COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2 – FORM 109 COMPLETE PRACTICE EXAM QUESTIONS AND
ANSWERS | VERIFIED SOLUTIONS | UPDATED 2026/2027 STUDY GUIDE
Examiner/Administrator: National Board of Osteopathic Medical Examiners (NBOME)
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPREHENSIVE OSTEOPATHIC
MEDICAL SELF-ASSESSMENT EXAMINATION
COMSAE PHASE 2 – FORM 109
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 180 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-INSPIRED OSTEOPATHIC MEDICAL COMPETENCY ASSESSMENT || ALIGNED
WITH CURRENT COMLEX-USA BLUEPRINTS || CLINICAL DECISION-MAKING ||
OSTEOPATHIC PRINCIPLES & PRACTICE || PATIENT MANAGEMENT INTEGRATION ||
100% ORIGINAL VERIFIED STUDY CONTENT || COMPREHENSIVE BOARD PREPARATION
RESOURCE || PREPARED FOR PHASE 2 COGNITIVE EVALUATION || PROFESSIONAL
EXAMINATION USE ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Questions 1–8 → Internal Medicine & Clinical Decision-Making
Q1. A 67-year-old man presents with progressive exertional dyspnea, bilateral lower-
extremity edema, and orthopnea over the past 3 months. Examination reveals elevated
,jugular venous pressure, bibasilar crackles, and an S3 gallop. Echocardiography
demonstrates an ejection fraction of 30%. Which medication has been shown to
reduce mortality in this patient population?
A. Furosemide
B. Digoxin
C. Enalapril
D. Hydrochlorothiazide
Correct Answer: 🔴 C. Enalapril
Explanation: 🔹 ACE inhibitors such as enalapril are foundational therapies for heart
failure with reduced ejection fraction (HFrEF) because they decrease afterload, reduce
maladaptive ventricular remodeling, and significantly reduce mortality. Furosemide
improves symptoms but has not demonstrated mortality benefit. Digoxin may improve
symptoms and reduce hospitalizations but does not reduce mortality.
Hydrochlorothiazide is less effective in symptomatic HFrEF and lacks mortality data. The
patient demonstrates classic systolic heart failure findings requiring guideline-directed
medical therapy.
Q2. A 29-year-old woman presents with fatigue, heat intolerance, palpitations, and
unintentional weight loss. Examination shows a diffuse goiter and fine tremor.
Laboratory studies reveal suppressed TSH and elevated free T4. Which additional
finding is most consistent with the underlying diagnosis?
A. Delayed relaxation phase of deep tendon reflexes
B. Hypercholesterolemia
C. Pretibial myxedema
D. Bradycardia
Correct Answer: 🔴 C. Pretibial myxedema
Explanation: 🔹 The patient most likely has Graves disease, an autoimmune cause of
hyperthyroidism characterized by thyroid-stimulating immunoglobulins. Pretibial
myxedema is a classic extrathyroidal manifestation caused by glycosaminoglycan
deposition. Delayed reflex relaxation, hypercholesterolemia, and bradycardia are
,associated with hypothyroidism rather than hyperthyroidism. Graves disease often also
presents with ophthalmopathy and diffuse goiter.
Q3. A 58-year-old man with a history of chronic alcohol use presents with confusion,
ophthalmoplegia, and gait instability. Which vitamin deficiency is most likely
responsible?
A. Pyridoxine
B. Thiamine
C. Cyanocobalamin
D. Riboflavin
Correct Answer: 🔴 B. Thiamine
Explanation: 🔹 The triad of confusion, ophthalmoplegia, and ataxia indicates Wernicke
encephalopathy caused by thiamine deficiency. Chronic alcohol use impairs thiamine
absorption and utilization. Prompt administration of thiamine before glucose is essential
to prevent progression to Korsakoff syndrome. Pyridoxine deficiency commonly causes
neuropathy, cyanocobalamin deficiency causes subacute combined degeneration, and
riboflavin deficiency causes cheilosis and glossitis.
Q4. A hospitalized patient develops fever and diarrhea after completing a course of
clindamycin for aspiration pneumonia. Stool testing is positive for toxin-producing
bacteria. Which organism is the most likely cause?
A. Escherichia coli O157:H7
B. Clostridioides difficile
C. Campylobacter jejuni
D. Vibrio cholerae
Correct Answer: 🔴 B. Clostridioides difficile
Explanation: 🔹 Clostridioides difficile infection commonly occurs following antibiotic
exposure, particularly clindamycin, fluoroquinolones, and cephalosporins. Symptoms
include watery diarrhea, abdominal pain, and fever. The organism produces toxins
causing pseudomembranous colitis. E. coli O157:H7 causes hemorrhagic colitis,
, Campylobacter commonly causes inflammatory diarrhea after poultry exposure, and
Vibrio cholerae causes profuse rice-water diarrhea.
Q5. A 72-year-old woman presents with sudden onset right-sided weakness and
aphasia lasting 45 minutes that completely resolves. MRI reveals no infarction. Which
diagnosis is most appropriate?
A. Lacunar infarct
B. Transient ischemic attack
C. Intracerebral hemorrhage
D. Focal seizure disorder
Correct Answer: 🔴 B. Transient ischemic attack
Explanation: 🔹 A transient ischemic attack (TIA) involves temporary neurologic
dysfunction caused by focal cerebral ischemia without evidence of acute infarction.
Symptoms typically resolve within 24 hours, often within minutes. TIAs are important
predictors of future stroke risk and require urgent secondary prevention measures.
Intracerebral hemorrhage would not resolve so rapidly and usually demonstrates
imaging abnormalities.
Q6. A 44-year-old man presents with episodic wheezing, chest tightness, and nocturnal
cough. Spirometry demonstrates reversible airflow obstruction following
bronchodilator administration. Which pathophysiologic process primarily underlies this
disease?
A. Destruction of alveolar septa
B. Fixed bronchial fibrosis
C. Chronic airway inflammation and hyperresponsiveness
D. Loss of pulmonary vascular compliance
Correct Answer: 🔴 C. Chronic airway inflammation and hyperresponsiveness
Explanation: 🔹 Asthma is characterized by chronic inflammatory airway disease leading
to bronchial hyperresponsiveness and reversible airflow obstruction. Inflammatory
mediators contribute to mucus production, edema, and smooth muscle constriction.
(COMSAE) PHASE 2 – FORM 109 COMPLETE PRACTICE EXAM QUESTIONS AND
ANSWERS | VERIFIED SOLUTIONS | UPDATED 2026/2027 STUDY GUIDE
Examiner/Administrator: National Board of Osteopathic Medical Examiners (NBOME)
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPREHENSIVE OSTEOPATHIC
MEDICAL SELF-ASSESSMENT EXAMINATION
COMSAE PHASE 2 – FORM 109
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 180 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-INSPIRED OSTEOPATHIC MEDICAL COMPETENCY ASSESSMENT || ALIGNED
WITH CURRENT COMLEX-USA BLUEPRINTS || CLINICAL DECISION-MAKING ||
OSTEOPATHIC PRINCIPLES & PRACTICE || PATIENT MANAGEMENT INTEGRATION ||
100% ORIGINAL VERIFIED STUDY CONTENT || COMPREHENSIVE BOARD PREPARATION
RESOURCE || PREPARED FOR PHASE 2 COGNITIVE EVALUATION || PROFESSIONAL
EXAMINATION USE ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Questions 1–8 → Internal Medicine & Clinical Decision-Making
Q1. A 67-year-old man presents with progressive exertional dyspnea, bilateral lower-
extremity edema, and orthopnea over the past 3 months. Examination reveals elevated
,jugular venous pressure, bibasilar crackles, and an S3 gallop. Echocardiography
demonstrates an ejection fraction of 30%. Which medication has been shown to
reduce mortality in this patient population?
A. Furosemide
B. Digoxin
C. Enalapril
D. Hydrochlorothiazide
Correct Answer: 🔴 C. Enalapril
Explanation: 🔹 ACE inhibitors such as enalapril are foundational therapies for heart
failure with reduced ejection fraction (HFrEF) because they decrease afterload, reduce
maladaptive ventricular remodeling, and significantly reduce mortality. Furosemide
improves symptoms but has not demonstrated mortality benefit. Digoxin may improve
symptoms and reduce hospitalizations but does not reduce mortality.
Hydrochlorothiazide is less effective in symptomatic HFrEF and lacks mortality data. The
patient demonstrates classic systolic heart failure findings requiring guideline-directed
medical therapy.
Q2. A 29-year-old woman presents with fatigue, heat intolerance, palpitations, and
unintentional weight loss. Examination shows a diffuse goiter and fine tremor.
Laboratory studies reveal suppressed TSH and elevated free T4. Which additional
finding is most consistent with the underlying diagnosis?
A. Delayed relaxation phase of deep tendon reflexes
B. Hypercholesterolemia
C. Pretibial myxedema
D. Bradycardia
Correct Answer: 🔴 C. Pretibial myxedema
Explanation: 🔹 The patient most likely has Graves disease, an autoimmune cause of
hyperthyroidism characterized by thyroid-stimulating immunoglobulins. Pretibial
myxedema is a classic extrathyroidal manifestation caused by glycosaminoglycan
deposition. Delayed reflex relaxation, hypercholesterolemia, and bradycardia are
,associated with hypothyroidism rather than hyperthyroidism. Graves disease often also
presents with ophthalmopathy and diffuse goiter.
Q3. A 58-year-old man with a history of chronic alcohol use presents with confusion,
ophthalmoplegia, and gait instability. Which vitamin deficiency is most likely
responsible?
A. Pyridoxine
B. Thiamine
C. Cyanocobalamin
D. Riboflavin
Correct Answer: 🔴 B. Thiamine
Explanation: 🔹 The triad of confusion, ophthalmoplegia, and ataxia indicates Wernicke
encephalopathy caused by thiamine deficiency. Chronic alcohol use impairs thiamine
absorption and utilization. Prompt administration of thiamine before glucose is essential
to prevent progression to Korsakoff syndrome. Pyridoxine deficiency commonly causes
neuropathy, cyanocobalamin deficiency causes subacute combined degeneration, and
riboflavin deficiency causes cheilosis and glossitis.
Q4. A hospitalized patient develops fever and diarrhea after completing a course of
clindamycin for aspiration pneumonia. Stool testing is positive for toxin-producing
bacteria. Which organism is the most likely cause?
A. Escherichia coli O157:H7
B. Clostridioides difficile
C. Campylobacter jejuni
D. Vibrio cholerae
Correct Answer: 🔴 B. Clostridioides difficile
Explanation: 🔹 Clostridioides difficile infection commonly occurs following antibiotic
exposure, particularly clindamycin, fluoroquinolones, and cephalosporins. Symptoms
include watery diarrhea, abdominal pain, and fever. The organism produces toxins
causing pseudomembranous colitis. E. coli O157:H7 causes hemorrhagic colitis,
, Campylobacter commonly causes inflammatory diarrhea after poultry exposure, and
Vibrio cholerae causes profuse rice-water diarrhea.
Q5. A 72-year-old woman presents with sudden onset right-sided weakness and
aphasia lasting 45 minutes that completely resolves. MRI reveals no infarction. Which
diagnosis is most appropriate?
A. Lacunar infarct
B. Transient ischemic attack
C. Intracerebral hemorrhage
D. Focal seizure disorder
Correct Answer: 🔴 B. Transient ischemic attack
Explanation: 🔹 A transient ischemic attack (TIA) involves temporary neurologic
dysfunction caused by focal cerebral ischemia without evidence of acute infarction.
Symptoms typically resolve within 24 hours, often within minutes. TIAs are important
predictors of future stroke risk and require urgent secondary prevention measures.
Intracerebral hemorrhage would not resolve so rapidly and usually demonstrates
imaging abnormalities.
Q6. A 44-year-old man presents with episodic wheezing, chest tightness, and nocturnal
cough. Spirometry demonstrates reversible airflow obstruction following
bronchodilator administration. Which pathophysiologic process primarily underlies this
disease?
A. Destruction of alveolar septa
B. Fixed bronchial fibrosis
C. Chronic airway inflammation and hyperresponsiveness
D. Loss of pulmonary vascular compliance
Correct Answer: 🔴 C. Chronic airway inflammation and hyperresponsiveness
Explanation: 🔹 Asthma is characterized by chronic inflammatory airway disease leading
to bronchial hyperresponsiveness and reversible airflow obstruction. Inflammatory
mediators contribute to mucus production, edema, and smooth muscle constriction.
