Question 6 — Gastroenterology
A 55-year-old man with cirrhosis presents with massive
hematemesis. After airway stabilization and large-bore IV
access, which medication should be administered
immediately while preparing for endoscopy?
A. IV proton pump inhibitor alone
B. Oral propranolol
C. IV octreotide
D. IV metoclopramide
Rationale: Acute variceal hemorrhage is treated with
vasoactive therapy such as octreotide to reduce portal venous
Form 115i Practice Exam Questions
Answers and Verified Rationales
Question 1 — Cardiology
A 68-year-old man with hypertension and hyperlipidemia
develops sudden substernal chest pain radiating to his left
arm. ECG shows ST-segment elevations in leads II, III, and aVF.
Blood pressure is 86/58 mm Hg, jugular venous pressure is
elevated, and the lungs are clear. Which of the following is
the most appropriate immediate management?
A. Intravenous furosemide
B. Sublingual nitroglycerin
C. Intravenous isotonic crystalloid
D. Intravenous metoprolol
Rationale: Inferior myocardial infarction with hypotension,
elevated JVP, and clear lungs suggests right ventricular
infarction due to right coronary artery occlusion. The right
ventricle is preload dependent, so cautious IV fluid
administration improves right-sided filling and cardiac output.
Nitrates and diuretics decrease preload and may worsen
hypotension.
Question 2 — Pulmonology
,A 27-year-old woman presents with acute dyspnea and
pleuritic chest pain 5 days after returning from a long-haul
flight. She is tachycardic and mildly hypoxemic. CT
angiography demonstrates bilateral pulmonary emboli.
Which finding would most strongly indicate a massive, high-
risk pulmonary embolism requiring urgent reperfusion
therapy?
A. Mild pleuritic chest pain
B. Elevated D-dimer
C. Right ventricular dilation on CT
D. Persistent hypotension despite adequate fluid
resuscitation
Rationale: Hemodynamic instability, defined by sustained
hypotension or shock, indicates high-risk pulmonary
embolism with significant right ventricular failure. These
patients may require systemic thrombolysis or catheter-
based/surgical reperfusion. RV dilation alone indicates strain
but does not necessarily establish high-risk PE.
Question 3 — Nephrology
A 72-year-old man develops oliguria after receiving contrast
for coronary angiography. Two days later, serum creatinine
rises from 1.0 to 2.4 mg/dL. Urinalysis shows muddy brown
granular casts. Which renal process is most likely responsible?
A. Acute interstitial nephritis
B. Prerenal azotemia
,C. Acute tubular injury with tubular epithelial necrosis
D. Rapidly progressive glomerulonephritis
Rationale: Contrast-associated acute kidney injury commonly
produces acute tubular injury. Muddy brown granular casts
are characteristic of tubular epithelial injury and necrosis.
Prerenal disease typically has bland sediment, whereas
interstitial nephritis produces pyuria and WBC casts.
Question 4 — Endocrinology
A 34-year-old woman presents with fatigue, weight loss,
hyperpigmentation, hypotension, hyponatremia, and
hyperkalemia. Laboratory testing reveals low cortisol and
elevated ACTH. Which additional finding is most likely?
A. Low renin activity
B. Hypercalcemia due to PTH excess
C. Elevated plasma renin activity with low aldosterone
D. Increased cortisol after ACTH administration
Rationale: Primary adrenal insufficiency causes destruction or
dysfunction of the adrenal cortex, resulting in low cortisol,
low aldosterone, and elevated ACTH. Loss of aldosterone
causes sodium loss, hyperkalemia, hypovolemia, and
increased renin activity. ACTH stimulation produces an
inadequate cortisol response.
Question 5 — Infectious Disease
, A 63-year-old man with diabetes presents with fever,
hypotension, confusion, and rapidly progressive pain in his
lower leg. The skin is erythematous with bullae and crepitus.
Which is the most appropriate next step?
A. Oral clindamycin and outpatient follow-up
B. MRI before initiating treatment
C. Needle aspiration followed by observation
D. Immediate surgical exploration and debridement with
broad-spectrum IV antibiotics
Rationale: Severe pain out of proportion, systemic toxicity,
bullae, crepitus, and rapid progression strongly suggest
necrotizing fasciitis. Treatment requires immediate surgical
debridement and empiric broad-spectrum antibiotics.
Imaging should not delay definitive surgical management in a
clinically unstable patient.
Question 6 — Gastroenterology
A 55-year-old man with cirrhosis presents with massive
hematemesis. After airway stabilization and large-bore IV
access, which medication should be administered
immediately while preparing for endoscopy?
A. IV proton pump inhibitor alone
B. Oral propranolol
C. IV octreotide
D. IV metoclopramide
Rationale: Acute variceal hemorrhage is treated with
vasoactive therapy such as octreotide to reduce portal venous
