COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2 FORM 101 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 101
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-ALIGNED OSTEOPATHIC MEDICAL ASSESSMENT || CLINICAL SCIENCES
BLUEPRINT COMPATIBLE || INTERNAL MEDICINE || SURGERY || PEDIATRICS ||
OBSTETRICS & GYNECOLOGY || PSYCHIATRY || EMERGENCY MEDICINE || OSTEOPATHIC
PRINCIPLES & PRACTICE || COMPREHENSIVE CLINICAL REASONING || 100% ORIGINAL
VERIFIED STUDY CONTENT || PROFESSIONAL EXAMINATION PREPARATION MATERIAL
|| UPDATED FOR CURRENT CLINICAL GUIDELINES || PREPARED FOR BOARD EXAM
SUCCESS
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Clinical Decision-Making
,Q1. A 67-year-old man presents to the emergency department with crushing
substernal chest pain radiating to the left arm for 45 minutes. ECG demonstrates ST-
segment elevation in leads II, III, and aVF. Blood pressure is 82/54 mmHg, and jugular
venous distention is present. Lungs are clear to auscultation. Which additional finding
is most likely present?
A. Pulmonary crackles and diffuse wheezing
B. Bradycardia due to AV nodal ischemia
C. Hyperdynamic carotid pulses
D. Widened pulse pressure
Correct Answer: 🔴 B. Bradycardia due to AV nodal ischemia
Explanation: 🔹 Inferior myocardial infarctions commonly involve the right coronary
artery, which supplies the AV node in most individuals. Therefore, bradycardia and
varying degrees of AV block are frequent complications. Hypotension with clear lungs
and elevated jugular venous pressure suggests right ventricular infarction. Pulmonary
crackles are more typical of left ventricular failure. Hyperdynamic pulses and widened
pulse pressure are not characteristic features of acute inferior STEMI. Prompt reperfusion
therapy is indicated to reduce morbidity and mortality.
Q2. A 52-year-old woman with long-standing type 2 diabetes mellitus presents with
progressive lower-extremity edema and fatigue. Laboratory studies reveal nephrotic-
range proteinuria and a serum albumin of 2.3 g/dL. Which renal histologic finding is
most strongly associated with her condition?
A. Crescent formation within Bowman space
B. Nodular glomerulosclerosis
C. Wire-loop lesions
D. Linear IgA deposition
Correct Answer: 🔴 B. Nodular glomerulosclerosis
Explanation: 🔹 Diabetic nephropathy classically produces Kimmelstiel-Wilson nodules,
also known as nodular glomerulosclerosis. These lesions develop from mesangial matrix
expansion caused by chronic hyperglycemia. Crescent formation is associated with
rapidly progressive glomerulonephritis. Wire-loop lesions occur in lupus nephritis, while
,IgA deposition characterizes IgA nephropathy. Persistent proteinuria in diabetes strongly
suggests diabetic nephropathy progression.
Q3. A 34-year-old woman presents with fatigue, arthralgias, and a malar rash
worsened by sun exposure. Urinalysis shows hematuria and proteinuria. Which
antibody is most specific for her underlying disease?
A. Anti-histone antibody
B. Rheumatoid factor
C. Anti-Smith antibody
D. Anti-centromere antibody
Correct Answer: 🔴 C. Anti-Smith antibody
Explanation: 🔹 The patient most likely has systemic lupus erythematosus (SLE). Anti-
Smith antibodies are highly specific for SLE, although less sensitive than ANA testing.
Anti-histone antibodies are associated with drug-induced lupus. Rheumatoid factor is
commonly present in rheumatoid arthritis, and anti-centromere antibodies are
associated with limited systemic sclerosis. Renal involvement in SLE can lead to serious
complications requiring immunosuppressive therapy.
Q4. A 71-year-old man with chronic obstructive pulmonary disease develops
worsening dyspnea and confusion. Arterial blood gas reveals pH 7.29, PaCO₂ 68
mmHg, and HCO₃⁻ 31 mEq/L. Which acid-base disorder is present?
A. Acute respiratory alkalosis
B. Chronic respiratory acidosis with metabolic compensation
C. Metabolic acidosis with respiratory compensation
D. Mixed metabolic alkalosis and respiratory alkalosis
Correct Answer: 🔴 B. Chronic respiratory acidosis with metabolic compensation
Explanation: 🔹 Elevated PaCO₂ with elevated bicarbonate indicates chronic respiratory
acidosis with renal compensation. COPD patients retain carbon dioxide chronically, and
the kidneys compensate by increasing bicarbonate retention. The acidemic pH indicates
decompensation or acute worsening. Acute respiratory alkalosis would demonstrate low
, PaCO₂, while metabolic acidosis would show low bicarbonate. Recognition of chronic
compensation patterns is essential in pulmonary disease management.
Q5. A 28-year-old man presents with episodic wheezing, cough, and chest tightness
that worsen at night. Spirometry demonstrates reversible airflow obstruction after
bronchodilator administration. Which inflammatory mediator plays the greatest role in
the pathogenesis of this disease?
A. Neutrophil elastase
B. Histamine released from mast cells
C. Dopamine
D. Bradykinin deficiency
Correct Answer: 🔴 B. Histamine released from mast cells
Explanation: 🔹 Asthma is characterized by airway hyperresponsiveness mediated
largely through mast-cell degranulation and release of inflammatory mediators such as
histamine and leukotrienes. Reversible airflow obstruction is a hallmark feature.
Neutrophil elastase is more associated with emphysema. Dopamine and bradykinin
deficiency are not central to asthma pathogenesis. Proper recognition of inflammatory
pathways guides therapy selection including corticosteroids and leukotriene inhibitors.
Q6. A hospitalized patient develops sudden pleuritic chest pain and dyspnea three
days after orthopedic surgery. CT angiography confirms pulmonary embolism. Which
physiologic change is most likely present?
A. Increased pulmonary dead space
B. Decreased alveolar ventilation
C. Increased lung compliance
D. Elevated left atrial pressure
Correct Answer: 🔴 A. Increased pulmonary dead space
Explanation: 🔹 Pulmonary embolism obstructs pulmonary arterial blood flow, causing
ventilated alveoli to receive inadequate perfusion, thereby increasing physiologic dead
space. Ventilation-perfusion mismatch results in hypoxemia and tachypnea. Lung
(COMSAE) PHASE 2 FORM 101 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 101
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-ALIGNED OSTEOPATHIC MEDICAL ASSESSMENT || CLINICAL SCIENCES
BLUEPRINT COMPATIBLE || INTERNAL MEDICINE || SURGERY || PEDIATRICS ||
OBSTETRICS & GYNECOLOGY || PSYCHIATRY || EMERGENCY MEDICINE || OSTEOPATHIC
PRINCIPLES & PRACTICE || COMPREHENSIVE CLINICAL REASONING || 100% ORIGINAL
VERIFIED STUDY CONTENT || PROFESSIONAL EXAMINATION PREPARATION MATERIAL
|| UPDATED FOR CURRENT CLINICAL GUIDELINES || PREPARED FOR BOARD EXAM
SUCCESS
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Clinical Decision-Making
,Q1. A 67-year-old man presents to the emergency department with crushing
substernal chest pain radiating to the left arm for 45 minutes. ECG demonstrates ST-
segment elevation in leads II, III, and aVF. Blood pressure is 82/54 mmHg, and jugular
venous distention is present. Lungs are clear to auscultation. Which additional finding
is most likely present?
A. Pulmonary crackles and diffuse wheezing
B. Bradycardia due to AV nodal ischemia
C. Hyperdynamic carotid pulses
D. Widened pulse pressure
Correct Answer: 🔴 B. Bradycardia due to AV nodal ischemia
Explanation: 🔹 Inferior myocardial infarctions commonly involve the right coronary
artery, which supplies the AV node in most individuals. Therefore, bradycardia and
varying degrees of AV block are frequent complications. Hypotension with clear lungs
and elevated jugular venous pressure suggests right ventricular infarction. Pulmonary
crackles are more typical of left ventricular failure. Hyperdynamic pulses and widened
pulse pressure are not characteristic features of acute inferior STEMI. Prompt reperfusion
therapy is indicated to reduce morbidity and mortality.
Q2. A 52-year-old woman with long-standing type 2 diabetes mellitus presents with
progressive lower-extremity edema and fatigue. Laboratory studies reveal nephrotic-
range proteinuria and a serum albumin of 2.3 g/dL. Which renal histologic finding is
most strongly associated with her condition?
A. Crescent formation within Bowman space
B. Nodular glomerulosclerosis
C. Wire-loop lesions
D. Linear IgA deposition
Correct Answer: 🔴 B. Nodular glomerulosclerosis
Explanation: 🔹 Diabetic nephropathy classically produces Kimmelstiel-Wilson nodules,
also known as nodular glomerulosclerosis. These lesions develop from mesangial matrix
expansion caused by chronic hyperglycemia. Crescent formation is associated with
rapidly progressive glomerulonephritis. Wire-loop lesions occur in lupus nephritis, while
,IgA deposition characterizes IgA nephropathy. Persistent proteinuria in diabetes strongly
suggests diabetic nephropathy progression.
Q3. A 34-year-old woman presents with fatigue, arthralgias, and a malar rash
worsened by sun exposure. Urinalysis shows hematuria and proteinuria. Which
antibody is most specific for her underlying disease?
A. Anti-histone antibody
B. Rheumatoid factor
C. Anti-Smith antibody
D. Anti-centromere antibody
Correct Answer: 🔴 C. Anti-Smith antibody
Explanation: 🔹 The patient most likely has systemic lupus erythematosus (SLE). Anti-
Smith antibodies are highly specific for SLE, although less sensitive than ANA testing.
Anti-histone antibodies are associated with drug-induced lupus. Rheumatoid factor is
commonly present in rheumatoid arthritis, and anti-centromere antibodies are
associated with limited systemic sclerosis. Renal involvement in SLE can lead to serious
complications requiring immunosuppressive therapy.
Q4. A 71-year-old man with chronic obstructive pulmonary disease develops
worsening dyspnea and confusion. Arterial blood gas reveals pH 7.29, PaCO₂ 68
mmHg, and HCO₃⁻ 31 mEq/L. Which acid-base disorder is present?
A. Acute respiratory alkalosis
B. Chronic respiratory acidosis with metabolic compensation
C. Metabolic acidosis with respiratory compensation
D. Mixed metabolic alkalosis and respiratory alkalosis
Correct Answer: 🔴 B. Chronic respiratory acidosis with metabolic compensation
Explanation: 🔹 Elevated PaCO₂ with elevated bicarbonate indicates chronic respiratory
acidosis with renal compensation. COPD patients retain carbon dioxide chronically, and
the kidneys compensate by increasing bicarbonate retention. The acidemic pH indicates
decompensation or acute worsening. Acute respiratory alkalosis would demonstrate low
, PaCO₂, while metabolic acidosis would show low bicarbonate. Recognition of chronic
compensation patterns is essential in pulmonary disease management.
Q5. A 28-year-old man presents with episodic wheezing, cough, and chest tightness
that worsen at night. Spirometry demonstrates reversible airflow obstruction after
bronchodilator administration. Which inflammatory mediator plays the greatest role in
the pathogenesis of this disease?
A. Neutrophil elastase
B. Histamine released from mast cells
C. Dopamine
D. Bradykinin deficiency
Correct Answer: 🔴 B. Histamine released from mast cells
Explanation: 🔹 Asthma is characterized by airway hyperresponsiveness mediated
largely through mast-cell degranulation and release of inflammatory mediators such as
histamine and leukotrienes. Reversible airflow obstruction is a hallmark feature.
Neutrophil elastase is more associated with emphysema. Dopamine and bradykinin
deficiency are not central to asthma pathogenesis. Proper recognition of inflammatory
pathways guides therapy selection including corticosteroids and leukotriene inhibitors.
Q6. A hospitalized patient develops sudden pleuritic chest pain and dyspnea three
days after orthopedic surgery. CT angiography confirms pulmonary embolism. Which
physiologic change is most likely present?
A. Increased pulmonary dead space
B. Decreased alveolar ventilation
C. Increased lung compliance
D. Elevated left atrial pressure
Correct Answer: 🔴 A. Increased pulmonary dead space
Explanation: 🔹 Pulmonary embolism obstructs pulmonary arterial blood flow, causing
ventilated alveoli to receive inadequate perfusion, thereby increasing physiologic dead
space. Ventilation-perfusion mismatch results in hypoxemia and tachypnea. Lung
