COMSAE Phase 1 Level 1 ASA 111i 2026–2027
Actual Final Exam | Comprehensive Questions
and Answers, Detailed Explanations, High-Yield
Review, and Board Exam Preparation Guide
1. A 64-year-old man with hypertension presents with acute left-sided weakness
and facial droop onset 1.5 hours ago. CT head no hemorrhage. Next step?
A) Aspirin 325 mg
B) IV tissue plasminogen activator
C) Mechanical thrombectomy
D) Clopidogrel 300 mg
Rationale: IV tPA is indicated within 3 hours of ischemic stroke without
contraindications.
2. A 73-year-old woman with atrial fibrillation on warfarin (INR 5.1) has sudden
severe headache. CT shows left parietal intraparenchymal hemorrhage. Immediate
treatment?
A) Vitamin K 10 mg IV
B) Fresh frozen plasma
C) Prothrombin complex concentrate
D) Hold warfarin and observe
Rationale: PCC rapidly reverses warfarin in intracranial hemorrhage; FFP slower.
3. A 59-year-old man with type 2 diabetes, CKD stage 3 (eGFR 43), HbA1c 8.6%
on metformin and glimepiride. Which medication reduces cardiovascular mortality
and slows CKD progression?
A) Sitagliptin
B) Empagliflozin
C) Pioglitazone
D) Insulin glargine
Rationale: SGLT2 inhibitors reduce CV death, HF hospitalization, and slow eGFR
decline.
4. A 55-year-old man with chest pain radiating to jaw, diaphoresis. ECG: ST
elevation in leads V1–V4. Which artery is occluded?
,A) Right coronary artery
B) Left anterior descending
C) Left circumflex
D) Posterior descending
Rationale: Anterior ST elevation = LAD occlusion.
5. A patient with heart failure with reduced ejection fraction (HFrEF) on lisinopril,
carvedilol, and furosemide. Which medication is most likely to reduce sudden
cardiac death?
A) Digoxin
B) Spironolactone
C) Hydralazine
D) Ivabradine
Rationale: Mineralocorticoid receptor antagonists reduce SCD in HFrEF.
6. A 28-year-old with palpitations, lightheadedness. ECG shows delta wave, short
PR, wide QRS. Diagnosis?
A) Wolff-Parkinson-White syndrome
B) Long QT syndrome
C) Brugada syndrome
D) AV nodal reentry tachycardia
Rationale: Delta wave + short PR = WPW (accessory pathway).
7. A patient with infective endocarditis has Osler nodes, Janeway lesions, and a
new regurgitant murmur. Most common causative organism in IV drug users?
A) Streptococcus viridans
B) Staphylococcus aureus
C) Enterococcus faecalis
D) Coxiella burnetii
Rationale: IV drug use → acute endocarditis → S. aureus.
8. A 45-year-old with hypertension has a blood pressure of 180/110 mmHg, but no
symptoms. ECG shows LVH. Which antihypertensive is best to prevent stroke?
A) Hydrochlorothiazide
B) Lisinopril
C) Amlodipine
D) Clonidine
,Rationale: ACE inhibitors reduce stroke risk and regress LVH.
9. A patient with aortic stenosis presents with syncope during exertion. The
mechanism is:
A) Vasodilation with fixed cardiac output
B) Bradycardia from vagal tone
C) Atrial fibrillation
D) Pulmonary hypertension
Rationale: Exercise causes systemic vasodilation but stenotic valve limits
increased CO → syncope.
10. A 62-year-old with chest pain at rest, ECG shows transient ST elevation.
Troponin normal. Diagnosis?
A) NSTEMI
B) Prinzmetal (variant) angina
C) Unstable angina
D) Pericarditis
Rationale: Transient ST elevation with normal troponin = vasospastic angina.
11. A patient with deep vein thrombosis develops sudden dyspnea, tachycardia,
and hypotension. ECG shows S1Q3T3 pattern. Next best step?
A) Heparin drip
B) CT pulmonary angiography
C) Thrombolytics
D) Venous duplex
Rationale: Suspected massive PE → diagnostic CT angio before thrombolytics.
12. A newborn has a continuous "machinery" murmur at left upper sternal border,
bounding pulses. Diagnosis?
A) Ventricular septal defect
B) Patent ductus arteriosus
C) Atrial septal defect
D) Tetralogy of Fallot
Rationale: PDA causes continuous murmur from aorta to pulmonary artery.
13. Which medication for hypertension is contraindicated in pregnancy?
A) Labetalol
B) Nifedipine
, C) Lisinopril
D) Methyldopa
Rationale: ACE inhibitors cause fetal renal agenesis and oligohydramnios.
14. A patient with hypertrophic cardiomyopathy has a systolic murmur that
increases with Valsalva. Mechanism?
A) Increased preload
B) Decreased preload → increased obstruction
C) Increased afterload
D) Decreased contractility
Rationale: Reduced preload (Valsalva, standing) worsens LV outflow obstruction.
15. A 70-year-old with sudden severe tearing chest pain radiating to back, BP
difference in arms. Most likely diagnosis?
A) Pulmonary embolism
B) Aortic dissection
C) Myocardial infarction
D) Pericarditis
Rationale: Tearing pain + unequal pulses = aortic dissection.
16. A patient with atrial fibrillation has CHA₂DS₂-VASc score of 4. Which
anticoagulant is most appropriate?
A) Aspirin 81 mg
B) Apixaban
C) Clopidogrel
D) No anticoagulation
Rationale: DOACs (apixaban, rivaroxaban) preferred over warfarin for
nonvalvular AF.
17. A 55-year-old with chronic stable angina takes nitroglycerin. Which adverse
effect is most common?
A) Headache
B) Bradycardia
C) Hypertension
D) Dry cough
Rationale: Nitrate-induced headache from vasodilation; tolerance develops.
Actual Final Exam | Comprehensive Questions
and Answers, Detailed Explanations, High-Yield
Review, and Board Exam Preparation Guide
1. A 64-year-old man with hypertension presents with acute left-sided weakness
and facial droop onset 1.5 hours ago. CT head no hemorrhage. Next step?
A) Aspirin 325 mg
B) IV tissue plasminogen activator
C) Mechanical thrombectomy
D) Clopidogrel 300 mg
Rationale: IV tPA is indicated within 3 hours of ischemic stroke without
contraindications.
2. A 73-year-old woman with atrial fibrillation on warfarin (INR 5.1) has sudden
severe headache. CT shows left parietal intraparenchymal hemorrhage. Immediate
treatment?
A) Vitamin K 10 mg IV
B) Fresh frozen plasma
C) Prothrombin complex concentrate
D) Hold warfarin and observe
Rationale: PCC rapidly reverses warfarin in intracranial hemorrhage; FFP slower.
3. A 59-year-old man with type 2 diabetes, CKD stage 3 (eGFR 43), HbA1c 8.6%
on metformin and glimepiride. Which medication reduces cardiovascular mortality
and slows CKD progression?
A) Sitagliptin
B) Empagliflozin
C) Pioglitazone
D) Insulin glargine
Rationale: SGLT2 inhibitors reduce CV death, HF hospitalization, and slow eGFR
decline.
4. A 55-year-old man with chest pain radiating to jaw, diaphoresis. ECG: ST
elevation in leads V1–V4. Which artery is occluded?
,A) Right coronary artery
B) Left anterior descending
C) Left circumflex
D) Posterior descending
Rationale: Anterior ST elevation = LAD occlusion.
5. A patient with heart failure with reduced ejection fraction (HFrEF) on lisinopril,
carvedilol, and furosemide. Which medication is most likely to reduce sudden
cardiac death?
A) Digoxin
B) Spironolactone
C) Hydralazine
D) Ivabradine
Rationale: Mineralocorticoid receptor antagonists reduce SCD in HFrEF.
6. A 28-year-old with palpitations, lightheadedness. ECG shows delta wave, short
PR, wide QRS. Diagnosis?
A) Wolff-Parkinson-White syndrome
B) Long QT syndrome
C) Brugada syndrome
D) AV nodal reentry tachycardia
Rationale: Delta wave + short PR = WPW (accessory pathway).
7. A patient with infective endocarditis has Osler nodes, Janeway lesions, and a
new regurgitant murmur. Most common causative organism in IV drug users?
A) Streptococcus viridans
B) Staphylococcus aureus
C) Enterococcus faecalis
D) Coxiella burnetii
Rationale: IV drug use → acute endocarditis → S. aureus.
8. A 45-year-old with hypertension has a blood pressure of 180/110 mmHg, but no
symptoms. ECG shows LVH. Which antihypertensive is best to prevent stroke?
A) Hydrochlorothiazide
B) Lisinopril
C) Amlodipine
D) Clonidine
,Rationale: ACE inhibitors reduce stroke risk and regress LVH.
9. A patient with aortic stenosis presents with syncope during exertion. The
mechanism is:
A) Vasodilation with fixed cardiac output
B) Bradycardia from vagal tone
C) Atrial fibrillation
D) Pulmonary hypertension
Rationale: Exercise causes systemic vasodilation but stenotic valve limits
increased CO → syncope.
10. A 62-year-old with chest pain at rest, ECG shows transient ST elevation.
Troponin normal. Diagnosis?
A) NSTEMI
B) Prinzmetal (variant) angina
C) Unstable angina
D) Pericarditis
Rationale: Transient ST elevation with normal troponin = vasospastic angina.
11. A patient with deep vein thrombosis develops sudden dyspnea, tachycardia,
and hypotension. ECG shows S1Q3T3 pattern. Next best step?
A) Heparin drip
B) CT pulmonary angiography
C) Thrombolytics
D) Venous duplex
Rationale: Suspected massive PE → diagnostic CT angio before thrombolytics.
12. A newborn has a continuous "machinery" murmur at left upper sternal border,
bounding pulses. Diagnosis?
A) Ventricular septal defect
B) Patent ductus arteriosus
C) Atrial septal defect
D) Tetralogy of Fallot
Rationale: PDA causes continuous murmur from aorta to pulmonary artery.
13. Which medication for hypertension is contraindicated in pregnancy?
A) Labetalol
B) Nifedipine
, C) Lisinopril
D) Methyldopa
Rationale: ACE inhibitors cause fetal renal agenesis and oligohydramnios.
14. A patient with hypertrophic cardiomyopathy has a systolic murmur that
increases with Valsalva. Mechanism?
A) Increased preload
B) Decreased preload → increased obstruction
C) Increased afterload
D) Decreased contractility
Rationale: Reduced preload (Valsalva, standing) worsens LV outflow obstruction.
15. A 70-year-old with sudden severe tearing chest pain radiating to back, BP
difference in arms. Most likely diagnosis?
A) Pulmonary embolism
B) Aortic dissection
C) Myocardial infarction
D) Pericarditis
Rationale: Tearing pain + unequal pulses = aortic dissection.
16. A patient with atrial fibrillation has CHA₂DS₂-VASc score of 4. Which
anticoagulant is most appropriate?
A) Aspirin 81 mg
B) Apixaban
C) Clopidogrel
D) No anticoagulation
Rationale: DOACs (apixaban, rivaroxaban) preferred over warfarin for
nonvalvular AF.
17. A 55-year-old with chronic stable angina takes nitroglycerin. Which adverse
effect is most common?
A) Headache
B) Bradycardia
C) Hypertension
D) Dry cough
Rationale: Nitrate-induced headache from vasodilation; tolerance develops.
