COMAT INTERNAL MEDICINE FINAL EXAM PREP (2026-2027)
HIGH-YIELD DOMAIN WEIGHTING (BASED ON NBOME
BLUEPRINT)QUESTIONS AND ANSWERS ALREADY GRADED A+
Cardiovascular System (Questions 1-15)
Q1. A 67-year-old male with a history of hypertension presents with sudden onset of "tearing"
chest pain radiating to the interscapular region. His blood pressure is 180/100 mmHg in the
right arm and 100/60 mmHg in the left arm. Which of the following is the most appropriate
initial diagnostic study?
A) Transthoracic echocardiogram
B) CT angiography of the chest
C) Chest X-ray
D) Cardiac catheterization
Answer: B – CT angiography of the chest
Rationale: The presentation is classic for acute aortic dissection, especially with the pulse
differential and tearing pain . CT angiography is the preferred initial imaging study for suspected
aortic dissection due to its high sensitivity and rapid acquisition. TTE may miss descending aortic
dissections. Chest X-ray (widened mediastinum) is neither sensitive nor specific. Cardiac
catheterization is not first-line and could be dangerous if the dissection involves the coronary
ostia .
Q2. A 68-year-old male presents with progressive dyspnea on exertion, orthopnea, and
paroxysmal nocturnal dyspnea. Physical examination reveals jugular venous distention, bibasilar
crackles, and an S3 gallop. What is the most common cause of an S3 heart sound?
A) Aortic stenosis
B) Hypertrophic cardiomyopathy
C) Congestive heart failure
D) Mitral regurgitation
Answer: C – Congestive heart failure
,Rationale: An S3 gallop occurs during early diastole due to rapid ventricular filling and is most
commonly associated with congestive heart failure, though it can be a normal finding in children
and young adults . An S3 in an older adult is a hallmark of elevated ventricular filling pressures
and systolic heart failure. Aortic stenosis produces a systolic ejection murmur, and hypertrophic
cardiomyopathy typically causes a systolic murmur that increases with Valsalva. Mitral
regurgitation is a holosystolic murmur .
Q3. A 55-year-old male with a history of prior myocardial infarction presents with a diastolic
decrescendo murmur best heard at the left upper sternal border. The murmur is most
consistent with:
A) Aortic stenosis
B) Aortic regurgitation
C) Mitral stenosis
D) Pulmonic stenosis
Answer: B – Aortic regurgitation
Rationale: Aortic regurgitation produces an early decrescendo diastolic murmur best
auscultated at the second left intercostal space (left upper sternal border) with the patient
leaning forward and breath held in expiration . This is the classic location for aortic
regurgitation; the right upper sternal border is an alternative site. Aortic stenosis is a systolic
murmur. Mitral stenosis produces a diastolic rumble. Pulmonic stenosis produces a systolic
ejection murmur .
Q4. A 70-year-old male with known systolic heart failure (EF 30%) presents with worsening
dyspnea and a new S3 gallop. He is currently on lisinopril, metoprolol succinate, and
furosemide. Which medication is most likely to reduce mortality and should be initiated next?
A) Spironolactone
B) Hydralazine/isosorbide dinitrate
C) Digoxin
D) Amiodarone
Answer: A – Spironolactone
Rationale: In patients with NYHA class II-IV heart failure with reduced ejection fraction (HFrEF),
spironolactone (or eplerenone) reduces mortality . Hydralazine/isosorbide dinitrate is indicated
primarily in African American patients with persistent symptoms despite optimal therapy.
,Digoxin reduces hospitalizations but not mortality. Amiodarone has no mortality benefit and has
significant toxicity .
Q5. A 62-year-old woman with a history of hypertension and diabetes presents with substernal
chest pressure when walking two blocks, relieved with rest. ECG shows no ST changes. What is
the most appropriate initial diagnostic test?
A) Coronary angiography
B) Exercise stress test
C) CT angiography
D) Resting echocardiogram
Answer: B – Exercise stress test
Rationale: Stable angina symptoms warrant stress testing to assess for inducible ischemia .
Exercise ECG is first-line if the patient can exercise and baseline ECG is normal. Coronary
angiography is reserved for high-risk features or positive stress test. CT angiography is an
alternative but not first-line for typical stable angina .
Q6. A patient presents with acute onset of tearing chest pain radiating to the back, pulse 110,
BP 160/90 in right arm, 100/70 in left arm. Which vascular structure is most likely involved?
A) Ascending aorta
B) Descending aorta
C) Pulmonary artery
D) Coronary artery
Answer: B – Descending aorta
Rationale: The blood pressure differential between arms suggests involvement of the aortic
arch or descending aorta . Type B dissections (descending aorta) often present with pulse
deficits and blood pressure differences between arms. Ascending aortic dissections (Type A)
more commonly present with aortic regurgitation, pericardial effusion, or myocardial ischemia .
Q7. A 55-year-old patient is found to have a blood pressure of 210/120 mmHg but reports no
symptoms. He has no evidence of end-organ damage on exam or lab work. Which of the
following is the most appropriate initial management?
, A) Hospital admission for IV nitroprusside
B) Oral nifedipine
C) Oral antihypertensive therapy with close outpatient follow-up
D) IV labetalol immediately
Answer: C – Oral antihypertensive therapy with close outpatient follow-up
Rationale: Asymptomatic severe hypertension (hypertensive urgency) is defined by severely
elevated BP without acute end-organ damage . These patients can be managed in an outpatient
setting with oral antihypertensives; rapid reduction in BP is not needed and may be harmful.
Hospital admission is reserved for hypertensive emergencies where IV agents are required .
Q8. A patient presents with substernal chest pain that began 2 hours ago. ECG shows ST-
segment elevation in leads II, III, and aVF. Blood pressure is 90/60 mmHg, heart rate is 45 beats
per minute. The most likely occluded artery is the:
A) Left anterior descending artery
B) Right coronary artery
C) Left circumflex artery
D) Posterior descending artery
Answer: B – Right coronary artery
Rationale: ST-segment elevations in leads II, III, and aVF indicate an inferior wall myocardial
infarction . The right coronary artery supplies the inferior wall in most individuals. The RCA also
supplies the SA node in 60% of individuals and the AV node in 80-90%; thus, inferior MIs
frequently cause bradycardias and AV blocks. The LAD produces anterior MIs (V1-V4) .
Q9. A patient with new-onset acute pericarditis is most likely to exhibit which ECG finding?
A) Diffuse ST-segment elevation with PR segment depression
B) Q waves in leads II, III, and aVF
C) Deep, symmetric T-wave inversions
D) Prolonged QT interval
Answer: A – Diffuse ST-segment elevation with PR segment depression
Rationale: Acute pericarditis classically shows diffuse concave ST-segment elevation in most
leads (except aVR and V1) along with PR-segment depression . Q waves suggest prior MI. Deep
HIGH-YIELD DOMAIN WEIGHTING (BASED ON NBOME
BLUEPRINT)QUESTIONS AND ANSWERS ALREADY GRADED A+
Cardiovascular System (Questions 1-15)
Q1. A 67-year-old male with a history of hypertension presents with sudden onset of "tearing"
chest pain radiating to the interscapular region. His blood pressure is 180/100 mmHg in the
right arm and 100/60 mmHg in the left arm. Which of the following is the most appropriate
initial diagnostic study?
A) Transthoracic echocardiogram
B) CT angiography of the chest
C) Chest X-ray
D) Cardiac catheterization
Answer: B – CT angiography of the chest
Rationale: The presentation is classic for acute aortic dissection, especially with the pulse
differential and tearing pain . CT angiography is the preferred initial imaging study for suspected
aortic dissection due to its high sensitivity and rapid acquisition. TTE may miss descending aortic
dissections. Chest X-ray (widened mediastinum) is neither sensitive nor specific. Cardiac
catheterization is not first-line and could be dangerous if the dissection involves the coronary
ostia .
Q2. A 68-year-old male presents with progressive dyspnea on exertion, orthopnea, and
paroxysmal nocturnal dyspnea. Physical examination reveals jugular venous distention, bibasilar
crackles, and an S3 gallop. What is the most common cause of an S3 heart sound?
A) Aortic stenosis
B) Hypertrophic cardiomyopathy
C) Congestive heart failure
D) Mitral regurgitation
Answer: C – Congestive heart failure
,Rationale: An S3 gallop occurs during early diastole due to rapid ventricular filling and is most
commonly associated with congestive heart failure, though it can be a normal finding in children
and young adults . An S3 in an older adult is a hallmark of elevated ventricular filling pressures
and systolic heart failure. Aortic stenosis produces a systolic ejection murmur, and hypertrophic
cardiomyopathy typically causes a systolic murmur that increases with Valsalva. Mitral
regurgitation is a holosystolic murmur .
Q3. A 55-year-old male with a history of prior myocardial infarction presents with a diastolic
decrescendo murmur best heard at the left upper sternal border. The murmur is most
consistent with:
A) Aortic stenosis
B) Aortic regurgitation
C) Mitral stenosis
D) Pulmonic stenosis
Answer: B – Aortic regurgitation
Rationale: Aortic regurgitation produces an early decrescendo diastolic murmur best
auscultated at the second left intercostal space (left upper sternal border) with the patient
leaning forward and breath held in expiration . This is the classic location for aortic
regurgitation; the right upper sternal border is an alternative site. Aortic stenosis is a systolic
murmur. Mitral stenosis produces a diastolic rumble. Pulmonic stenosis produces a systolic
ejection murmur .
Q4. A 70-year-old male with known systolic heart failure (EF 30%) presents with worsening
dyspnea and a new S3 gallop. He is currently on lisinopril, metoprolol succinate, and
furosemide. Which medication is most likely to reduce mortality and should be initiated next?
A) Spironolactone
B) Hydralazine/isosorbide dinitrate
C) Digoxin
D) Amiodarone
Answer: A – Spironolactone
Rationale: In patients with NYHA class II-IV heart failure with reduced ejection fraction (HFrEF),
spironolactone (or eplerenone) reduces mortality . Hydralazine/isosorbide dinitrate is indicated
primarily in African American patients with persistent symptoms despite optimal therapy.
,Digoxin reduces hospitalizations but not mortality. Amiodarone has no mortality benefit and has
significant toxicity .
Q5. A 62-year-old woman with a history of hypertension and diabetes presents with substernal
chest pressure when walking two blocks, relieved with rest. ECG shows no ST changes. What is
the most appropriate initial diagnostic test?
A) Coronary angiography
B) Exercise stress test
C) CT angiography
D) Resting echocardiogram
Answer: B – Exercise stress test
Rationale: Stable angina symptoms warrant stress testing to assess for inducible ischemia .
Exercise ECG is first-line if the patient can exercise and baseline ECG is normal. Coronary
angiography is reserved for high-risk features or positive stress test. CT angiography is an
alternative but not first-line for typical stable angina .
Q6. A patient presents with acute onset of tearing chest pain radiating to the back, pulse 110,
BP 160/90 in right arm, 100/70 in left arm. Which vascular structure is most likely involved?
A) Ascending aorta
B) Descending aorta
C) Pulmonary artery
D) Coronary artery
Answer: B – Descending aorta
Rationale: The blood pressure differential between arms suggests involvement of the aortic
arch or descending aorta . Type B dissections (descending aorta) often present with pulse
deficits and blood pressure differences between arms. Ascending aortic dissections (Type A)
more commonly present with aortic regurgitation, pericardial effusion, or myocardial ischemia .
Q7. A 55-year-old patient is found to have a blood pressure of 210/120 mmHg but reports no
symptoms. He has no evidence of end-organ damage on exam or lab work. Which of the
following is the most appropriate initial management?
, A) Hospital admission for IV nitroprusside
B) Oral nifedipine
C) Oral antihypertensive therapy with close outpatient follow-up
D) IV labetalol immediately
Answer: C – Oral antihypertensive therapy with close outpatient follow-up
Rationale: Asymptomatic severe hypertension (hypertensive urgency) is defined by severely
elevated BP without acute end-organ damage . These patients can be managed in an outpatient
setting with oral antihypertensives; rapid reduction in BP is not needed and may be harmful.
Hospital admission is reserved for hypertensive emergencies where IV agents are required .
Q8. A patient presents with substernal chest pain that began 2 hours ago. ECG shows ST-
segment elevation in leads II, III, and aVF. Blood pressure is 90/60 mmHg, heart rate is 45 beats
per minute. The most likely occluded artery is the:
A) Left anterior descending artery
B) Right coronary artery
C) Left circumflex artery
D) Posterior descending artery
Answer: B – Right coronary artery
Rationale: ST-segment elevations in leads II, III, and aVF indicate an inferior wall myocardial
infarction . The right coronary artery supplies the inferior wall in most individuals. The RCA also
supplies the SA node in 60% of individuals and the AV node in 80-90%; thus, inferior MIs
frequently cause bradycardias and AV blocks. The LAD produces anterior MIs (V1-V4) .
Q9. A patient with new-onset acute pericarditis is most likely to exhibit which ECG finding?
A) Diffuse ST-segment elevation with PR segment depression
B) Q waves in leads II, III, and aVF
C) Deep, symmetric T-wave inversions
D) Prolonged QT interval
Answer: A – Diffuse ST-segment elevation with PR segment depression
Rationale: Acute pericarditis classically shows diffuse concave ST-segment elevation in most
leads (except aVR and V1) along with PR-segment depression . Q waves suggest prior MI. Deep
