COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2 FORM 102 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 102
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME BLUEPRINT-ALIGNED COMPREHENSIVE PRACTICE EXAM || CLINICAL
DECISION-MAKING ASSESSMENT || OSTEOPATHIC PRINCIPLES & PRACTICE
INTEGRATION || INTERNAL MEDICINE || SURGERY || PEDIATRICS || OBSTETRICS &
GYNECOLOGY || PSYCHIATRY || EMERGENCY MEDICINE || FAMILY MEDICINE || HIGH-
YIELD BOARD PREPARATION || 100% ORIGINAL VERIFIED CONTENT || PROFESSIONAL
STUDY GUIDE || PREPARED FOR CLINICAL BOARD EXAMINATION SUCCESS ||
COMPREHENSIVE EXAM REVIEW MATERIAL || PROFESSIONAL EXAMINATION USE
ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Questions 1–8 → Internal Medicine & Clinical Reasoning
,Q1. A 67-year-old man presents with progressive dyspnea, orthopnea, and bilateral
lower-extremity edema for 3 weeks. 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 provide a mortality
benefit in this patient’s condition?
A. Furosemide
B. Digoxin
C. Lisinopril
D. Hydrochlorothiazide
Correct Answer: 🔴 C. Lisinopril
Explanation: 🔹 ACE inhibitors such as lisinopril significantly reduce mortality in patients
with heart failure with reduced ejection fraction (HFrEF) by decreasing afterload,
reducing maladaptive remodeling, and improving cardiac output. Furosemide improves
symptoms but has not shown mortality reduction. Digoxin may decrease hospitalizations
but does not improve survival. Hydrochlorothiazide is not a primary mortality-reducing
agent in HFrEF. The patient’s S3 gallop, edema, and reduced EF are classic findings of
systolic heart failure.
Q2. A 54-year-old woman with poorly controlled type 2 diabetes presents with burning
pain and numbness in both feet that worsens at night. Examination reveals decreased
vibratory sensation and absent ankle reflexes bilaterally. Which pathophysiologic
mechanism most likely explains her symptoms?
A. Autoimmune demyelination
B. Microvascular nerve ischemia
C. Dopamine deficiency
D. Compression neuropathy
Correct Answer: 🔴 B. Microvascular nerve ischemia
Explanation: 🔹 Diabetic peripheral neuropathy primarily results from chronic
hyperglycemia causing microvascular damage and metabolic injury to peripheral nerves.
Sorbitol accumulation, oxidative stress, and ischemic injury contribute to axonal
degeneration. Autoimmune demyelination is characteristic of Guillain-Barré syndrome.
,Dopamine deficiency causes Parkinson disease. Compression neuropathy is focal rather
than symmetric stocking-glove neuropathy.
Q3. A 72-year-old smoker presents with hematuria and weight loss. CT imaging
demonstrates a renal mass. Which paraneoplastic syndrome is most commonly
associated with renal cell carcinoma?
A. Hypercalcemia due to PTHrP secretion
B. SIADH
C. ACTH deficiency
D. Hypoglycemia from insulin secretion
Correct Answer: 🔴 A. Hypercalcemia due to PTHrP secretion
Explanation: 🔹 Renal cell carcinoma is strongly associated with paraneoplastic
syndromes, including hypercalcemia from parathyroid hormone–related peptide
secretion, polycythemia from erythropoietin production, and hypertension from renin
secretion. SIADH is more commonly linked to small cell lung carcinoma. ACTH deficiency
is not a typical paraneoplastic phenomenon. Insulin-mediated hypoglycemia is
uncommon in renal malignancies.
Q4. A hospitalized patient develops fever, hypotension, and diffuse flushing shortly
after initiation of intravenous vancomycin. Which mechanism most likely caused this
reaction?
A. IgE-mediated mast cell degranulation
B. Complement deficiency
C. Direct histamine release
D. Immune complex deposition
Correct Answer: 🔴 C. Direct histamine release
Explanation: 🔹 Vancomycin infusion reaction, commonly called “red man syndrome,”
results from direct mast cell degranulation and histamine release rather than IgE-
mediated hypersensitivity. Slowing the infusion rate and administering antihistamines
, usually resolves symptoms. Immune complex deposition describes type III
hypersensitivity. Complement deficiency does not explain this acute presentation.
Q5. A 43-year-old man presents with episodic headaches, diaphoresis, and
palpitations. Blood pressure is 210/120 mmHg during episodes. Plasma metanephrines
are elevated. Which tumor is most likely responsible?
A. Adrenal cortical adenoma
B. Pheochromocytoma
C. Pituitary adenoma
D. Pancreatic insulinoma
Correct Answer: 🔴 B. Pheochromocytoma
Explanation: 🔹 Pheochromocytoma is a catecholamine-secreting tumor arising from
chromaffin cells of the adrenal medulla. Episodic hypertension, headaches, diaphoresis,
and palpitations are hallmark findings. Elevated plasma metanephrines are highly
sensitive for diagnosis. Adrenal cortical adenomas typically produce cortisol or
aldosterone. Pituitary adenomas do not cause catecholamine surges. Insulinomas cause
hypoglycemia.
Q6. A 60-year-old woman presents with fatigue and pruritus. Laboratory studies show
elevated alkaline phosphatase and positive antimitochondrial antibodies. Which
diagnosis is most likely?
A. Primary biliary cholangitis
B. Acute viral hepatitis
C. Hemochromatosis
D. Wilson disease
Correct Answer: 🔴 A. Primary biliary cholangitis
Explanation: 🔹 Primary biliary cholangitis is an autoimmune destruction of intrahepatic
bile ducts, commonly affecting middle-aged women. Elevated alkaline phosphatase,
fatigue, pruritus, and antimitochondrial antibodies are classic findings. Viral hepatitis
(COMSAE) PHASE 2 FORM 102 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 102
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME BLUEPRINT-ALIGNED COMPREHENSIVE PRACTICE EXAM || CLINICAL
DECISION-MAKING ASSESSMENT || OSTEOPATHIC PRINCIPLES & PRACTICE
INTEGRATION || INTERNAL MEDICINE || SURGERY || PEDIATRICS || OBSTETRICS &
GYNECOLOGY || PSYCHIATRY || EMERGENCY MEDICINE || FAMILY MEDICINE || HIGH-
YIELD BOARD PREPARATION || 100% ORIGINAL VERIFIED CONTENT || PROFESSIONAL
STUDY GUIDE || PREPARED FOR CLINICAL BOARD EXAMINATION SUCCESS ||
COMPREHENSIVE EXAM REVIEW MATERIAL || PROFESSIONAL EXAMINATION USE
ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Questions 1–8 → Internal Medicine & Clinical Reasoning
,Q1. A 67-year-old man presents with progressive dyspnea, orthopnea, and bilateral
lower-extremity edema for 3 weeks. 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 provide a mortality
benefit in this patient’s condition?
A. Furosemide
B. Digoxin
C. Lisinopril
D. Hydrochlorothiazide
Correct Answer: 🔴 C. Lisinopril
Explanation: 🔹 ACE inhibitors such as lisinopril significantly reduce mortality in patients
with heart failure with reduced ejection fraction (HFrEF) by decreasing afterload,
reducing maladaptive remodeling, and improving cardiac output. Furosemide improves
symptoms but has not shown mortality reduction. Digoxin may decrease hospitalizations
but does not improve survival. Hydrochlorothiazide is not a primary mortality-reducing
agent in HFrEF. The patient’s S3 gallop, edema, and reduced EF are classic findings of
systolic heart failure.
Q2. A 54-year-old woman with poorly controlled type 2 diabetes presents with burning
pain and numbness in both feet that worsens at night. Examination reveals decreased
vibratory sensation and absent ankle reflexes bilaterally. Which pathophysiologic
mechanism most likely explains her symptoms?
A. Autoimmune demyelination
B. Microvascular nerve ischemia
C. Dopamine deficiency
D. Compression neuropathy
Correct Answer: 🔴 B. Microvascular nerve ischemia
Explanation: 🔹 Diabetic peripheral neuropathy primarily results from chronic
hyperglycemia causing microvascular damage and metabolic injury to peripheral nerves.
Sorbitol accumulation, oxidative stress, and ischemic injury contribute to axonal
degeneration. Autoimmune demyelination is characteristic of Guillain-Barré syndrome.
,Dopamine deficiency causes Parkinson disease. Compression neuropathy is focal rather
than symmetric stocking-glove neuropathy.
Q3. A 72-year-old smoker presents with hematuria and weight loss. CT imaging
demonstrates a renal mass. Which paraneoplastic syndrome is most commonly
associated with renal cell carcinoma?
A. Hypercalcemia due to PTHrP secretion
B. SIADH
C. ACTH deficiency
D. Hypoglycemia from insulin secretion
Correct Answer: 🔴 A. Hypercalcemia due to PTHrP secretion
Explanation: 🔹 Renal cell carcinoma is strongly associated with paraneoplastic
syndromes, including hypercalcemia from parathyroid hormone–related peptide
secretion, polycythemia from erythropoietin production, and hypertension from renin
secretion. SIADH is more commonly linked to small cell lung carcinoma. ACTH deficiency
is not a typical paraneoplastic phenomenon. Insulin-mediated hypoglycemia is
uncommon in renal malignancies.
Q4. A hospitalized patient develops fever, hypotension, and diffuse flushing shortly
after initiation of intravenous vancomycin. Which mechanism most likely caused this
reaction?
A. IgE-mediated mast cell degranulation
B. Complement deficiency
C. Direct histamine release
D. Immune complex deposition
Correct Answer: 🔴 C. Direct histamine release
Explanation: 🔹 Vancomycin infusion reaction, commonly called “red man syndrome,”
results from direct mast cell degranulation and histamine release rather than IgE-
mediated hypersensitivity. Slowing the infusion rate and administering antihistamines
, usually resolves symptoms. Immune complex deposition describes type III
hypersensitivity. Complement deficiency does not explain this acute presentation.
Q5. A 43-year-old man presents with episodic headaches, diaphoresis, and
palpitations. Blood pressure is 210/120 mmHg during episodes. Plasma metanephrines
are elevated. Which tumor is most likely responsible?
A. Adrenal cortical adenoma
B. Pheochromocytoma
C. Pituitary adenoma
D. Pancreatic insulinoma
Correct Answer: 🔴 B. Pheochromocytoma
Explanation: 🔹 Pheochromocytoma is a catecholamine-secreting tumor arising from
chromaffin cells of the adrenal medulla. Episodic hypertension, headaches, diaphoresis,
and palpitations are hallmark findings. Elevated plasma metanephrines are highly
sensitive for diagnosis. Adrenal cortical adenomas typically produce cortisol or
aldosterone. Pituitary adenomas do not cause catecholamine surges. Insulinomas cause
hypoglycemia.
Q6. A 60-year-old woman presents with fatigue and pruritus. Laboratory studies show
elevated alkaline phosphatase and positive antimitochondrial antibodies. Which
diagnosis is most likely?
A. Primary biliary cholangitis
B. Acute viral hepatitis
C. Hemochromatosis
D. Wilson disease
Correct Answer: 🔴 A. Primary biliary cholangitis
Explanation: 🔹 Primary biliary cholangitis is an autoimmune destruction of intrahepatic
bile ducts, commonly affecting middle-aged women. Elevated alkaline phosphatase,
fatigue, pruritus, and antimitochondrial antibodies are classic findings. Viral hepatitis
