COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2 FORM 112 COMPLETE PRACTICE EXAM QUESTIONS AND
ANSWERS | VERIFIED SOLUTIONS | UPDATED 2026/2027 STUDY GUIDE
Examiner/Administrator: National Board of Osteopathic Medical Examiners
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPREHENSIVE OSTEOPATHIC
MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2
FORM 112
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME || ALIGNED WITH CURRENT OSTEOPATHIC MEDICAL LICENSING BLUEPRINTS ||
CLINICAL SCIENCES || OSTEOPATHIC PRINCIPLES & PRACTICE || COMPREHENSIVE
CLINICAL DECISION-MAKING || 100% VERIFIED STUDY RESOURCE || PROFESSIONAL
MEDICAL EXAM PREPARATION || UPDATED FOR 2026/2027 EXAM CONTENT OUTLINES
|| PREPARED FOR OSTEOPATHIC LICENSING & BOARD REVIEW || PROFESSIONAL
ACADEMIC EXAMINATION USE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
OFFICIAL PRACTICE RESOURCE
PREPARED FOR ADVANCED OSTEOPATHIC REVIEW
CLINICAL APPLICATION • DIAGNOSTICS
ETHICS • OMM • PATIENT MANAGEMENT
,━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine, Emergency Medicine & Clinical Decision-Making
Q1. A 67-year-old man presents to the emergency department with acute crushing
substernal chest pain radiating to his left arm. Electrocardiography demonstrates ST-
segment elevations in leads II, III, and aVF. Shortly after arrival, he becomes
hypotensive with clear lung fields and elevated jugular venous pressure. Which
additional infarction is most likely responsible for his hemodynamic instability?
A. Left ventricular anterior wall infarction
B. Right ventricular infarction
C. Septal infarction
D. Posterolateral infarction
Correct Answer: 🔴 B. Right ventricular infarction
Explanation: 🔹 Inferior myocardial infarctions involving the right coronary artery may
extend into the right ventricle. Patients classically develop hypotension, elevated jugular
venous pressure, and clear lung fields due to impaired right ventricular filling and
reduced preload to the left ventricle. Anterior wall infarctions usually produce pulmonary
edema rather than clear lungs. Septal infarctions commonly lead to conduction
abnormalities, while posterolateral infarctions do not classically produce this preload-
dependent shock pattern. Recognition is important because nitrates can significantly
worsen hypotension in right ventricular infarction.
Q2. A 42-year-old woman presents with progressive fatigue, pruritus, and right upper
quadrant discomfort. Laboratory studies show elevated alkaline phosphatase and
positive antimitochondrial antibodies. Which condition is most strongly associated
with this patient's diagnosis?
A. Ulcerative colitis
B. Sjögren syndrome
C. Hemochromatosis
D. Alpha-1 antitrypsin deficiency
Correct Answer: 🔴 B. Sjögren syndrome
,Explanation: 🔹 This patient has primary biliary cholangitis, an autoimmune destruction
of intrahepatic bile ducts commonly affecting middle-aged women. It is strongly
associated with other autoimmune diseases, particularly Sjögren syndrome, systemic
sclerosis, and autoimmune thyroid disease. Ulcerative colitis is more strongly associated
with primary sclerosing cholangitis. Hemochromatosis and alpha-1 antitrypsin deficiency
cause different patterns of chronic liver disease.
Q3. A 29-year-old man presents with fever, productive cough, and pleuritic chest pain.
Chest radiography reveals right lower lobe consolidation. Gram stain demonstrates
gram-positive diplococci. Which virulence factor most contributes to the organism’s
pathogenicity?
A. Protein A
B. Polysaccharide capsule
C. Endotoxin lipid A
D. M protein
Correct Answer: 🔴 B. Polysaccharide capsule
Explanation: 🔹 Streptococcus pneumoniae is the most likely pathogen. Its
polysaccharide capsule inhibits phagocytosis and is the primary virulence factor
responsible for invasive disease. Protein A is associated with Staphylococcus aureus, M
protein with Streptococcus pyogenes, and lipid A with gram-negative bacteria.
Pneumococcal vaccines target capsular antigens because of their central role in
virulence.
Q4. A hospitalized patient develops sudden onset dyspnea, pleuritic chest pain, and
tachycardia 4 days after hip replacement surgery. Arterial blood gas reveals respiratory
alkalosis. Which physiologic change is most likely present?
A. Increased pulmonary capillary wedge pressure
B. Decreased alveolar dead space
C. Increased ventilation-perfusion mismatch
D. Decreased pulmonary vascular resistance
, Correct Answer: 🔴 C. Increased ventilation-perfusion mismatch
Explanation: 🔹 This patient likely has a pulmonary embolism. Emboli obstruct perfusion
to ventilated alveoli, increasing dead space and causing ventilation-perfusion mismatch.
Hyperventilation produces respiratory alkalosis early in the disease process. Pulmonary
vascular resistance rises rather than falls, and pulmonary capillary wedge pressure is
usually normal unless massive embolism causes cardiac compromise.
Q5. A 58-year-old woman with longstanding diabetes mellitus presents with
nephrotic-range proteinuria. Renal biopsy demonstrates nodular glomerulosclerosis.
Which mechanism most directly contributes to this pathology?
A. Immune complex deposition
B. Nonenzymatic glycosylation of basement membranes
C. Amyloid deposition
D. ANCA-mediated vasculitis
Correct Answer: 🔴 B. Nonenzymatic glycosylation of basement membranes
Explanation: 🔹 Diabetic nephropathy results from chronic hyperglycemia causing
nonenzymatic glycosylation of proteins within glomerular basement membranes. This
leads to mesangial expansion and Kimmelstiel-Wilson nodules. Immune complexes are
more characteristic of lupus nephritis, amyloid deposition produces Congo red-positive
fibrils, and ANCA vasculitis causes rapidly progressive glomerulonephritis.
Q6. A 34-year-old woman presents with episodic palpitations, diaphoresis, and
headaches. Blood pressure is persistently elevated. Plasma metanephrines are
elevated. Which embryologic structure gives rise to the tumor responsible for this
condition?
A. Neural crest cells
B. Mesodermal somites
C. Endodermal pharyngeal pouches
D. Intermediate mesoderm
Correct Answer: 🔴 A. Neural crest cells
(COMSAE) PHASE 2 FORM 112 COMPLETE PRACTICE EXAM QUESTIONS AND
ANSWERS | VERIFIED SOLUTIONS | UPDATED 2026/2027 STUDY GUIDE
Examiner/Administrator: National Board of Osteopathic Medical Examiners
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPREHENSIVE OSTEOPATHIC
MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2
FORM 112
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME || ALIGNED WITH CURRENT OSTEOPATHIC MEDICAL LICENSING BLUEPRINTS ||
CLINICAL SCIENCES || OSTEOPATHIC PRINCIPLES & PRACTICE || COMPREHENSIVE
CLINICAL DECISION-MAKING || 100% VERIFIED STUDY RESOURCE || PROFESSIONAL
MEDICAL EXAM PREPARATION || UPDATED FOR 2026/2027 EXAM CONTENT OUTLINES
|| PREPARED FOR OSTEOPATHIC LICENSING & BOARD REVIEW || PROFESSIONAL
ACADEMIC EXAMINATION USE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
OFFICIAL PRACTICE RESOURCE
PREPARED FOR ADVANCED OSTEOPATHIC REVIEW
CLINICAL APPLICATION • DIAGNOSTICS
ETHICS • OMM • PATIENT MANAGEMENT
,━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine, Emergency Medicine & Clinical Decision-Making
Q1. A 67-year-old man presents to the emergency department with acute crushing
substernal chest pain radiating to his left arm. Electrocardiography demonstrates ST-
segment elevations in leads II, III, and aVF. Shortly after arrival, he becomes
hypotensive with clear lung fields and elevated jugular venous pressure. Which
additional infarction is most likely responsible for his hemodynamic instability?
A. Left ventricular anterior wall infarction
B. Right ventricular infarction
C. Septal infarction
D. Posterolateral infarction
Correct Answer: 🔴 B. Right ventricular infarction
Explanation: 🔹 Inferior myocardial infarctions involving the right coronary artery may
extend into the right ventricle. Patients classically develop hypotension, elevated jugular
venous pressure, and clear lung fields due to impaired right ventricular filling and
reduced preload to the left ventricle. Anterior wall infarctions usually produce pulmonary
edema rather than clear lungs. Septal infarctions commonly lead to conduction
abnormalities, while posterolateral infarctions do not classically produce this preload-
dependent shock pattern. Recognition is important because nitrates can significantly
worsen hypotension in right ventricular infarction.
Q2. A 42-year-old woman presents with progressive fatigue, pruritus, and right upper
quadrant discomfort. Laboratory studies show elevated alkaline phosphatase and
positive antimitochondrial antibodies. Which condition is most strongly associated
with this patient's diagnosis?
A. Ulcerative colitis
B. Sjögren syndrome
C. Hemochromatosis
D. Alpha-1 antitrypsin deficiency
Correct Answer: 🔴 B. Sjögren syndrome
,Explanation: 🔹 This patient has primary biliary cholangitis, an autoimmune destruction
of intrahepatic bile ducts commonly affecting middle-aged women. It is strongly
associated with other autoimmune diseases, particularly Sjögren syndrome, systemic
sclerosis, and autoimmune thyroid disease. Ulcerative colitis is more strongly associated
with primary sclerosing cholangitis. Hemochromatosis and alpha-1 antitrypsin deficiency
cause different patterns of chronic liver disease.
Q3. A 29-year-old man presents with fever, productive cough, and pleuritic chest pain.
Chest radiography reveals right lower lobe consolidation. Gram stain demonstrates
gram-positive diplococci. Which virulence factor most contributes to the organism’s
pathogenicity?
A. Protein A
B. Polysaccharide capsule
C. Endotoxin lipid A
D. M protein
Correct Answer: 🔴 B. Polysaccharide capsule
Explanation: 🔹 Streptococcus pneumoniae is the most likely pathogen. Its
polysaccharide capsule inhibits phagocytosis and is the primary virulence factor
responsible for invasive disease. Protein A is associated with Staphylococcus aureus, M
protein with Streptococcus pyogenes, and lipid A with gram-negative bacteria.
Pneumococcal vaccines target capsular antigens because of their central role in
virulence.
Q4. A hospitalized patient develops sudden onset dyspnea, pleuritic chest pain, and
tachycardia 4 days after hip replacement surgery. Arterial blood gas reveals respiratory
alkalosis. Which physiologic change is most likely present?
A. Increased pulmonary capillary wedge pressure
B. Decreased alveolar dead space
C. Increased ventilation-perfusion mismatch
D. Decreased pulmonary vascular resistance
, Correct Answer: 🔴 C. Increased ventilation-perfusion mismatch
Explanation: 🔹 This patient likely has a pulmonary embolism. Emboli obstruct perfusion
to ventilated alveoli, increasing dead space and causing ventilation-perfusion mismatch.
Hyperventilation produces respiratory alkalosis early in the disease process. Pulmonary
vascular resistance rises rather than falls, and pulmonary capillary wedge pressure is
usually normal unless massive embolism causes cardiac compromise.
Q5. A 58-year-old woman with longstanding diabetes mellitus presents with
nephrotic-range proteinuria. Renal biopsy demonstrates nodular glomerulosclerosis.
Which mechanism most directly contributes to this pathology?
A. Immune complex deposition
B. Nonenzymatic glycosylation of basement membranes
C. Amyloid deposition
D. ANCA-mediated vasculitis
Correct Answer: 🔴 B. Nonenzymatic glycosylation of basement membranes
Explanation: 🔹 Diabetic nephropathy results from chronic hyperglycemia causing
nonenzymatic glycosylation of proteins within glomerular basement membranes. This
leads to mesangial expansion and Kimmelstiel-Wilson nodules. Immune complexes are
more characteristic of lupus nephritis, amyloid deposition produces Congo red-positive
fibrils, and ANCA vasculitis causes rapidly progressive glomerulonephritis.
Q6. A 34-year-old woman presents with episodic palpitations, diaphoresis, and
headaches. Blood pressure is persistently elevated. Plasma metanephrines are
elevated. Which embryologic structure gives rise to the tumor responsible for this
condition?
A. Neural crest cells
B. Mesodermal somites
C. Endodermal pharyngeal pouches
D. Intermediate mesoderm
Correct Answer: 🔴 A. Neural crest cells
