1
COMSAE Phase 1 Form 110 COMPLETE 176 REAL
EXAM QUESTIONS AND CORRECT VERIFIED
ANSWERS/ ALREADY GRADED A+ (MOST RECENT!!)
Cardiovascular System (Questions 1–20)
1. A 58-year-old man with a history of hypertension and type 2 diabetes presents
to the emergency department with acute onset of tearing chest pain radiating to
his back. His blood pressure is 150/90 mm Hg in the right arm and 110/70 mm Hg
in the left arm. A chest X-ray shows a widened mediastinum. Which of the
following is the most likely diagnosis?
A) Acute myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Esophageal rupture
: Correct Answer : C
✅ BIGGEST EXPLANATION: Aortic dissection classically presents with sudden,
severe, tearing chest or back pain that may migrate. A difference in blood
pressure between arms (systolic difference >20 mm Hg) is a key physical exam
finding due to differential flow into branch vessels. Widened mediastinum on
chest X-ray is a classic radiographic clue. ❌ A (MI) – Would present with
pressure-like substernal pain, often with ECG changes and troponin elevation, not
typically tearing pain or BP differential. ❌ B (PE) – Sudden dyspnea, pleuritic
chest pain, and hypoxia are more common; tearing pain and mediastinal widening
are not typical. ❌ D (Boerhaave syndrome) – Esophageal rupture presents with
severe chest pain after vomiting, subcutaneous emphysema, and mediastinal
widening, but not BP differential.
2. A 72-year-old woman with heart failure with reduced ejection fraction (HFrEF)
is prescribed an angiotensin-converting enzyme (ACE) inhibitor. Which of the
pg. 1
,2
following adverse effects is most likely to occur early in treatment and should be
monitored closely?
A) Hyperkalemia
B) First-dose hypotension
C) Dry cough
D) Angioedema
: Correct Answer : B
✅ BIGGEST EXPLANATION: First-dose hypotension is a well-described effect of
ACE inhibitors, especially in volume-depleted patients, those on high-dose
diuretics, or those with heart failure. It typically occurs within 1-2 hours of the
first dose and can be minimized by starting with a low dose and ensuring
adequate hydration. ❌ A (Hyperkalemia) – Can occur but usually develops over
days to weeks, not immediately after the first dose. ❌ C (Dry cough) – A
common side effect but typically occurs weeks to months after initiation. ❌ D
(Angioedema) – Rare (0.1-0.2%) and can occur at any time but is not the most
likely early effect.
3. A 45-year-old man with no prior medical history presents to the clinic with a
blood pressure of 150/95 mm Hg on three separate occasions. His physical exam
is unremarkable, and basic metabolic panel shows potassium of 2.8 mEq/L. Which
of the following is the most likely underlying cause?
A) Primary essential hypertension
B) Renal artery stenosis
C) Primary aldosteronism (Conn’s syndrome)
D) Cushing’s syndrome
: Correct Answer : C
✅ BIGGEST EXPLANATION: Hypokalemia in the setting of hypertension is a
classic clue for primary hyperaldosteronism (Conn’s syndrome). Aldosterone
excess causes sodium retention (leading to hypertension) and potassium wasting
(leading to hypokalemia). The combination of hypertension and unexplained
hypokalemia should prompt screening with an aldosterone-to-renin ratio. ❌ A
(Essential hypertension) – Does not typically cause hypokalemia. ❌ B (Renal
pg. 2
,3
artery stenosis) – May cause hypertension and, in some cases, hypokalemia due
to secondary aldosteronism, but primary aldosteronism is more common and
should be ruled out first. ❌ D (Cushing’s syndrome) – Can cause hypertension
and hypokalemia (due to mineralocorticoid activity), but physical exam features
(moon facies, striae) are usually present.
4. A 68-year-old man with a history of heart failure is admitted with shortness of
breath. His heart rate is 118 bpm, blood pressure 90/60 mm Hg, and he has
crackles throughout both lungs. An echocardiogram shows a left ventricular
ejection fraction of 25%. Which of the following medications should be initiated
first for acute decompensation?
A) Carvedilol
B) Furosemide
C) Lisinopril
D) Spironolactone
: Correct Answer : B
✅ BIGGEST EXPLANATION: In acute decompensated heart failure with volume
overload (crackles, dyspnea), the immediate priority is to reduce preload. IV
furosemide (a loop diuretic) rapidly relieves pulmonary congestion by increasing
sodium and water excretion. ❌ A (Carvedilol) – Beta-blockers are chronic
therapy that improve mortality but should not be initiated in acutely
decompensated HF because they can worsen heart failure. ❌ C (Lisinopril) – ACE
inhibitors are important for long-term management but do not provide rapid
symptom relief. ❌ D (Spironolactone) – A weak diuretic; too slow for acute
decompensation; may cause hyperkalemia.
5. A 55-year-old man with a history of myocardial infarction presents with
palpitations. ECG shows a regular, narrow-complex tachycardia at 180 bpm
without visible P waves. Carotid sinus massage slows the rate transiently. What is
the most likely rhythm?
A) Atrial flutter
B) Atrioventricular nodal reentrant tachycardia (AVNRT)
pg. 3
, 4
C) Atrial fibrillation
D) Sinus tachycardia
: Correct Answer : B
✅ BIGGEST EXPLANATION: AVNRT is a common cause of paroxysmal regular
narrow-complex tachycardia. P waves are often not visible because they are
buried in the QRS complex. Vagal maneuvers (e.g., carotid sinus massage) may
terminate AVNRT or slow the rate transiently. ❌ A (Atrial flutter) – Typically
presents with sawtooth flutter waves (F waves) and often has a ventricular rate
that is a fraction of the atrial rate (e.g., 2:1, 3:1). ❌ C (Atrial fibrillation) –
Irregularly irregular rhythm without distinct P waves; vagal maneuvers do not
convert it. ❌ D (Sinus tachycardia) – P waves are present; rate increases
gradually with physiologic triggers.
6. Which of the following ECG findings is most characteristic of hyperkalemia?
A) Peaked T waves
B) U waves
C) ST-segment elevation
D) Prolonged QT interval
: Correct Answer : A
✅ BIGGEST EXPLANATION: Peaked, tented T waves are the earliest ECG
manifestation of hyperkalemia (typically when serum K⁺ > 5.5 mEq/L). As
potassium rises, QRS widens, P wave flattens, and ultimately a sine wave pattern
precedes asystole. ❌ B (U waves) – Characteristic of hypokalemia. ❌ C
(ST-segment elevation) – Seen in acute myocardial infarction, pericarditis, and
early repolarization. ❌ D (Prolonged QT) – Seen in hypocalcemia, certain
medications, and congenital long QT syndrome.
7. A 62-year-old woman with a history of hypertension is started on a thiazide
diuretic. One week later, she complains of muscle weakness and fatigue. Her labs
show sodium 138 mEq/L, potassium 2.9 mEq/L, chloride 95 mEq/L, and
bicarbonate 32 mEq/L. What is the most likely acid-base disorder?
pg. 4
COMSAE Phase 1 Form 110 COMPLETE 176 REAL
EXAM QUESTIONS AND CORRECT VERIFIED
ANSWERS/ ALREADY GRADED A+ (MOST RECENT!!)
Cardiovascular System (Questions 1–20)
1. A 58-year-old man with a history of hypertension and type 2 diabetes presents
to the emergency department with acute onset of tearing chest pain radiating to
his back. His blood pressure is 150/90 mm Hg in the right arm and 110/70 mm Hg
in the left arm. A chest X-ray shows a widened mediastinum. Which of the
following is the most likely diagnosis?
A) Acute myocardial infarction
B) Pulmonary embolism
C) Aortic dissection
D) Esophageal rupture
: Correct Answer : C
✅ BIGGEST EXPLANATION: Aortic dissection classically presents with sudden,
severe, tearing chest or back pain that may migrate. A difference in blood
pressure between arms (systolic difference >20 mm Hg) is a key physical exam
finding due to differential flow into branch vessels. Widened mediastinum on
chest X-ray is a classic radiographic clue. ❌ A (MI) – Would present with
pressure-like substernal pain, often with ECG changes and troponin elevation, not
typically tearing pain or BP differential. ❌ B (PE) – Sudden dyspnea, pleuritic
chest pain, and hypoxia are more common; tearing pain and mediastinal widening
are not typical. ❌ D (Boerhaave syndrome) – Esophageal rupture presents with
severe chest pain after vomiting, subcutaneous emphysema, and mediastinal
widening, but not BP differential.
2. A 72-year-old woman with heart failure with reduced ejection fraction (HFrEF)
is prescribed an angiotensin-converting enzyme (ACE) inhibitor. Which of the
pg. 1
,2
following adverse effects is most likely to occur early in treatment and should be
monitored closely?
A) Hyperkalemia
B) First-dose hypotension
C) Dry cough
D) Angioedema
: Correct Answer : B
✅ BIGGEST EXPLANATION: First-dose hypotension is a well-described effect of
ACE inhibitors, especially in volume-depleted patients, those on high-dose
diuretics, or those with heart failure. It typically occurs within 1-2 hours of the
first dose and can be minimized by starting with a low dose and ensuring
adequate hydration. ❌ A (Hyperkalemia) – Can occur but usually develops over
days to weeks, not immediately after the first dose. ❌ C (Dry cough) – A
common side effect but typically occurs weeks to months after initiation. ❌ D
(Angioedema) – Rare (0.1-0.2%) and can occur at any time but is not the most
likely early effect.
3. A 45-year-old man with no prior medical history presents to the clinic with a
blood pressure of 150/95 mm Hg on three separate occasions. His physical exam
is unremarkable, and basic metabolic panel shows potassium of 2.8 mEq/L. Which
of the following is the most likely underlying cause?
A) Primary essential hypertension
B) Renal artery stenosis
C) Primary aldosteronism (Conn’s syndrome)
D) Cushing’s syndrome
: Correct Answer : C
✅ BIGGEST EXPLANATION: Hypokalemia in the setting of hypertension is a
classic clue for primary hyperaldosteronism (Conn’s syndrome). Aldosterone
excess causes sodium retention (leading to hypertension) and potassium wasting
(leading to hypokalemia). The combination of hypertension and unexplained
hypokalemia should prompt screening with an aldosterone-to-renin ratio. ❌ A
(Essential hypertension) – Does not typically cause hypokalemia. ❌ B (Renal
pg. 2
,3
artery stenosis) – May cause hypertension and, in some cases, hypokalemia due
to secondary aldosteronism, but primary aldosteronism is more common and
should be ruled out first. ❌ D (Cushing’s syndrome) – Can cause hypertension
and hypokalemia (due to mineralocorticoid activity), but physical exam features
(moon facies, striae) are usually present.
4. A 68-year-old man with a history of heart failure is admitted with shortness of
breath. His heart rate is 118 bpm, blood pressure 90/60 mm Hg, and he has
crackles throughout both lungs. An echocardiogram shows a left ventricular
ejection fraction of 25%. Which of the following medications should be initiated
first for acute decompensation?
A) Carvedilol
B) Furosemide
C) Lisinopril
D) Spironolactone
: Correct Answer : B
✅ BIGGEST EXPLANATION: In acute decompensated heart failure with volume
overload (crackles, dyspnea), the immediate priority is to reduce preload. IV
furosemide (a loop diuretic) rapidly relieves pulmonary congestion by increasing
sodium and water excretion. ❌ A (Carvedilol) – Beta-blockers are chronic
therapy that improve mortality but should not be initiated in acutely
decompensated HF because they can worsen heart failure. ❌ C (Lisinopril) – ACE
inhibitors are important for long-term management but do not provide rapid
symptom relief. ❌ D (Spironolactone) – A weak diuretic; too slow for acute
decompensation; may cause hyperkalemia.
5. A 55-year-old man with a history of myocardial infarction presents with
palpitations. ECG shows a regular, narrow-complex tachycardia at 180 bpm
without visible P waves. Carotid sinus massage slows the rate transiently. What is
the most likely rhythm?
A) Atrial flutter
B) Atrioventricular nodal reentrant tachycardia (AVNRT)
pg. 3
, 4
C) Atrial fibrillation
D) Sinus tachycardia
: Correct Answer : B
✅ BIGGEST EXPLANATION: AVNRT is a common cause of paroxysmal regular
narrow-complex tachycardia. P waves are often not visible because they are
buried in the QRS complex. Vagal maneuvers (e.g., carotid sinus massage) may
terminate AVNRT or slow the rate transiently. ❌ A (Atrial flutter) – Typically
presents with sawtooth flutter waves (F waves) and often has a ventricular rate
that is a fraction of the atrial rate (e.g., 2:1, 3:1). ❌ C (Atrial fibrillation) –
Irregularly irregular rhythm without distinct P waves; vagal maneuvers do not
convert it. ❌ D (Sinus tachycardia) – P waves are present; rate increases
gradually with physiologic triggers.
6. Which of the following ECG findings is most characteristic of hyperkalemia?
A) Peaked T waves
B) U waves
C) ST-segment elevation
D) Prolonged QT interval
: Correct Answer : A
✅ BIGGEST EXPLANATION: Peaked, tented T waves are the earliest ECG
manifestation of hyperkalemia (typically when serum K⁺ > 5.5 mEq/L). As
potassium rises, QRS widens, P wave flattens, and ultimately a sine wave pattern
precedes asystole. ❌ B (U waves) – Characteristic of hypokalemia. ❌ C
(ST-segment elevation) – Seen in acute myocardial infarction, pericarditis, and
early repolarization. ❌ D (Prolonged QT) – Seen in hypocalcemia, certain
medications, and congenital long QT syndrome.
7. A 62-year-old woman with a history of hypertension is started on a thiazide
diuretic. One week later, she complains of muscle weakness and fatigue. Her labs
show sodium 138 mEq/L, potassium 2.9 mEq/L, chloride 95 mEq/L, and
bicarbonate 32 mEq/L. What is the most likely acid-base disorder?
pg. 4
