COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2 FORM 104 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 104
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 EXAMINATION || CLINICAL DECISION-MAKING
ASSESSMENT || OSTEOPATHIC PRINCIPLES & PRACTICE || INTERNAL MEDICINE ||
PEDIATRICS || SURGERY || OBSTETRICS & GYNECOLOGY || PSYCHIATRY || EMERGENCY
MEDICINE || PROFESSIONAL STUDY GUIDE || UPDATED 2026/2027 PRACTICE EXAM ||
100% ORIGINAL VERIFIED PREPARATION MATERIAL || COMPREHENSIVE BOARD
REVIEW || PREPARED FOR PROFESSIONAL LICENSING EXAMINATION USE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
PROFESSIONAL ACADEMIC EDITION
FOR EDUCATIONAL & EXAM PREPARATION PURPOSES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
,Internal Medicine & Clinical Reasoning
Q1. A 67-year-old man presents with progressive exertional dyspnea and bilateral
lower-extremity edema over the past 3 months. He has a history of hypertension,
diabetes mellitus, and obesity. Physical examination reveals jugular venous distention,
bibasilar crackles, and an S4 gallop. Echocardiography demonstrates a preserved
ejection fraction of 60% with impaired ventricular relaxation. Which of the following is
the most likely underlying pathophysiologic mechanism?
A. Reduced ventricular compliance leading to impaired diastolic filling
B. Destruction of myocardial contractile fibers causing systolic dysfunction
C. Autoimmune inflammation of the myocardium causing chamber dilation
D. Chronic volume overload resulting in eccentric hypertrophy
Correct Answer: 🔴 A. Reduced ventricular compliance leading to impaired diastolic
filling
Explanation: 🔹 This patient has heart failure with preserved ejection fraction (HFpEF),
also called diastolic heart failure. Long-standing hypertension and diabetes contribute to
ventricular hypertrophy and stiffness, impairing ventricular relaxation and reducing
compliance during diastole. Ejection fraction remains preserved because systolic
contraction is relatively intact. Option B describes systolic heart failure with reduced EF.
Option C is more consistent with myocarditis. Option D describes chronic regurgitant
lesions causing eccentric hypertrophy rather than impaired relaxation.
Q2. A 24-year-old woman presents with fatigue, jaundice, and dark urine. Laboratory
testing shows hemoglobin of 8.1 g/dL, elevated lactate dehydrogenase, elevated
indirect bilirubin, and reduced haptoglobin. Direct Coombs test is positive. Which of
the following is the most appropriate initial treatment?
A. Oral iron supplementation
B. High-dose corticosteroid therapy
C. Splenectomy immediately
D. Plasma exchange therapy
Correct Answer: 🔴 B. High-dose corticosteroid therapy
,Explanation: 🔹 This patient has warm autoimmune hemolytic anemia, evidenced by
hemolysis and a positive direct Coombs test. First-line treatment involves corticosteroids
to suppress antibody-mediated red blood cell destruction. Iron supplementation does not
treat immune-mediated hemolysis. Splenectomy may be considered in refractory disease
but is not initial management. Plasma exchange is primarily used for thrombotic
thrombocytopenic purpura or severe autoimmune neurologic disorders.
Q3. A 58-year-old smoker presents with hematuria and flank discomfort. CT imaging
reveals a renal mass. Laboratory studies demonstrate elevated hematocrit and
hypercalcemia. Which of the following tumors most likely explains these findings?
A. Wilms tumor
B. Transitional cell carcinoma
C. Renal cell carcinoma
D. Angiomyolipoma
Correct Answer: 🔴 C. Renal cell carcinoma
Explanation: 🔹 Renal cell carcinoma classically presents with hematuria, flank pain, and
a renal mass. It is also associated with paraneoplastic syndromes such as erythropoietin
production causing polycythemia and parathyroid hormone-related peptide causing
hypercalcemia. Transitional cell carcinoma more commonly presents with painless
hematuria without these endocrine manifestations. Wilms tumor occurs primarily in
children. Angiomyolipoma is benign and strongly associated with tuberous sclerosis.
Q4. A hospitalized patient receiving broad-spectrum antibiotics develops profuse
watery diarrhea and abdominal cramping. Stool testing is positive for Clostridioides
difficile toxin. Which of the following is the most appropriate first-line therapy?
A. Oral vancomycin
B. Intravenous metronidazole only
C. Ciprofloxacin therapy
D. Loperamide administration
Correct Answer: 🔴 A. Oral vancomycin
, Explanation: 🔹 Current guidelines recommend oral vancomycin or fidaxomicin as first-
line treatment for symptomatic Clostridioides difficile infection. Intravenous
metronidazole alone is insufficient because therapeutic colonic concentrations are
limited. Ciprofloxacin may worsen antibiotic-associated colitis. Antimotility agents like
loperamide are avoided because they may increase toxin retention and precipitate toxic
megacolon.
Q5. A 72-year-old woman with atrial fibrillation suddenly develops severe abdominal
pain out of proportion to physical examination findings. Lactate levels are elevated.
Which of the following is the most likely diagnosis?
A. Acute pancreatitis
B. Mesenteric ischemia
C. Small bowel obstruction
D. Diverticulitis
Correct Answer: 🔴 B. Mesenteric ischemia
Explanation: 🔹 Acute mesenteric ischemia commonly results from arterial emboli in
patients with atrial fibrillation. Severe pain out of proportion to examination findings is
highly characteristic. Elevated lactate suggests bowel ischemia and tissue hypoperfusion.
Pancreatitis typically causes epigastric pain radiating to the back with elevated lipase.
Small bowel obstruction presents with vomiting and distention. Diverticulitis generally
causes localized left lower quadrant tenderness.
Q6. A 45-year-old man presents with episodic headaches, diaphoresis, and
palpitations. Blood pressure is 210/110 mmHg during attacks. Urinary metanephrines
are markedly elevated. Which of the following is the best next step before surgery?
A. Begin beta-blocker therapy immediately
B. Start alpha-adrenergic blockade first
C. Restrict dietary sodium aggressively
D. Administer intravenous insulin therapy
Correct Answer: 🔴 B. Start alpha-adrenergic blockade first
(COMSAE) PHASE 2 FORM 104 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 104
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 EXAMINATION || CLINICAL DECISION-MAKING
ASSESSMENT || OSTEOPATHIC PRINCIPLES & PRACTICE || INTERNAL MEDICINE ||
PEDIATRICS || SURGERY || OBSTETRICS & GYNECOLOGY || PSYCHIATRY || EMERGENCY
MEDICINE || PROFESSIONAL STUDY GUIDE || UPDATED 2026/2027 PRACTICE EXAM ||
100% ORIGINAL VERIFIED PREPARATION MATERIAL || COMPREHENSIVE BOARD
REVIEW || PREPARED FOR PROFESSIONAL LICENSING EXAMINATION USE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
PROFESSIONAL ACADEMIC EDITION
FOR EDUCATIONAL & EXAM PREPARATION PURPOSES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━
,Internal Medicine & Clinical Reasoning
Q1. A 67-year-old man presents with progressive exertional dyspnea and bilateral
lower-extremity edema over the past 3 months. He has a history of hypertension,
diabetes mellitus, and obesity. Physical examination reveals jugular venous distention,
bibasilar crackles, and an S4 gallop. Echocardiography demonstrates a preserved
ejection fraction of 60% with impaired ventricular relaxation. Which of the following is
the most likely underlying pathophysiologic mechanism?
A. Reduced ventricular compliance leading to impaired diastolic filling
B. Destruction of myocardial contractile fibers causing systolic dysfunction
C. Autoimmune inflammation of the myocardium causing chamber dilation
D. Chronic volume overload resulting in eccentric hypertrophy
Correct Answer: 🔴 A. Reduced ventricular compliance leading to impaired diastolic
filling
Explanation: 🔹 This patient has heart failure with preserved ejection fraction (HFpEF),
also called diastolic heart failure. Long-standing hypertension and diabetes contribute to
ventricular hypertrophy and stiffness, impairing ventricular relaxation and reducing
compliance during diastole. Ejection fraction remains preserved because systolic
contraction is relatively intact. Option B describes systolic heart failure with reduced EF.
Option C is more consistent with myocarditis. Option D describes chronic regurgitant
lesions causing eccentric hypertrophy rather than impaired relaxation.
Q2. A 24-year-old woman presents with fatigue, jaundice, and dark urine. Laboratory
testing shows hemoglobin of 8.1 g/dL, elevated lactate dehydrogenase, elevated
indirect bilirubin, and reduced haptoglobin. Direct Coombs test is positive. Which of
the following is the most appropriate initial treatment?
A. Oral iron supplementation
B. High-dose corticosteroid therapy
C. Splenectomy immediately
D. Plasma exchange therapy
Correct Answer: 🔴 B. High-dose corticosteroid therapy
,Explanation: 🔹 This patient has warm autoimmune hemolytic anemia, evidenced by
hemolysis and a positive direct Coombs test. First-line treatment involves corticosteroids
to suppress antibody-mediated red blood cell destruction. Iron supplementation does not
treat immune-mediated hemolysis. Splenectomy may be considered in refractory disease
but is not initial management. Plasma exchange is primarily used for thrombotic
thrombocytopenic purpura or severe autoimmune neurologic disorders.
Q3. A 58-year-old smoker presents with hematuria and flank discomfort. CT imaging
reveals a renal mass. Laboratory studies demonstrate elevated hematocrit and
hypercalcemia. Which of the following tumors most likely explains these findings?
A. Wilms tumor
B. Transitional cell carcinoma
C. Renal cell carcinoma
D. Angiomyolipoma
Correct Answer: 🔴 C. Renal cell carcinoma
Explanation: 🔹 Renal cell carcinoma classically presents with hematuria, flank pain, and
a renal mass. It is also associated with paraneoplastic syndromes such as erythropoietin
production causing polycythemia and parathyroid hormone-related peptide causing
hypercalcemia. Transitional cell carcinoma more commonly presents with painless
hematuria without these endocrine manifestations. Wilms tumor occurs primarily in
children. Angiomyolipoma is benign and strongly associated with tuberous sclerosis.
Q4. A hospitalized patient receiving broad-spectrum antibiotics develops profuse
watery diarrhea and abdominal cramping. Stool testing is positive for Clostridioides
difficile toxin. Which of the following is the most appropriate first-line therapy?
A. Oral vancomycin
B. Intravenous metronidazole only
C. Ciprofloxacin therapy
D. Loperamide administration
Correct Answer: 🔴 A. Oral vancomycin
, Explanation: 🔹 Current guidelines recommend oral vancomycin or fidaxomicin as first-
line treatment for symptomatic Clostridioides difficile infection. Intravenous
metronidazole alone is insufficient because therapeutic colonic concentrations are
limited. Ciprofloxacin may worsen antibiotic-associated colitis. Antimotility agents like
loperamide are avoided because they may increase toxin retention and precipitate toxic
megacolon.
Q5. A 72-year-old woman with atrial fibrillation suddenly develops severe abdominal
pain out of proportion to physical examination findings. Lactate levels are elevated.
Which of the following is the most likely diagnosis?
A. Acute pancreatitis
B. Mesenteric ischemia
C. Small bowel obstruction
D. Diverticulitis
Correct Answer: 🔴 B. Mesenteric ischemia
Explanation: 🔹 Acute mesenteric ischemia commonly results from arterial emboli in
patients with atrial fibrillation. Severe pain out of proportion to examination findings is
highly characteristic. Elevated lactate suggests bowel ischemia and tissue hypoperfusion.
Pancreatitis typically causes epigastric pain radiating to the back with elevated lipase.
Small bowel obstruction presents with vomiting and distention. Diverticulitis generally
causes localized left lower quadrant tenderness.
Q6. A 45-year-old man presents with episodic headaches, diaphoresis, and
palpitations. Blood pressure is 210/110 mmHg during attacks. Urinary metanephrines
are markedly elevated. Which of the following is the best next step before surgery?
A. Begin beta-blocker therapy immediately
B. Start alpha-adrenergic blockade first
C. Restrict dietary sodium aggressively
D. Administer intravenous insulin therapy
Correct Answer: 🔴 B. Start alpha-adrenergic blockade first
