2026 COMSAE 114 – Latest Questions and Verified Answers +
Detailed Study Guide | Guaranteed Pass | Fully Updated &
Trusted by DO Students
1. A 68-year-old man with stage IV non-small cell lung cancer and malignant pleural effusion
presents with dyspnea. He has failed first-line chemotherapy and declines further systemic
therapy. He requests a thoracentesis for symptomatic relief, but a repeat procedure has a high
chance of recurrence. What is the most appropriate next step in management?
A. Perform a therapeutic thoracentesis and discuss pleurodesis as an option for recurrent effusions
B. Refer the patient for urgent palliative radiation therapy to the mediastinum
C. Initiate empiric diuretic therapy to reduce the effusion volume
D. Place a chest tube for immediate pleurodesis without prior thoracentesis
Answer: A. Perform a therapeutic thoracentesis and discuss pleurodesis as an option for
recurrent effusions
2. A 42-year-old woman with systemic lupus erythematosus presents with fever, pleuritic chest
pain, and shortness of breath. Chest CT shows a moderate pericardial effusion. Labs show
elevated anti-dsDNA and low C3. She is hemodynamically stable. What is the best next step in
management?
A. Start high-dose corticosteroids and monitor for tamponade
B. Perform immediate pericardiocentesis to drain the effusion
C. Administer colchicine for recurrent pericarditis
D. Start empiric antibiotics for purulent pericarditis
Answer: A. Start high-dose corticosteroids and monitor for tamponade
3. A 55-year-old man with alcoholic cirrhosis presents with acute dyspnea. Chest x-ray shows a
massive right-sided pleural effusion. Thoracentesis reveals a transudative fluid with a
serum-to-pleural protein ratio of 0.4 and an SAAG >1.1 g/dL. Which of the following is the most
appropriate initial management?
A. Therapeutic thoracentesis and manage liver disease; consider TIPS for refractory cases
B. Initiate empiric antibiotics for spontaneous bacterial empyema
C. Perform pleurodesis to prevent reaccumulation
D. Start diuretics and follow up in clinic without thoracentesis
Answer: A. Therapeutic thoracentesis and manage liver disease; consider TIPS for refractory
cases
4. A 70-year-old woman with interstitial lung disease (IPF) presents with worsening cough and
new infiltrates on chest CT. She is on nintedanib. Bronchoalveolar lavage (BAL) is negative for
infection but shows >50% lymphocytes. What is the most likely diagnosis?
A. Acute exacerbation of IPF
B. Hypersensitivity pneumonitis
C. Drug-induced pneumonitis from nintedanib
D. Pulmonary alveolar proteinosis
Answer: B. Hypersensitivity pneumonitis
5. A 32-year-old healthcare worker has a needlestick injury from an HIV-positive patient. The
, source patient has a viral load of 100,000 copies/mL and is on no antiretroviral therapy. What is
the preferred post-exposure prophylaxis (PEP) regimen?
A. Tenofovir/emtricitabine plus dolutegravir for 28 days
B. Zidovudine monotherapy for 4 weeks
C. Ritonavir-boosted darunavir plus tenofovir for 28 days
D. Tenofovir/emtricitabine plus raltegravir for 14 days
Answer: A. Tenofovir/emtricitabine plus dolutegravir for 28 days
6. A 28-year-old medical resident reports to the occupational health clinic after a needlestick
injury from a patient with chronic hepatitis B (HBsAg positive, HBeAg positive). The resident
has documented immunity (anti-HBs >10 mIU/mL) after vaccination. What is the most
appropriate management?
A. No further action; do not test the source or start prophylaxis
B. Administer hepatitis B immune globulin (HBIG) and a booster vaccine
C. Start tenofovir prophylaxis and repeat anti-HBs levels in 1 month
D. Perform baseline testing of the source for HBV DNA before deciding
Answer: A. No further action; do not test the source or start prophylaxis
7. A 45-year-old homeless man is admitted with productive cough, night sweats, and weight
loss. Sputum smear is positive for acid-fast bacilli and GeneXpert confirms rifampin-sensitive
Mycobacterium tuberculosis. He lives in a shelter. Which of the following public health actions
is most important?
A. Initiate directly observed therapy (DOT) and contact tracing of shelter residents
B. Isolate the patient in a negative pressure room for the entire 6-month treatment
C. Recommence isoniazid preventive therapy for all shelter residents
D. Obtain sputum cultures monthly to ensure clearance
Answer: A. Initiate directly observed therapy (DOT) and contact tracing of shelter residents
8. A 60-year-old woman with type 2 diabetes and CKD stage 3 is newly diagnosed with heart
failure with reduced ejection fraction (HFrEF). She is prescribed a combination of metoprolol
succinate and lisinopril. Which of the following is the most important consideration regarding
her medication management?
A. Monitor serum creatinine and potassium after starting lisinopril, and titrate metoprolol slowly to target dose
B. Discontinue lisinopril because she has CKD stage 3
C. Start sacubitril/valsartan immediately without a prior ACE inhibitor
D. Avoid metoprolol because of her diabetes
Answer: A. Monitor serum creatinine and potassium after starting lisinopril, and titrate
metoprolol slowly to target dose
9. A 55-year-old man presents with progressive shortness of breath and fatigue.
Echocardiogram shows cardiac amyloidosis with preserved ejection fraction. He is referred for
genetic testing. Which of the following findings is most characteristic of hereditary
transthyretin amyloidosis (ATTRv)?
A. Cardiomyopathy with bilateral carpal tunnel syndrome and a family history of peripheral neuropathy in a
young-adult relative
B. Restrictive cardiomyopathy with macroglossia and gum hyperplasia
C. Isolated dilated cardiomyopathy without extracardiac symptoms
Detailed Study Guide | Guaranteed Pass | Fully Updated &
Trusted by DO Students
1. A 68-year-old man with stage IV non-small cell lung cancer and malignant pleural effusion
presents with dyspnea. He has failed first-line chemotherapy and declines further systemic
therapy. He requests a thoracentesis for symptomatic relief, but a repeat procedure has a high
chance of recurrence. What is the most appropriate next step in management?
A. Perform a therapeutic thoracentesis and discuss pleurodesis as an option for recurrent effusions
B. Refer the patient for urgent palliative radiation therapy to the mediastinum
C. Initiate empiric diuretic therapy to reduce the effusion volume
D. Place a chest tube for immediate pleurodesis without prior thoracentesis
Answer: A. Perform a therapeutic thoracentesis and discuss pleurodesis as an option for
recurrent effusions
2. A 42-year-old woman with systemic lupus erythematosus presents with fever, pleuritic chest
pain, and shortness of breath. Chest CT shows a moderate pericardial effusion. Labs show
elevated anti-dsDNA and low C3. She is hemodynamically stable. What is the best next step in
management?
A. Start high-dose corticosteroids and monitor for tamponade
B. Perform immediate pericardiocentesis to drain the effusion
C. Administer colchicine for recurrent pericarditis
D. Start empiric antibiotics for purulent pericarditis
Answer: A. Start high-dose corticosteroids and monitor for tamponade
3. A 55-year-old man with alcoholic cirrhosis presents with acute dyspnea. Chest x-ray shows a
massive right-sided pleural effusion. Thoracentesis reveals a transudative fluid with a
serum-to-pleural protein ratio of 0.4 and an SAAG >1.1 g/dL. Which of the following is the most
appropriate initial management?
A. Therapeutic thoracentesis and manage liver disease; consider TIPS for refractory cases
B. Initiate empiric antibiotics for spontaneous bacterial empyema
C. Perform pleurodesis to prevent reaccumulation
D. Start diuretics and follow up in clinic without thoracentesis
Answer: A. Therapeutic thoracentesis and manage liver disease; consider TIPS for refractory
cases
4. A 70-year-old woman with interstitial lung disease (IPF) presents with worsening cough and
new infiltrates on chest CT. She is on nintedanib. Bronchoalveolar lavage (BAL) is negative for
infection but shows >50% lymphocytes. What is the most likely diagnosis?
A. Acute exacerbation of IPF
B. Hypersensitivity pneumonitis
C. Drug-induced pneumonitis from nintedanib
D. Pulmonary alveolar proteinosis
Answer: B. Hypersensitivity pneumonitis
5. A 32-year-old healthcare worker has a needlestick injury from an HIV-positive patient. The
, source patient has a viral load of 100,000 copies/mL and is on no antiretroviral therapy. What is
the preferred post-exposure prophylaxis (PEP) regimen?
A. Tenofovir/emtricitabine plus dolutegravir for 28 days
B. Zidovudine monotherapy for 4 weeks
C. Ritonavir-boosted darunavir plus tenofovir for 28 days
D. Tenofovir/emtricitabine plus raltegravir for 14 days
Answer: A. Tenofovir/emtricitabine plus dolutegravir for 28 days
6. A 28-year-old medical resident reports to the occupational health clinic after a needlestick
injury from a patient with chronic hepatitis B (HBsAg positive, HBeAg positive). The resident
has documented immunity (anti-HBs >10 mIU/mL) after vaccination. What is the most
appropriate management?
A. No further action; do not test the source or start prophylaxis
B. Administer hepatitis B immune globulin (HBIG) and a booster vaccine
C. Start tenofovir prophylaxis and repeat anti-HBs levels in 1 month
D. Perform baseline testing of the source for HBV DNA before deciding
Answer: A. No further action; do not test the source or start prophylaxis
7. A 45-year-old homeless man is admitted with productive cough, night sweats, and weight
loss. Sputum smear is positive for acid-fast bacilli and GeneXpert confirms rifampin-sensitive
Mycobacterium tuberculosis. He lives in a shelter. Which of the following public health actions
is most important?
A. Initiate directly observed therapy (DOT) and contact tracing of shelter residents
B. Isolate the patient in a negative pressure room for the entire 6-month treatment
C. Recommence isoniazid preventive therapy for all shelter residents
D. Obtain sputum cultures monthly to ensure clearance
Answer: A. Initiate directly observed therapy (DOT) and contact tracing of shelter residents
8. A 60-year-old woman with type 2 diabetes and CKD stage 3 is newly diagnosed with heart
failure with reduced ejection fraction (HFrEF). She is prescribed a combination of metoprolol
succinate and lisinopril. Which of the following is the most important consideration regarding
her medication management?
A. Monitor serum creatinine and potassium after starting lisinopril, and titrate metoprolol slowly to target dose
B. Discontinue lisinopril because she has CKD stage 3
C. Start sacubitril/valsartan immediately without a prior ACE inhibitor
D. Avoid metoprolol because of her diabetes
Answer: A. Monitor serum creatinine and potassium after starting lisinopril, and titrate
metoprolol slowly to target dose
9. A 55-year-old man presents with progressive shortness of breath and fatigue.
Echocardiogram shows cardiac amyloidosis with preserved ejection fraction. He is referred for
genetic testing. Which of the following findings is most characteristic of hereditary
transthyretin amyloidosis (ATTRv)?
A. Cardiomyopathy with bilateral carpal tunnel syndrome and a family history of peripheral neuropathy in a
young-adult relative
B. Restrictive cardiomyopathy with macroglossia and gum hyperplasia
C. Isolated dilated cardiomyopathy without extracardiac symptoms
