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NBOME COMSAE Overview – The Complete 176
Question Test Bank All questions with correct verified
answers & detailed rationales – graded A+ for the
newest 2026 actual exam
Question 1
A 68-year-old man with a history of hypertension and diabetes presents with
substernal chest pressure that radiates to his left arm. He is diaphoretic and
nauseous. An ECG shows ST-segment elevation in leads V1-V4. What is the most
appropriate immediate management?
A. Administer oral aspirin and sublingual nitroglycerin and monitor.
B. Perform a bedside echocardiogram to assess wall motion.
C. Wait for cardiac enzyme results before starting treatment.
D. Initiate immediate reperfusion therapy (PCI or fibrinolysis).
<details> <summary>Click for Answer & Rationale</summary>
: Correct Answer : D. Initiate immediate reperfusion therapy (PCI or
fibrinolysis).
Rationale: The patient is presenting with an ST-Segment Elevation Myocardial
Infarction (STEMI), a medical emergency caused by complete occlusion of a
coronary artery. Time is muscle; therefore, the priority is to restore blood flow to
the affected area of the heart. This is done via emergent percutaneous coronary
intervention (PCI) or, if PCI is not available in a timely manner, with fibrinolytics.
• Why the other options are wrong:
o A. Aspirin and nitroglycerin are adjunctive treatments that should be
given, but the priority is still urgent reperfusion.
o B. Bedside echocardiogram could delay definitive care and is not
necessary for immediate decision-making.
pg. 1
,2
o C. Waiting for cardiac enzymes would delay reperfusion therapy,
increasing the amount of myocardium that is irreversibly damaged.
</details>
Question 2
A 55-year-old man with a history of chronic heavy alcohol use presents with
confusion, ataxia, and nystagmus. Which vitamin deficiency is the most likely
cause of this triad?
A. Vitamin B3 (Niacin)
B. Vitamin B12 (Cobalamin)
C. Vitamin B1 (Thiamine)
D. Vitamin B9 (Folate)
<details> <summary>Click for Answer & Rationale</summary>
: Correct Answer : C. Vitamin B1 (Thiamine)
Rationale: This classic triad of symptoms—ophthalmoplegia, ataxia, and
confusion—is characteristic of Wernicke’s encephalopathy. This neurologic
emergency is caused by a severe deficiency in thiamine (vitamin B1) and is most
commonly seen in patients with chronic alcohol use disorder due to poor
nutrition and impaired absorption.
• Why the other options are wrong:
o A. Niacin deficiency causes pellagra, which presents with the three
Ds: dermatitis, diarrhea, and dementia.
o B. Vitamin B12 deficiency can cause subacute combined
degeneration of the spinal cord, leading to neuropathy and cognitive
changes, but not the acute triad of Wernicke's encephalopathy.
o D. Folate deficiency classically presents with macrocytic anemia.
</details>
pg. 2
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Question 3
A 23-year-old woman presents with a sudden-onset, severe headache, stiff neck,
and photophobia. Her temperature is 39.4°C (103°F). A lumbar puncture reveals
cloudy CSF with a low glucose level, a high protein level, and a predominance of
neutrophils. What is the most likely diagnosis?
A. Viral Meningitis
B. Bacterial Meningitis
C. Fungal Meningitis
D. Subarachnoid Hemorrhage
<details> <summary>Click for Answer & Rationale</summary>
: Correct Answer : B. Bacterial Meningitis
Rationale: The patient’s presentation (fever, stiff neck, photophobia) with CSF
findings of a low glucose, elevated protein, and a neutrophilic pleocytosis are
hallmarks of acute bacterial meningitis. This is a medical emergency requiring
prompt antibiotic therapy.
• Why the other options are wrong:
o A. Viral meningitis typically has a self-limited course, and the CSF
analysis would more likely show a lymphocytic predominance with
normal or mildly elevated protein and normal glucose.
o C. Fungal meningitis is usually a subacute or chronic presentation,
common in immunocompromised patients. CSF would also show a
lymphocytic predominance.
o D. Subarachnoid hemorrhage typically presents with a “thunderclap”
headache, often without fever. The CSF would be bloody or
xanthochromic, not purulent.
</details>
Question 4
A 45-year-old male presents with a painless, raised, erythematous plaque on his
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chest that has slowly enlarged over several years. The plaque has a “stuck-on”
appearance with a waxy, scaly surface. What is the most likely diagnosis?
A. Seborrheic Keratosis
B. Basal Cell Carcinoma
C. Psoriasis
D. Squamous Cell Carcinoma
<details> <summary>Click for Answer & Rationale</summary>
: Correct Answer : A. Seborrheic Keratosis
Rationale: The description of a slowly enlarging, painless, waxy, “stuck-on” plaque
is classic for a seborrheic keratosis. These are common, benign skin growths that
often appear in middle-aged and older adults.
• Why the other options are wrong:
o B. Basal cell carcinoma is also slow-growing but often presents as a
pearly papule with telangiectasias, not with a waxy, “stuck-on”
appearance.
o C. Psoriasis presents as well-demarcated, erythematous plaques with
a thick, silvery scale, not a waxy, “stuck-on” appearance.
o D. Squamous cell carcinoma is often more indurated, ulcerated, and
faster-growing.
</details>
Question 5
Which of the following describes the Correct Alignment of the Naming
Convention for a Sacral Torsion?
A. The side of the sacral base rotation is named first, and the side of the oblique
axis is named second.
B. The side of the oblique axis is named first, and the side of the sacral base
rotation is named second.
C. The side of the deep sulcus is named first.
D. The side of the shallow sulcus is named first.
pg. 4
NBOME COMSAE Overview – The Complete 176
Question Test Bank All questions with correct verified
answers & detailed rationales – graded A+ for the
newest 2026 actual exam
Question 1
A 68-year-old man with a history of hypertension and diabetes presents with
substernal chest pressure that radiates to his left arm. He is diaphoretic and
nauseous. An ECG shows ST-segment elevation in leads V1-V4. What is the most
appropriate immediate management?
A. Administer oral aspirin and sublingual nitroglycerin and monitor.
B. Perform a bedside echocardiogram to assess wall motion.
C. Wait for cardiac enzyme results before starting treatment.
D. Initiate immediate reperfusion therapy (PCI or fibrinolysis).
<details> <summary>Click for Answer & Rationale</summary>
: Correct Answer : D. Initiate immediate reperfusion therapy (PCI or
fibrinolysis).
Rationale: The patient is presenting with an ST-Segment Elevation Myocardial
Infarction (STEMI), a medical emergency caused by complete occlusion of a
coronary artery. Time is muscle; therefore, the priority is to restore blood flow to
the affected area of the heart. This is done via emergent percutaneous coronary
intervention (PCI) or, if PCI is not available in a timely manner, with fibrinolytics.
• Why the other options are wrong:
o A. Aspirin and nitroglycerin are adjunctive treatments that should be
given, but the priority is still urgent reperfusion.
o B. Bedside echocardiogram could delay definitive care and is not
necessary for immediate decision-making.
pg. 1
,2
o C. Waiting for cardiac enzymes would delay reperfusion therapy,
increasing the amount of myocardium that is irreversibly damaged.
</details>
Question 2
A 55-year-old man with a history of chronic heavy alcohol use presents with
confusion, ataxia, and nystagmus. Which vitamin deficiency is the most likely
cause of this triad?
A. Vitamin B3 (Niacin)
B. Vitamin B12 (Cobalamin)
C. Vitamin B1 (Thiamine)
D. Vitamin B9 (Folate)
<details> <summary>Click for Answer & Rationale</summary>
: Correct Answer : C. Vitamin B1 (Thiamine)
Rationale: This classic triad of symptoms—ophthalmoplegia, ataxia, and
confusion—is characteristic of Wernicke’s encephalopathy. This neurologic
emergency is caused by a severe deficiency in thiamine (vitamin B1) and is most
commonly seen in patients with chronic alcohol use disorder due to poor
nutrition and impaired absorption.
• Why the other options are wrong:
o A. Niacin deficiency causes pellagra, which presents with the three
Ds: dermatitis, diarrhea, and dementia.
o B. Vitamin B12 deficiency can cause subacute combined
degeneration of the spinal cord, leading to neuropathy and cognitive
changes, but not the acute triad of Wernicke's encephalopathy.
o D. Folate deficiency classically presents with macrocytic anemia.
</details>
pg. 2
,3
Question 3
A 23-year-old woman presents with a sudden-onset, severe headache, stiff neck,
and photophobia. Her temperature is 39.4°C (103°F). A lumbar puncture reveals
cloudy CSF with a low glucose level, a high protein level, and a predominance of
neutrophils. What is the most likely diagnosis?
A. Viral Meningitis
B. Bacterial Meningitis
C. Fungal Meningitis
D. Subarachnoid Hemorrhage
<details> <summary>Click for Answer & Rationale</summary>
: Correct Answer : B. Bacterial Meningitis
Rationale: The patient’s presentation (fever, stiff neck, photophobia) with CSF
findings of a low glucose, elevated protein, and a neutrophilic pleocytosis are
hallmarks of acute bacterial meningitis. This is a medical emergency requiring
prompt antibiotic therapy.
• Why the other options are wrong:
o A. Viral meningitis typically has a self-limited course, and the CSF
analysis would more likely show a lymphocytic predominance with
normal or mildly elevated protein and normal glucose.
o C. Fungal meningitis is usually a subacute or chronic presentation,
common in immunocompromised patients. CSF would also show a
lymphocytic predominance.
o D. Subarachnoid hemorrhage typically presents with a “thunderclap”
headache, often without fever. The CSF would be bloody or
xanthochromic, not purulent.
</details>
Question 4
A 45-year-old male presents with a painless, raised, erythematous plaque on his
pg. 3
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chest that has slowly enlarged over several years. The plaque has a “stuck-on”
appearance with a waxy, scaly surface. What is the most likely diagnosis?
A. Seborrheic Keratosis
B. Basal Cell Carcinoma
C. Psoriasis
D. Squamous Cell Carcinoma
<details> <summary>Click for Answer & Rationale</summary>
: Correct Answer : A. Seborrheic Keratosis
Rationale: The description of a slowly enlarging, painless, waxy, “stuck-on” plaque
is classic for a seborrheic keratosis. These are common, benign skin growths that
often appear in middle-aged and older adults.
• Why the other options are wrong:
o B. Basal cell carcinoma is also slow-growing but often presents as a
pearly papule with telangiectasias, not with a waxy, “stuck-on”
appearance.
o C. Psoriasis presents as well-demarcated, erythematous plaques with
a thick, silvery scale, not a waxy, “stuck-on” appearance.
o D. Squamous cell carcinoma is often more indurated, ulcerated, and
faster-growing.
</details>
Question 5
Which of the following describes the Correct Alignment of the Naming
Convention for a Sacral Torsion?
A. The side of the sacral base rotation is named first, and the side of the oblique
axis is named second.
B. The side of the oblique axis is named first, and the side of the sacral base
rotation is named second.
C. The side of the deep sulcus is named first.
D. The side of the shallow sulcus is named first.
pg. 4
