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COMSAE Phase 2 Form 113 Practice
Exam Questions And Correct Answers
(Verified Answers) Plus Rationales
2025|2026 Q&A | Instant Download Pdf
Question 1
A 62-year-old man presents with crushing substernal chest pain radiating to his left
arm for 45 minutes. ECG reveals ST-segment elevation in leads II, III, and aVF.
Which coronary artery is most likely occluded?
A) Left anterior descending artery
B) Right coronary artery
C) Left circumflex artery
D) Posterior descending artery
Rationale & Explanation:
ST-segment elevations in leads II, III, and aVF indicate an inferior wall
myocardial infarction. The inferior wall of the left ventricle is supplied by
the right coronary artery (RCA) in approximately 80% of individuals (right-
dominant circulation). The remaining 20% have left-dominant circulation where
the left circumflex supplies the inferior wall .
Clinical correlates:
• RCA occlusion often presents with bradycardia (sinus bradycardia or AV
block) due to increased vagal tone or ischemia to the AV node (supplied by
RCA in 90% of people)
,2
• May also involve the right ventricle (obtain right-sided ECG leads V3R-
V4R)
• Complications: hypotension, heart block, mitral regurgitation (if papillary
muscle involved)
Key distinction:
• LAD occlusion → anterior wall MI (V1-V4)
• LCx occlusion → lateral wall MI (I, aVL, V5-V6)
Question 2
A patient with atrial fibrillation is at increased risk for which complication?
A) Pulmonary fibrosis
B) Ischemic stroke
C) Aortic dissection
D) Deep vein thrombosis
Rationale & Explanation:
Atrial fibrillation (AF) causes stagnation of blood in the left atrium, particularly
in the left atrial appendage. This leads to thrombus formation, and embolization of
thrombus to the cerebral circulation causes ischemic stroke .
Key facts:
• AF increases stroke risk 5-fold across all ages
• Responsible for 15-20% of all ischemic strokes
• Risk stratification: CHA₂DS₂-VASc score (Congestive HF, Hypertension,
Age ≥75 (2 points), Diabetes, Stroke/TIA (2 points), Vascular disease, Age
65-74, Sex category female)
,3
• Anticoagulation (warfarin, DOACs) reduces stroke risk by 60-70%
Stroke prevention in AF:
CHA₂DS₂-VASc Recommendation
0 (male) or 1 (female) No anticoagulation
≥1 (male) or ≥2 (female) Anticoagulation
Question 3
A patient with sudden severe chest pain radiating to the back has unequal arm
blood pressures (right arm 190/100, left arm 110/70). Which diagnosis is most
likely?
A) Pulmonary embolism
B) Aortic dissection
C) Pneumothorax
D) Acute pericarditis
Rationale & Explanation:
The classic presentation of aortic dissection includes:
• Sudden, severe "tearing" or "ripping" chest pain that may radiate to the
back or interscapular region
• Blood pressure differential between arms (≥20 mmHg systolic) due to
extension of the dissection flap into the aortic arch vessels
• Risk factors: Hypertension (most common), connective tissue disorders
(Marfan, Ehlers-Danlos), bicuspid aortic valve, cocaine use, trauma
, 4
Types of aortic dissection:
Type Involvement Management
Type Ascending aorta (with or without
Surgical emergency
A (Stanford) arch/descending)
Type Medical management (beta-
Descending aorta only
B (Stanford) blockers, BP control)
Diagnosis: CT angiography of the chest, abdomen, pelvis is the study of choice.
Question 4
A 55-year-old man with a history of hypertension presents with sudden-onset
severe headache, nausea, vomiting, and confusion. BP is 220/120 mmHg.
Funduscopic exam shows hemorrhages and exudates. What is the most appropriate
initial treatment?
A) Oral clonidine
B) Sublingual nifedipine
C) IV nicardipine or labetalol
D) Oral labetalol
Rationale & Explanation:
This is hypertensive emergency – severe hypertension with end-organ
damage (retinal hemorrhages and exudates indicate hypertensive retinopathy).
Immediate blood pressure reduction is required to prevent further target organ
damage .
Guidelines for hypertensive emergency:
COMSAE Phase 2 Form 113 Practice
Exam Questions And Correct Answers
(Verified Answers) Plus Rationales
2025|2026 Q&A | Instant Download Pdf
Question 1
A 62-year-old man presents with crushing substernal chest pain radiating to his left
arm for 45 minutes. ECG reveals ST-segment elevation in leads II, III, and aVF.
Which coronary artery is most likely occluded?
A) Left anterior descending artery
B) Right coronary artery
C) Left circumflex artery
D) Posterior descending artery
Rationale & Explanation:
ST-segment elevations in leads II, III, and aVF indicate an inferior wall
myocardial infarction. The inferior wall of the left ventricle is supplied by
the right coronary artery (RCA) in approximately 80% of individuals (right-
dominant circulation). The remaining 20% have left-dominant circulation where
the left circumflex supplies the inferior wall .
Clinical correlates:
• RCA occlusion often presents with bradycardia (sinus bradycardia or AV
block) due to increased vagal tone or ischemia to the AV node (supplied by
RCA in 90% of people)
,2
• May also involve the right ventricle (obtain right-sided ECG leads V3R-
V4R)
• Complications: hypotension, heart block, mitral regurgitation (if papillary
muscle involved)
Key distinction:
• LAD occlusion → anterior wall MI (V1-V4)
• LCx occlusion → lateral wall MI (I, aVL, V5-V6)
Question 2
A patient with atrial fibrillation is at increased risk for which complication?
A) Pulmonary fibrosis
B) Ischemic stroke
C) Aortic dissection
D) Deep vein thrombosis
Rationale & Explanation:
Atrial fibrillation (AF) causes stagnation of blood in the left atrium, particularly
in the left atrial appendage. This leads to thrombus formation, and embolization of
thrombus to the cerebral circulation causes ischemic stroke .
Key facts:
• AF increases stroke risk 5-fold across all ages
• Responsible for 15-20% of all ischemic strokes
• Risk stratification: CHA₂DS₂-VASc score (Congestive HF, Hypertension,
Age ≥75 (2 points), Diabetes, Stroke/TIA (2 points), Vascular disease, Age
65-74, Sex category female)
,3
• Anticoagulation (warfarin, DOACs) reduces stroke risk by 60-70%
Stroke prevention in AF:
CHA₂DS₂-VASc Recommendation
0 (male) or 1 (female) No anticoagulation
≥1 (male) or ≥2 (female) Anticoagulation
Question 3
A patient with sudden severe chest pain radiating to the back has unequal arm
blood pressures (right arm 190/100, left arm 110/70). Which diagnosis is most
likely?
A) Pulmonary embolism
B) Aortic dissection
C) Pneumothorax
D) Acute pericarditis
Rationale & Explanation:
The classic presentation of aortic dissection includes:
• Sudden, severe "tearing" or "ripping" chest pain that may radiate to the
back or interscapular region
• Blood pressure differential between arms (≥20 mmHg systolic) due to
extension of the dissection flap into the aortic arch vessels
• Risk factors: Hypertension (most common), connective tissue disorders
(Marfan, Ehlers-Danlos), bicuspid aortic valve, cocaine use, trauma
, 4
Types of aortic dissection:
Type Involvement Management
Type Ascending aorta (with or without
Surgical emergency
A (Stanford) arch/descending)
Type Medical management (beta-
Descending aorta only
B (Stanford) blockers, BP control)
Diagnosis: CT angiography of the chest, abdomen, pelvis is the study of choice.
Question 4
A 55-year-old man with a history of hypertension presents with sudden-onset
severe headache, nausea, vomiting, and confusion. BP is 220/120 mmHg.
Funduscopic exam shows hemorrhages and exudates. What is the most appropriate
initial treatment?
A) Oral clonidine
B) Sublingual nifedipine
C) IV nicardipine or labetalol
D) Oral labetalol
Rationale & Explanation:
This is hypertensive emergency – severe hypertension with end-organ
damage (retinal hemorrhages and exudates indicate hypertensive retinopathy).
Immediate blood pressure reduction is required to prevent further target organ
damage .
Guidelines for hypertensive emergency:
