2026 VERION COMSAE Phase 2 Form 113i
Practice Exam Questions with Answers &
Detailed Rationales
Question 1
A 67-year-old man with a 45-pack-year smoking history
presents with progressive dyspnea, weight loss, and a
persistent cough. CT of the chest reveals a 4.5-cm central
hilar mass. Serum sodium is 121 mEq/L, serum osmolality is
low, and urine osmolality is inappropriately elevated. He
appears euvolemic on examination. Which of the following is
the most likely mechanism responsible for this patient's
electrolyte abnormality?
A. Increased secretion of atrial natriuretic peptide
B. Renal resistance to antidiuretic hormone
C. Ectopic secretion of antidiuretic hormone
D. Increased aldosterone secretion
Rationale: The patient has euvolemic hypotonic hyponatremia
with inappropriately concentrated urine, consistent with
SIADH. A central hilar lung mass in a heavy smoker strongly
suggests small cell lung carcinoma, which can ectopically
produce ADH. SIADH causes increased free-water retention,
dilutional hyponatremia, and low serum osmolality. Primary
polydipsia produces maximally dilute urine, while adrenal
,insufficiency and hypothyroidism should be excluded in the
evaluation of euvolemic hyponatremia.
Question 2
A 29-year-old woman presents with fatigue, palpitations, and
heat intolerance. She has diffuse thyroid enlargement and
bilateral proptosis. Laboratory studies show elevated free T4
and suppressed TSH. She is started on methimazole. Two
weeks later, she develops fever, severe sore throat, and
profound malaise. Which of the following is the most
appropriate next step?
A. Continue methimazole and administer acetaminophen
B. Add propranolol and continue methimazole
C. Switch immediately to radioactive iodine therapy
D. Discontinue methimazole and obtain an urgent complete
blood count
Rationale: Fever and severe pharyngitis in a patient receiving
methimazole raise concern for agranulocytosis, a rare but
potentially fatal adverse effect of thionamides. The drug
should be stopped immediately, and a CBC with differential
should be obtained. If severe neutropenia is confirmed,
appropriate treatment includes supportive care and often
granulocyte colony-stimulating factor. Radioactive iodine may
be considered later but does not address the immediate
potentially life-threatening complication.
Question 3
,A 74-year-old woman with atrial fibrillation is brought to the
emergency department because of sudden right-sided
weakness and aphasia. She was last seen normal 90 minutes
ago. CT of the head shows no hemorrhage. Her blood
pressure is 178/102 mm Hg, and glucose is normal. Which of
the following is the most appropriate immediate treatment if
no contraindications are identified?
A. Aspirin alone
B. Immediate carotid endarterectomy
C. Intravenous heparin
D. Intravenous thrombolytic therapy
Rationale: This patient has an acute ischemic stroke with a
clearly defined time of onset and no intracranial hemorrhage
on CT. Intravenous thrombolysis is indicated in eligible
patients presenting within the appropriate therapeutic
window. Blood pressure must be below the threshold required
for thrombolytic administration; therefore, if necessary, it
should be carefully lowered with an intravenous
antihypertensive. Heparin is not routinely used for acute
ischemic stroke, and aspirin is generally used when
thrombolysis is not administered or after the appropriate
post-thrombolysis interval.
Question 4
A 58-year-old man presents with severe substernal chest pain
radiating to the left arm. ECG demonstrates ST-segment
elevations in leads II, III, and aVF. He becomes hypotensive
, after receiving sublingual nitroglycerin. Examination reveals
clear lungs and elevated jugular venous pressure. Which
coronary artery is most likely involved?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
Rationale: Inferior myocardial infarction with hypotension,
elevated JVP, and clear lungs suggests right ventricular
infarction, which commonly occurs with right coronary artery
occlusion. The right ventricle is preload dependent, so
venodilation from nitroglycerin can significantly reduce
cardiac output and worsen hypotension. In this setting,
intravenous fluids are typically used to support preload, while
nitrates should be avoided.
Question 5
A 35-year-old woman presents with episodic headaches,
diaphoresis, palpitations, and severe hypertension. CT reveals
a 4-cm adrenal mass. Laboratory testing confirms markedly
elevated plasma metanephrines. Before surgical removal,
which medication regimen is most appropriate?
A. Beta-blocker followed by alpha-blocker
B. Calcium-channel blocker followed by beta-blocker
C. Alpha-blocker followed by beta-blocker
D. ACE inhibitor followed by alpha-blocker
Practice Exam Questions with Answers &
Detailed Rationales
Question 1
A 67-year-old man with a 45-pack-year smoking history
presents with progressive dyspnea, weight loss, and a
persistent cough. CT of the chest reveals a 4.5-cm central
hilar mass. Serum sodium is 121 mEq/L, serum osmolality is
low, and urine osmolality is inappropriately elevated. He
appears euvolemic on examination. Which of the following is
the most likely mechanism responsible for this patient's
electrolyte abnormality?
A. Increased secretion of atrial natriuretic peptide
B. Renal resistance to antidiuretic hormone
C. Ectopic secretion of antidiuretic hormone
D. Increased aldosterone secretion
Rationale: The patient has euvolemic hypotonic hyponatremia
with inappropriately concentrated urine, consistent with
SIADH. A central hilar lung mass in a heavy smoker strongly
suggests small cell lung carcinoma, which can ectopically
produce ADH. SIADH causes increased free-water retention,
dilutional hyponatremia, and low serum osmolality. Primary
polydipsia produces maximally dilute urine, while adrenal
,insufficiency and hypothyroidism should be excluded in the
evaluation of euvolemic hyponatremia.
Question 2
A 29-year-old woman presents with fatigue, palpitations, and
heat intolerance. She has diffuse thyroid enlargement and
bilateral proptosis. Laboratory studies show elevated free T4
and suppressed TSH. She is started on methimazole. Two
weeks later, she develops fever, severe sore throat, and
profound malaise. Which of the following is the most
appropriate next step?
A. Continue methimazole and administer acetaminophen
B. Add propranolol and continue methimazole
C. Switch immediately to radioactive iodine therapy
D. Discontinue methimazole and obtain an urgent complete
blood count
Rationale: Fever and severe pharyngitis in a patient receiving
methimazole raise concern for agranulocytosis, a rare but
potentially fatal adverse effect of thionamides. The drug
should be stopped immediately, and a CBC with differential
should be obtained. If severe neutropenia is confirmed,
appropriate treatment includes supportive care and often
granulocyte colony-stimulating factor. Radioactive iodine may
be considered later but does not address the immediate
potentially life-threatening complication.
Question 3
,A 74-year-old woman with atrial fibrillation is brought to the
emergency department because of sudden right-sided
weakness and aphasia. She was last seen normal 90 minutes
ago. CT of the head shows no hemorrhage. Her blood
pressure is 178/102 mm Hg, and glucose is normal. Which of
the following is the most appropriate immediate treatment if
no contraindications are identified?
A. Aspirin alone
B. Immediate carotid endarterectomy
C. Intravenous heparin
D. Intravenous thrombolytic therapy
Rationale: This patient has an acute ischemic stroke with a
clearly defined time of onset and no intracranial hemorrhage
on CT. Intravenous thrombolysis is indicated in eligible
patients presenting within the appropriate therapeutic
window. Blood pressure must be below the threshold required
for thrombolytic administration; therefore, if necessary, it
should be carefully lowered with an intravenous
antihypertensive. Heparin is not routinely used for acute
ischemic stroke, and aspirin is generally used when
thrombolysis is not administered or after the appropriate
post-thrombolysis interval.
Question 4
A 58-year-old man presents with severe substernal chest pain
radiating to the left arm. ECG demonstrates ST-segment
elevations in leads II, III, and aVF. He becomes hypotensive
, after receiving sublingual nitroglycerin. Examination reveals
clear lungs and elevated jugular venous pressure. Which
coronary artery is most likely involved?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
Rationale: Inferior myocardial infarction with hypotension,
elevated JVP, and clear lungs suggests right ventricular
infarction, which commonly occurs with right coronary artery
occlusion. The right ventricle is preload dependent, so
venodilation from nitroglycerin can significantly reduce
cardiac output and worsen hypotension. In this setting,
intravenous fluids are typically used to support preload, while
nitrates should be avoided.
Question 5
A 35-year-old woman presents with episodic headaches,
diaphoresis, palpitations, and severe hypertension. CT reveals
a 4-cm adrenal mass. Laboratory testing confirms markedly
elevated plasma metanephrines. Before surgical removal,
which medication regimen is most appropriate?
A. Beta-blocker followed by alpha-blocker
B. Calcium-channel blocker followed by beta-blocker
C. Alpha-blocker followed by beta-blocker
D. ACE inhibitor followed by alpha-blocker
