1
COMSAE Phase 2 Form 108 :76 Question Test Bank All
questions with correct verified answers & detailed
rationales – graded A+ for the newest 2026 actual exam
SECTION 1: INTERNAL MEDICINE & CARDIOLOGY (Q1–15)
1. A 72-year-old man with hypertension and diabetes presents with substernal
chest pressure radiating to the left arm. An ECG shows ST-segment elevation in
leads V1–V4. Which coronary artery is most likely occluded?
A) Right coronary artery
B) Left circumflex
C) Left anterior descending (LAD)
D) Left main coronary artery
E) Posterior descending artery
: Correct Answer : C
Full Rotation & Rationale:
• A (RCA): Supplies the inferior wall; corresponding leads are II, III, aVF.
• B (LCx): Supplies the lateral wall; leads I, aVL, V5–V6.
• C (LAD): Correct. Leads V1–V4 correspond to the anterior wall and septum,
supplied by the LAD. Anterior STEMI = LAD occlusion.
• D (Left main): Would cause widespread ST depression in multiple leads
with ST elevation in aVR, not isolated anterior changes.
• E (PDA): Supplies the posterior/inferior wall; not anterior.
2. A 65-year-old woman with atrial fibrillation not on anticoagulation presents
with acute onset of right-sided weakness and aphasia. CT head is negative at 90
minutes. What is the most appropriate next step?
pg. 1
,2
A) Administer aspirin and clopidogrel
B) Administer IV alteplase (tPA)
C) Start a heparin infusion
D) Obtain a stat MRI
E) Perform a lumbar puncture
: Correct Answer : B
Full Rotation & Rationale:
• A (Aspirin/clopidogrel): For secondary prevention, not acute treatment.
• B (IV tPA): Correct. Within the 3–4.5 hour window, a negative CT rules out
hemorrhage, and tPA is the standard of care for acute ischemic stroke.
• C (Heparin): Not recommended for acute ischemic stroke due to increased
hemorrhage risk.
• D (MRI): May be useful but should not delay tPA administration.
• E (Lumbar puncture): Not indicated for ischemic stroke.
3. A 60-year-old man with a history of systolic heart failure (EF 30%) is on
lisinopril, carvedilol, and furosemide. He has dyspnea, crackles, and an S3
gallop. Which additional medication has been shown to reduce mortality in this
population?
A) Digoxin
B) Spironolactone
C) Amlodipine
D) Aspirin
E) Isosorbide dinitrate
: Correct Answer : B
Full Rotation & Rationale:
• A (Digoxin): Reduces hospitalizations but not mortality in HFrEF.
• B (Spironolactone): Correct. Mineralocorticoid receptor antagonists
(spironolactone, eplerenone) reduce mortality in HFrEF when added to
ACEi/ARB and beta-blocker.
pg. 2
,3
• C (Amlodipine): Not indicated for routine HFrEF; no mortality benefit.
• D (Aspirin): Not routine unless coronary artery disease; no mortality
reduction in heart failure.
• E (Isosorbide): Used in HFrEF in Black patients (with hydralazine) but not as
the next-line mortality reducer for all.
4. A 55-year-old woman with a history of hypertension presents with sudden,
severe tearing chest pain radiating to the back. Blood pressure is 180/100
mmHg in the right arm and 120/80 mmHg in the left. A new diastolic murmur is
heard at the left sternal border. What is the most likely diagnosis?
A) Acute myocardial infarction
B) Aortic dissection
C) Pulmonary embolism
D) Pericarditis
E) Esophageal rupture
: Correct Answer : B
Full Rotation & Rationale:
• A (MI): Chest pain is usually pressure, not tearing; no BP asymmetry.
• B (Aortic dissection): Correct. Tearing pain, pulse deficit (BP asymmetry),
and new aortic regurgitation murmur are classic for Stanford Type A
dissection.
• C (PE): Causes pleuritic pain and dyspnea, not tearing pain or BP
asymmetry.
• D (Pericarditis): Sharp, positional pain with friction rub, not tearing.
• E (Esophageal rupture): Causes severe pain but not BP asymmetry or aortic
regurgitation.
pg. 3
, 4
5. A client with decompensated heart failure has a BP of 85/50 mmHg, HR 120
bpm, and lactate 4.5 mmol/L. Which vasoactive agent should be administered
FIRST?
A) Dobutamine
B) Norepinephrine
C) Milrinone
D) Dopamine
E) Vasopressin
: Correct Answer : B
Full Rotation & Rationale:
• A (Dobutamine): An inotrope that may cause vasodilation and worsen
hypotension; used for low output but not as initial vasopressor in
hypotension.
• B (Norepinephrine): Correct. First-line vasopressor for cardiogenic shock
with hypotension and hypoperfusion.
• C (Milrinone): Inodilator that can cause significant hypotension.
• D (Dopamine): Associated with more arrhythmias and not first-line over
norepinephrine.
• E (Vasopressin): Second-line in septic shock, not first-line in cardiogenic
shock.
6. A 45-year-old man with a history of IV drug use presents with fever, a new
regurgitant murmur at the left lower sternal border, and Janeway lesions. Blood
cultures grow Staphylococcus aureus. Which valve is most likely affected?
A) Mitral valve
B) Aortic valve
C) Tricuspid valve
D) Pulmonic valve
E) Prosthetic mitral valve
pg. 4
COMSAE Phase 2 Form 108 :76 Question Test Bank All
questions with correct verified answers & detailed
rationales – graded A+ for the newest 2026 actual exam
SECTION 1: INTERNAL MEDICINE & CARDIOLOGY (Q1–15)
1. A 72-year-old man with hypertension and diabetes presents with substernal
chest pressure radiating to the left arm. An ECG shows ST-segment elevation in
leads V1–V4. Which coronary artery is most likely occluded?
A) Right coronary artery
B) Left circumflex
C) Left anterior descending (LAD)
D) Left main coronary artery
E) Posterior descending artery
: Correct Answer : C
Full Rotation & Rationale:
• A (RCA): Supplies the inferior wall; corresponding leads are II, III, aVF.
• B (LCx): Supplies the lateral wall; leads I, aVL, V5–V6.
• C (LAD): Correct. Leads V1–V4 correspond to the anterior wall and septum,
supplied by the LAD. Anterior STEMI = LAD occlusion.
• D (Left main): Would cause widespread ST depression in multiple leads
with ST elevation in aVR, not isolated anterior changes.
• E (PDA): Supplies the posterior/inferior wall; not anterior.
2. A 65-year-old woman with atrial fibrillation not on anticoagulation presents
with acute onset of right-sided weakness and aphasia. CT head is negative at 90
minutes. What is the most appropriate next step?
pg. 1
,2
A) Administer aspirin and clopidogrel
B) Administer IV alteplase (tPA)
C) Start a heparin infusion
D) Obtain a stat MRI
E) Perform a lumbar puncture
: Correct Answer : B
Full Rotation & Rationale:
• A (Aspirin/clopidogrel): For secondary prevention, not acute treatment.
• B (IV tPA): Correct. Within the 3–4.5 hour window, a negative CT rules out
hemorrhage, and tPA is the standard of care for acute ischemic stroke.
• C (Heparin): Not recommended for acute ischemic stroke due to increased
hemorrhage risk.
• D (MRI): May be useful but should not delay tPA administration.
• E (Lumbar puncture): Not indicated for ischemic stroke.
3. A 60-year-old man with a history of systolic heart failure (EF 30%) is on
lisinopril, carvedilol, and furosemide. He has dyspnea, crackles, and an S3
gallop. Which additional medication has been shown to reduce mortality in this
population?
A) Digoxin
B) Spironolactone
C) Amlodipine
D) Aspirin
E) Isosorbide dinitrate
: Correct Answer : B
Full Rotation & Rationale:
• A (Digoxin): Reduces hospitalizations but not mortality in HFrEF.
• B (Spironolactone): Correct. Mineralocorticoid receptor antagonists
(spironolactone, eplerenone) reduce mortality in HFrEF when added to
ACEi/ARB and beta-blocker.
pg. 2
,3
• C (Amlodipine): Not indicated for routine HFrEF; no mortality benefit.
• D (Aspirin): Not routine unless coronary artery disease; no mortality
reduction in heart failure.
• E (Isosorbide): Used in HFrEF in Black patients (with hydralazine) but not as
the next-line mortality reducer for all.
4. A 55-year-old woman with a history of hypertension presents with sudden,
severe tearing chest pain radiating to the back. Blood pressure is 180/100
mmHg in the right arm and 120/80 mmHg in the left. A new diastolic murmur is
heard at the left sternal border. What is the most likely diagnosis?
A) Acute myocardial infarction
B) Aortic dissection
C) Pulmonary embolism
D) Pericarditis
E) Esophageal rupture
: Correct Answer : B
Full Rotation & Rationale:
• A (MI): Chest pain is usually pressure, not tearing; no BP asymmetry.
• B (Aortic dissection): Correct. Tearing pain, pulse deficit (BP asymmetry),
and new aortic regurgitation murmur are classic for Stanford Type A
dissection.
• C (PE): Causes pleuritic pain and dyspnea, not tearing pain or BP
asymmetry.
• D (Pericarditis): Sharp, positional pain with friction rub, not tearing.
• E (Esophageal rupture): Causes severe pain but not BP asymmetry or aortic
regurgitation.
pg. 3
, 4
5. A client with decompensated heart failure has a BP of 85/50 mmHg, HR 120
bpm, and lactate 4.5 mmol/L. Which vasoactive agent should be administered
FIRST?
A) Dobutamine
B) Norepinephrine
C) Milrinone
D) Dopamine
E) Vasopressin
: Correct Answer : B
Full Rotation & Rationale:
• A (Dobutamine): An inotrope that may cause vasodilation and worsen
hypotension; used for low output but not as initial vasopressor in
hypotension.
• B (Norepinephrine): Correct. First-line vasopressor for cardiogenic shock
with hypotension and hypoperfusion.
• C (Milrinone): Inodilator that can cause significant hypotension.
• D (Dopamine): Associated with more arrhythmias and not first-line over
norepinephrine.
• E (Vasopressin): Second-line in septic shock, not first-line in cardiogenic
shock.
6. A 45-year-old man with a history of IV drug use presents with fever, a new
regurgitant murmur at the left lower sternal border, and Janeway lesions. Blood
cultures grow Staphylococcus aureus. Which valve is most likely affected?
A) Mitral valve
B) Aortic valve
C) Tricuspid valve
D) Pulmonic valve
E) Prosthetic mitral valve
pg. 4
