COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 3 FORM 105 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 3 – FORM 105
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-STYLE OSTEOPATHIC LICENSURE PREPARATION || ALIGNED WITH CURRENT
COMLEX-USA LEVEL 3 BLUEPRINTS || CLINICAL DECISION-MAKING & PATIENT
MANAGEMENT || OSTEOPATHIC PRINCIPLES & PRACTICE || PROFESSIONAL REVIEW
MATERIAL || UPDATED 2026/2027 EXAM CONTENT || 100% ORIGINAL EDUCATIONAL
PRACTICE QUESTIONS || COMPREHENSIVE PHYSICIAN ASSESSMENT PREPARATION ||
VERIFIED ACADEMIC FORMAT || PROFESSIONAL EXAMINATION USE ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Preventive Medicine
Q1. A 67-year-old man with a history of hypertension, hyperlipidemia, and type 2
diabetes mellitus presents with crushing substernal chest pain radiating to the left arm
,for 45 minutes. ECG demonstrates ST-segment elevations in leads II, III, and aVF. Blood
pressure is 84/56 mm Hg. Jugular venous distention is present, and the lungs are clear
to auscultation. Which of the following is the most appropriate immediate
management step?
A. Administer intravenous furosemide
B. Begin high-dose nitroglycerin infusion
C. Administer aggressive intravenous fluids
D. Initiate noninvasive positive pressure ventilation
Correct Answer: 🔴 C. Administer aggressive intravenous fluids
Explanation: 🔹 This patient has an inferior wall myocardial infarction with likely right
ventricular involvement, evidenced by hypotension, elevated jugular venous pressure,
and clear lung fields. Right ventricular infarctions are preload dependent; therefore,
aggressive intravenous fluid administration is the preferred initial intervention to
maintain cardiac output. Nitroglycerin and diuretics reduce preload and may worsen
hypotension. Noninvasive ventilation is unnecessary without pulmonary edema or
respiratory distress. Immediate reperfusion therapy is also indicated but fluid
resuscitation is the critical stabilization step in this presentation.
Q2. A 42-year-old woman presents with fatigue, pruritus, and progressive jaundice.
Laboratory studies reveal 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. Alpha-1 antitrypsin deficiency
D. Hemochromatosis
Correct Answer: 🔴 B. Sjögren syndrome
Explanation: 🔹 The patient most likely has primary biliary cholangitis (PBC),
characterized by cholestatic liver enzyme elevation and positive antimitochondrial
antibodies. PBC commonly occurs in middle-aged women and is associated with
autoimmune disorders, especially Sjögren syndrome, autoimmune thyroid disease, and
systemic sclerosis. Ulcerative colitis is more strongly associated with primary sclerosing
,cholangitis. Hemochromatosis and alpha-1 antitrypsin deficiency involve different
hepatic pathophysiologic mechanisms.
Q3. A hospitalized 73-year-old woman develops acute confusion, fluctuating attention,
and visual hallucinations 2 days after hip surgery. She repeatedly attempts to remove
her IV line. Which of the following is the most appropriate initial management?
A. Long-term benzodiazepine therapy
B. Immediate physical restraints
C. Identify and correct underlying causes
D. Electroconvulsive therapy
Correct Answer: 🔴 C. Identify and correct underlying causes
Explanation: 🔹 This patient has postoperative delirium, characterized by acute
fluctuating cognitive dysfunction and inattention. The cornerstone of management is
identification and treatment of precipitating causes such as infection, electrolyte
imbalance, pain, urinary retention, medication effects, or sleep deprivation. Physical
restraints should be avoided whenever possible because they may worsen agitation.
Benzodiazepines are generally reserved for alcohol or sedative withdrawal.
Electroconvulsive therapy is not indicated for delirium.
Q4. A 58-year-old man with cirrhosis presents with progressive abdominal distention
and dyspnea. Paracentesis demonstrates a serum-ascites albumin gradient (SAAG) of
1.5 g/dL. Which mechanism most directly contributed to the formation of this patient’s
ascites?
A. Decreased plasma oncotic pressure alone
B. Increased portal venous hydrostatic pressure
C. Peritoneal carcinomatosis
D. Pancreatic enzyme leakage into the peritoneum
Correct Answer: 🔴 B. Increased portal venous hydrostatic pressure
Explanation: 🔹 A SAAG ≥1.1 g/dL indicates portal hypertension as the primary
mechanism of ascites formation. In cirrhosis, elevated portal venous pressure increases
, hydrostatic pressure, promoting transudation of fluid into the peritoneal cavity. While
hypoalbuminemia contributes, portal hypertension is the dominant pathophysiologic
process. Low-SAAG ascites is more typical of malignancy, pancreatitis, or infection.
Q5. A 61-year-old woman with chronic kidney disease develops fatigue and worsening
exertional dyspnea. Laboratory studies show normocytic anemia with low reticulocyte
count. Which therapy most directly addresses the underlying mechanism?
A. Intravenous iron alone
B. Vitamin B12 replacement
C. Erythropoiesis-stimulating agent therapy
D. Emergent hemodialysis
Correct Answer: 🔴 C. Erythropoiesis-stimulating agent therapy
Explanation: 🔹 Chronic kidney disease causes decreased erythropoietin production by
renal peritubular interstitial cells, resulting in normocytic normochromic anemia.
Erythropoiesis-stimulating agents such as epoetin alfa directly address this mechanism.
Iron supplementation may be necessary if iron deficiency coexists but is not the primary
issue here. Vitamin B12 deficiency typically produces macrocytic anemia. Hemodialysis
does not correct the underlying erythropoietin deficiency.
Q6. A 34-year-old man presents with recurrent episodes of wheezing, cough, and
chest tightness that worsen at night. Spirometry demonstrates reversible airflow
obstruction after bronchodilator administration. Which inflammatory cell plays the
most central role in the pathogenesis of this condition?
A. Neutrophils
B. Eosinophils
C. Platelets
D. Basophils
Correct Answer: 🔴 B. Eosinophils
Explanation: 🔹 Asthma is characterized by chronic airway inflammation involving
eosinophils, mast cells, and Th2 lymphocytes. Eosinophilic inflammation contributes to
(COMSAE) PHASE 3 FORM 105 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 3 – FORM 105
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-STYLE OSTEOPATHIC LICENSURE PREPARATION || ALIGNED WITH CURRENT
COMLEX-USA LEVEL 3 BLUEPRINTS || CLINICAL DECISION-MAKING & PATIENT
MANAGEMENT || OSTEOPATHIC PRINCIPLES & PRACTICE || PROFESSIONAL REVIEW
MATERIAL || UPDATED 2026/2027 EXAM CONTENT || 100% ORIGINAL EDUCATIONAL
PRACTICE QUESTIONS || COMPREHENSIVE PHYSICIAN ASSESSMENT PREPARATION ||
VERIFIED ACADEMIC FORMAT || PROFESSIONAL EXAMINATION USE ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Preventive Medicine
Q1. A 67-year-old man with a history of hypertension, hyperlipidemia, and type 2
diabetes mellitus presents with crushing substernal chest pain radiating to the left arm
,for 45 minutes. ECG demonstrates ST-segment elevations in leads II, III, and aVF. Blood
pressure is 84/56 mm Hg. Jugular venous distention is present, and the lungs are clear
to auscultation. Which of the following is the most appropriate immediate
management step?
A. Administer intravenous furosemide
B. Begin high-dose nitroglycerin infusion
C. Administer aggressive intravenous fluids
D. Initiate noninvasive positive pressure ventilation
Correct Answer: 🔴 C. Administer aggressive intravenous fluids
Explanation: 🔹 This patient has an inferior wall myocardial infarction with likely right
ventricular involvement, evidenced by hypotension, elevated jugular venous pressure,
and clear lung fields. Right ventricular infarctions are preload dependent; therefore,
aggressive intravenous fluid administration is the preferred initial intervention to
maintain cardiac output. Nitroglycerin and diuretics reduce preload and may worsen
hypotension. Noninvasive ventilation is unnecessary without pulmonary edema or
respiratory distress. Immediate reperfusion therapy is also indicated but fluid
resuscitation is the critical stabilization step in this presentation.
Q2. A 42-year-old woman presents with fatigue, pruritus, and progressive jaundice.
Laboratory studies reveal 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. Alpha-1 antitrypsin deficiency
D. Hemochromatosis
Correct Answer: 🔴 B. Sjögren syndrome
Explanation: 🔹 The patient most likely has primary biliary cholangitis (PBC),
characterized by cholestatic liver enzyme elevation and positive antimitochondrial
antibodies. PBC commonly occurs in middle-aged women and is associated with
autoimmune disorders, especially Sjögren syndrome, autoimmune thyroid disease, and
systemic sclerosis. Ulcerative colitis is more strongly associated with primary sclerosing
,cholangitis. Hemochromatosis and alpha-1 antitrypsin deficiency involve different
hepatic pathophysiologic mechanisms.
Q3. A hospitalized 73-year-old woman develops acute confusion, fluctuating attention,
and visual hallucinations 2 days after hip surgery. She repeatedly attempts to remove
her IV line. Which of the following is the most appropriate initial management?
A. Long-term benzodiazepine therapy
B. Immediate physical restraints
C. Identify and correct underlying causes
D. Electroconvulsive therapy
Correct Answer: 🔴 C. Identify and correct underlying causes
Explanation: 🔹 This patient has postoperative delirium, characterized by acute
fluctuating cognitive dysfunction and inattention. The cornerstone of management is
identification and treatment of precipitating causes such as infection, electrolyte
imbalance, pain, urinary retention, medication effects, or sleep deprivation. Physical
restraints should be avoided whenever possible because they may worsen agitation.
Benzodiazepines are generally reserved for alcohol or sedative withdrawal.
Electroconvulsive therapy is not indicated for delirium.
Q4. A 58-year-old man with cirrhosis presents with progressive abdominal distention
and dyspnea. Paracentesis demonstrates a serum-ascites albumin gradient (SAAG) of
1.5 g/dL. Which mechanism most directly contributed to the formation of this patient’s
ascites?
A. Decreased plasma oncotic pressure alone
B. Increased portal venous hydrostatic pressure
C. Peritoneal carcinomatosis
D. Pancreatic enzyme leakage into the peritoneum
Correct Answer: 🔴 B. Increased portal venous hydrostatic pressure
Explanation: 🔹 A SAAG ≥1.1 g/dL indicates portal hypertension as the primary
mechanism of ascites formation. In cirrhosis, elevated portal venous pressure increases
, hydrostatic pressure, promoting transudation of fluid into the peritoneal cavity. While
hypoalbuminemia contributes, portal hypertension is the dominant pathophysiologic
process. Low-SAAG ascites is more typical of malignancy, pancreatitis, or infection.
Q5. A 61-year-old woman with chronic kidney disease develops fatigue and worsening
exertional dyspnea. Laboratory studies show normocytic anemia with low reticulocyte
count. Which therapy most directly addresses the underlying mechanism?
A. Intravenous iron alone
B. Vitamin B12 replacement
C. Erythropoiesis-stimulating agent therapy
D. Emergent hemodialysis
Correct Answer: 🔴 C. Erythropoiesis-stimulating agent therapy
Explanation: 🔹 Chronic kidney disease causes decreased erythropoietin production by
renal peritubular interstitial cells, resulting in normocytic normochromic anemia.
Erythropoiesis-stimulating agents such as epoetin alfa directly address this mechanism.
Iron supplementation may be necessary if iron deficiency coexists but is not the primary
issue here. Vitamin B12 deficiency typically produces macrocytic anemia. Hemodialysis
does not correct the underlying erythropoietin deficiency.
Q6. A 34-year-old man presents with recurrent episodes of wheezing, cough, and
chest tightness that worsen at night. Spirometry demonstrates reversible airflow
obstruction after bronchodilator administration. Which inflammatory cell plays the
most central role in the pathogenesis of this condition?
A. Neutrophils
B. Eosinophils
C. Platelets
D. Basophils
Correct Answer: 🔴 B. Eosinophils
Explanation: 🔹 Asthma is characterized by chronic airway inflammation involving
eosinophils, mast cells, and Th2 lymphocytes. Eosinophilic inflammation contributes to
