COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2 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 2 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 CLINICAL COMPETENCY ASSESSMENT || ALIGNED WITH CURRENT
COMLEX-USA LEVEL 2 CE BLUEPRINTS || INTERNAL MEDICINE || FAMILY MEDICINE ||
PEDIATRICS || OBSTETRICS & GYNECOLOGY || EMERGENCY MEDICINE || OSTEOPATHIC
PRINCIPLES & PRACTICE || CLINICAL DECISION-MAKING || HIGH-YIELD DIFFERENTIAL
DIAGNOSIS || 100% ORIGINAL VERIFIED PRACTICE MATERIAL || COMPREHENSIVE
PHYSICIAN LICENSURE PREPARATION || PROFESSIONAL MEDICAL EXAMINATION USE
ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Clinical Decision-Making (Questions 1–10)
,Q1. A 67-year-old man presents with progressive dyspnea, orthopnea, and bilateral
lower-extremity edema over the past 2 weeks. His history includes hypertension,
ischemic cardiomyopathy, and chronic kidney disease stage 3. Physical examination
reveals jugular venous distention, bibasilar crackles, and an S3 gallop. Chest
radiography demonstrates pulmonary vascular congestion. Which of the following is
the most appropriate immediate management step?
A. Initiate intravenous furosemide therapy
B. Begin high-dose intravenous corticosteroids
C. Administer aggressive intravenous normal saline
D. Schedule outpatient stress testing
Correct Answer: 🔴 A. Initiate intravenous furosemide therapy
Explanation: 🔹 This patient has acute decompensated heart failure characterized by
volume overload, pulmonary congestion, and reduced cardiac reserve. Intravenous
loop diuretics such as furosemide are first-line therapy because they rapidly decrease
preload and relieve pulmonary edema. Corticosteroids are inappropriate because
there is no evidence of inflammatory pulmonary disease. Intravenous saline would
worsen congestion and respiratory compromise. Stress testing is not appropriate
during acute decompensation and would not address the immediate hemodynamic
instability.
Q2. A 54-year-old woman with type 2 diabetes mellitus presents with crushing
substernal chest pain radiating to the left arm. ECG reveals ST-segment elevations in
leads II, III, and aVF. Which coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Posterior descending artery
Correct Answer: 🔴 C. Right coronary artery
Explanation: 🔹 Inferior wall myocardial infarctions typically produce ST elevations
in leads II, III, and aVF and are most commonly due to occlusion of the right coronary
artery. The LAD is associated with anterior wall infarctions, while the circumflex
,artery more commonly affects the lateral wall. Although the posterior descending
artery may be involved, it is usually a branch of the RCA and not the primary answer
in classic inferior STEMI presentations.
Q3. A hospitalized patient develops fever, hypotension, and diffuse erythema shortly
after receiving broad-spectrum antibiotics. Laboratory studies reveal eosinophilia and
elevated serum creatinine. Which diagnosis is most likely?
A. Acute tubular necrosis
B. Acute interstitial nephritis
C. Prerenal azotemia
D. Nephrotic syndrome
Correct Answer: 🔴 B. Acute interstitial nephritis
Explanation: 🔹 Acute interstitial nephritis is classically associated with drug
exposure, especially antibiotics, NSAIDs, and proton pump inhibitors. The triad of
fever, rash, and eosinophilia strongly supports the diagnosis. Elevated creatinine
reflects renal impairment caused by inflammatory infiltration of the renal
interstitium. Acute tubular necrosis usually follows ischemia or nephrotoxins without
eosinophilia or rash. Prerenal azotemia does not cause eosinophilia, and nephrotic
syndrome presents with heavy proteinuria and edema rather than systemic
hypersensitivity findings.
Q4. A 29-year-old woman presents with episodic palpitations, diaphoresis, and
headaches. Blood pressure is 198/110 mm Hg. Plasma metanephrines are markedly
elevated. Which tumor is the most likely diagnosis?
A. Adrenal adenoma
B. Pheochromocytoma
C. Aldosteronoma
D. Renal oncocytoma
Correct Answer: 🔴 B. Pheochromocytoma
, Explanation: 🔹 Pheochromocytoma is a catecholamine-secreting tumor arising from
chromaffin cells of the adrenal medulla. Episodic hypertension, headache, sweating,
and palpitations are classic findings. Elevated plasma metanephrines are highly
sensitive for diagnosis. Aldosteronoma primarily causes resistant hypertension with
hypokalemia, while adrenal adenomas are often nonfunctional. Renal oncocytomas
are generally incidental renal masses without catecholamine excess.
Q5. A 73-year-old smoker presents with painless hematuria and weight loss. CT
imaging reveals a renal mass with extension into the renal vein. Which diagnosis is
most likely?
A. Transitional cell carcinoma
B. Wilms tumor
C. Renal cell carcinoma
D. Polycystic kidney disease
Correct Answer: 🔴 C. Renal cell carcinoma
Explanation: 🔹 Renal cell carcinoma commonly presents with painless hematuria,
flank pain, and constitutional symptoms. Extension into the renal vein is a classic
feature. Smoking is a major risk factor. Transitional cell carcinoma typically arises
from the renal pelvis or bladder. Wilms tumor occurs in children, while polycystic
kidney disease causes enlarged cystic kidneys rather than a solid renal mass.
Q6. A 62-year-old man with cirrhosis develops confusion, asterixis, and elevated serum
ammonia. Which medication is most appropriate for reducing his symptoms?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Acetazolamide
Correct Answer: 🔴 B. Lactulose
Explanation: 🔹 Hepatic encephalopathy results from accumulation of ammonia and
other neurotoxins due to impaired hepatic detoxification. Lactulose acidifies the
(COMSAE) PHASE 2 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 2 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 CLINICAL COMPETENCY ASSESSMENT || ALIGNED WITH CURRENT
COMLEX-USA LEVEL 2 CE BLUEPRINTS || INTERNAL MEDICINE || FAMILY MEDICINE ||
PEDIATRICS || OBSTETRICS & GYNECOLOGY || EMERGENCY MEDICINE || OSTEOPATHIC
PRINCIPLES & PRACTICE || CLINICAL DECISION-MAKING || HIGH-YIELD DIFFERENTIAL
DIAGNOSIS || 100% ORIGINAL VERIFIED PRACTICE MATERIAL || COMPREHENSIVE
PHYSICIAN LICENSURE PREPARATION || PROFESSIONAL MEDICAL EXAMINATION USE
ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Clinical Decision-Making (Questions 1–10)
,Q1. A 67-year-old man presents with progressive dyspnea, orthopnea, and bilateral
lower-extremity edema over the past 2 weeks. His history includes hypertension,
ischemic cardiomyopathy, and chronic kidney disease stage 3. Physical examination
reveals jugular venous distention, bibasilar crackles, and an S3 gallop. Chest
radiography demonstrates pulmonary vascular congestion. Which of the following is
the most appropriate immediate management step?
A. Initiate intravenous furosemide therapy
B. Begin high-dose intravenous corticosteroids
C. Administer aggressive intravenous normal saline
D. Schedule outpatient stress testing
Correct Answer: 🔴 A. Initiate intravenous furosemide therapy
Explanation: 🔹 This patient has acute decompensated heart failure characterized by
volume overload, pulmonary congestion, and reduced cardiac reserve. Intravenous
loop diuretics such as furosemide are first-line therapy because they rapidly decrease
preload and relieve pulmonary edema. Corticosteroids are inappropriate because
there is no evidence of inflammatory pulmonary disease. Intravenous saline would
worsen congestion and respiratory compromise. Stress testing is not appropriate
during acute decompensation and would not address the immediate hemodynamic
instability.
Q2. A 54-year-old woman with type 2 diabetes mellitus presents with crushing
substernal chest pain radiating to the left arm. ECG reveals ST-segment elevations in
leads II, III, and aVF. Which coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Posterior descending artery
Correct Answer: 🔴 C. Right coronary artery
Explanation: 🔹 Inferior wall myocardial infarctions typically produce ST elevations
in leads II, III, and aVF and are most commonly due to occlusion of the right coronary
artery. The LAD is associated with anterior wall infarctions, while the circumflex
,artery more commonly affects the lateral wall. Although the posterior descending
artery may be involved, it is usually a branch of the RCA and not the primary answer
in classic inferior STEMI presentations.
Q3. A hospitalized patient develops fever, hypotension, and diffuse erythema shortly
after receiving broad-spectrum antibiotics. Laboratory studies reveal eosinophilia and
elevated serum creatinine. Which diagnosis is most likely?
A. Acute tubular necrosis
B. Acute interstitial nephritis
C. Prerenal azotemia
D. Nephrotic syndrome
Correct Answer: 🔴 B. Acute interstitial nephritis
Explanation: 🔹 Acute interstitial nephritis is classically associated with drug
exposure, especially antibiotics, NSAIDs, and proton pump inhibitors. The triad of
fever, rash, and eosinophilia strongly supports the diagnosis. Elevated creatinine
reflects renal impairment caused by inflammatory infiltration of the renal
interstitium. Acute tubular necrosis usually follows ischemia or nephrotoxins without
eosinophilia or rash. Prerenal azotemia does not cause eosinophilia, and nephrotic
syndrome presents with heavy proteinuria and edema rather than systemic
hypersensitivity findings.
Q4. A 29-year-old woman presents with episodic palpitations, diaphoresis, and
headaches. Blood pressure is 198/110 mm Hg. Plasma metanephrines are markedly
elevated. Which tumor is the most likely diagnosis?
A. Adrenal adenoma
B. Pheochromocytoma
C. Aldosteronoma
D. Renal oncocytoma
Correct Answer: 🔴 B. Pheochromocytoma
, Explanation: 🔹 Pheochromocytoma is a catecholamine-secreting tumor arising from
chromaffin cells of the adrenal medulla. Episodic hypertension, headache, sweating,
and palpitations are classic findings. Elevated plasma metanephrines are highly
sensitive for diagnosis. Aldosteronoma primarily causes resistant hypertension with
hypokalemia, while adrenal adenomas are often nonfunctional. Renal oncocytomas
are generally incidental renal masses without catecholamine excess.
Q5. A 73-year-old smoker presents with painless hematuria and weight loss. CT
imaging reveals a renal mass with extension into the renal vein. Which diagnosis is
most likely?
A. Transitional cell carcinoma
B. Wilms tumor
C. Renal cell carcinoma
D. Polycystic kidney disease
Correct Answer: 🔴 C. Renal cell carcinoma
Explanation: 🔹 Renal cell carcinoma commonly presents with painless hematuria,
flank pain, and constitutional symptoms. Extension into the renal vein is a classic
feature. Smoking is a major risk factor. Transitional cell carcinoma typically arises
from the renal pelvis or bladder. Wilms tumor occurs in children, while polycystic
kidney disease causes enlarged cystic kidneys rather than a solid renal mass.
Q6. A 62-year-old man with cirrhosis develops confusion, asterixis, and elevated serum
ammonia. Which medication is most appropriate for reducing his symptoms?
A. Spironolactone
B. Lactulose
C. Propranolol
D. Acetazolamide
Correct Answer: 🔴 B. Lactulose
Explanation: 🔹 Hepatic encephalopathy results from accumulation of ammonia and
other neurotoxins due to impaired hepatic detoxification. Lactulose acidifies the
