COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2 FORM 106 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 106
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME ALIGNED CLINICAL COMPETENCY BLUEPRINT || OSTEOPATHIC PRINCIPLES &
PRACTICE INTEGRATION || INTERNAL MEDICINE || SURGERY || PEDIATRICS ||
OBSTETRICS & GYNECOLOGY || EMERGENCY MEDICINE || FAMILY MEDICINE ||
COMPREHENSIVE CLINICAL DECISION-MAKING || HIGH-YIELD LEVEL 2 CE
PREPARATION || 100% ORIGINAL VERIFIED PRACTICE CONTENT || PROFESSIONAL
EXAMINATION REVIEW GUIDE || UPDATED CLINICAL MANAGEMENT STANDARDS ||
PREPARED FOR OSTEOPATHIC LICENSING & BOARD CERTIFICATION USE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
PROFESSIONAL ACADEMIC REVIEW COPY
FOR EDUCATIONAL & EXAM PREPARATION USE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
,Questions 1–10 — Internal Medicine & Clinical Decision-Making
Q1. A 67-year-old man presents with progressive dyspnea, orthopnea, and bilateral
lower-extremity edema over the past 3 weeks. Physical 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
reduce mortality most significantly when added early to guideline-directed therapy?
A. Furosemide
B. Digoxin
C. Sacubitril/valsartan
D. Verapamil
Correct Answer: 🔴 C. Sacubitril/valsartan
Explanation: 🔹 Sacubitril/valsartan is an angiotensin receptor-neprilysin inhibitor
(ARNI) that significantly reduces mortality and hospitalization in patients with heart
failure with reduced ejection fraction (HFrEF). Diuretics such as furosemide improve
symptoms but do not confer mortality benefit. Digoxin may reduce hospitalization
frequency but has not demonstrated substantial mortality reduction. Verapamil is
contraindicated in systolic heart failure because of its negative inotropic effects.
Q2. A 54-year-old woman with poorly controlled type 2 diabetes presents with fever,
flank pain, and dysuria. Urinalysis reveals pyuria and positive nitrites. CT imaging
shows gas within the renal parenchyma. Which organism is the most likely cause?
A. Staphylococcus saprophyticus
B. Escherichia coli
C. Enterococcus faecalis
D. Proteus mirabilis
Correct Answer: 🔴 B. Escherichia coli
Explanation: 🔹 Emphysematous pyelonephritis is a severe necrotizing infection most
commonly caused by Escherichia coli in diabetic patients. Gas production occurs due
to glucose fermentation within tissues. Proteus species may produce urease and
stones but are less commonly implicated. Staphylococcus saprophyticus typically
,causes uncomplicated cystitis in young women, while Enterococcus is a less frequent
cause of emphysematous infection.
Q3. A 23-year-old medical student develops fatigue, dark urine, and jaundice one
week after beginning trimethoprim-sulfamethoxazole therapy. Laboratory studies
reveal elevated LDH, decreased haptoglobin, and bite cells on peripheral smear. Which
underlying condition most likely predisposed this patient to the hemolysis?
A. Hereditary spherocytosis
B. Pyruvate kinase deficiency
C. Glucose-6-phosphate dehydrogenase deficiency
D. Autoimmune hemolytic anemia
Correct Answer: 🔴 C. Glucose-6-phosphate dehydrogenase deficiency
Explanation: 🔹 G6PD deficiency predisposes erythrocytes to oxidative damage from
sulfa drugs, antimalarials, and infections. Bite cells result from splenic macrophage
removal of Heinz body-containing erythrocytes. Hereditary spherocytosis produces
spherocytes rather than bite cells. Pyruvate kinase deficiency causes chronic
hemolysis but is not classically triggered by oxidant stress. Autoimmune hemolytic
anemia produces positive Coombs testing and spherocytes.
Q4. A hospitalized patient receiving unfractionated heparin develops
thrombocytopenia and digital ischemia 7 days after initiation of therapy. Which
mechanism best explains this complication?
A. Direct platelet toxicity
B. Autoantibody formation against platelet factor 4 complexes
C. Vitamin K depletion
D. Disseminated intravascular coagulation activation
Correct Answer: 🔴 B. Autoantibody formation against platelet factor 4 complexes
Explanation: 🔹 Heparin-induced thrombocytopenia (HIT) is caused by IgG
antibodies directed against heparin-platelet factor 4 complexes, resulting in
paradoxical thrombosis despite thrombocytopenia. Direct platelet toxicity is not the
, mechanism. Vitamin K depletion is associated with warfarin therapy. DIC may
produce thrombocytopenia but is not the primary pathophysiologic process in HIT.
Q5. A 44-year-old woman presents with episodic headaches, diaphoresis, and
palpitations. Her blood pressure is persistently elevated. Plasma metanephrines are
markedly elevated. Prior to surgical intervention, which medication should be
administered first?
A. Propranolol
B. Hydrochlorothiazide
C. Phenoxybenzamine
D. Lisinopril
Correct Answer: 🔴 C. Phenoxybenzamine
Explanation: 🔹 Pheochromocytoma requires alpha blockade before beta blockade to
avoid unopposed alpha-adrenergic vasoconstriction and hypertensive crisis.
Phenoxybenzamine is a nonselective irreversible alpha blocker used preoperatively.
Beta blockers such as propranolol should only be added after adequate alpha
blockade. Hydrochlorothiazide and lisinopril do not address catecholamine excess.
Q6. A 72-year-old smoker presents with hematuria and weight loss. CT scan reveals a
renal mass. Laboratory studies demonstrate elevated hematocrit and hypercalcemia.
Which diagnosis is most likely?
A. Transitional cell carcinoma
B. Wilms tumor
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 may also produce paraneoplastic syndromes including
erythropoietin-mediated polycythemia and PTHrP-mediated hypercalcemia.
Transitional cell carcinoma arises from the renal pelvis and is less associated with
(COMSAE) PHASE 2 FORM 106 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 106
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME ALIGNED CLINICAL COMPETENCY BLUEPRINT || OSTEOPATHIC PRINCIPLES &
PRACTICE INTEGRATION || INTERNAL MEDICINE || SURGERY || PEDIATRICS ||
OBSTETRICS & GYNECOLOGY || EMERGENCY MEDICINE || FAMILY MEDICINE ||
COMPREHENSIVE CLINICAL DECISION-MAKING || HIGH-YIELD LEVEL 2 CE
PREPARATION || 100% ORIGINAL VERIFIED PRACTICE CONTENT || PROFESSIONAL
EXAMINATION REVIEW GUIDE || UPDATED CLINICAL MANAGEMENT STANDARDS ||
PREPARED FOR OSTEOPATHIC LICENSING & BOARD CERTIFICATION USE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
PROFESSIONAL ACADEMIC REVIEW COPY
FOR EDUCATIONAL & EXAM PREPARATION USE
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
,Questions 1–10 — Internal Medicine & Clinical Decision-Making
Q1. A 67-year-old man presents with progressive dyspnea, orthopnea, and bilateral
lower-extremity edema over the past 3 weeks. Physical 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
reduce mortality most significantly when added early to guideline-directed therapy?
A. Furosemide
B. Digoxin
C. Sacubitril/valsartan
D. Verapamil
Correct Answer: 🔴 C. Sacubitril/valsartan
Explanation: 🔹 Sacubitril/valsartan is an angiotensin receptor-neprilysin inhibitor
(ARNI) that significantly reduces mortality and hospitalization in patients with heart
failure with reduced ejection fraction (HFrEF). Diuretics such as furosemide improve
symptoms but do not confer mortality benefit. Digoxin may reduce hospitalization
frequency but has not demonstrated substantial mortality reduction. Verapamil is
contraindicated in systolic heart failure because of its negative inotropic effects.
Q2. A 54-year-old woman with poorly controlled type 2 diabetes presents with fever,
flank pain, and dysuria. Urinalysis reveals pyuria and positive nitrites. CT imaging
shows gas within the renal parenchyma. Which organism is the most likely cause?
A. Staphylococcus saprophyticus
B. Escherichia coli
C. Enterococcus faecalis
D. Proteus mirabilis
Correct Answer: 🔴 B. Escherichia coli
Explanation: 🔹 Emphysematous pyelonephritis is a severe necrotizing infection most
commonly caused by Escherichia coli in diabetic patients. Gas production occurs due
to glucose fermentation within tissues. Proteus species may produce urease and
stones but are less commonly implicated. Staphylococcus saprophyticus typically
,causes uncomplicated cystitis in young women, while Enterococcus is a less frequent
cause of emphysematous infection.
Q3. A 23-year-old medical student develops fatigue, dark urine, and jaundice one
week after beginning trimethoprim-sulfamethoxazole therapy. Laboratory studies
reveal elevated LDH, decreased haptoglobin, and bite cells on peripheral smear. Which
underlying condition most likely predisposed this patient to the hemolysis?
A. Hereditary spherocytosis
B. Pyruvate kinase deficiency
C. Glucose-6-phosphate dehydrogenase deficiency
D. Autoimmune hemolytic anemia
Correct Answer: 🔴 C. Glucose-6-phosphate dehydrogenase deficiency
Explanation: 🔹 G6PD deficiency predisposes erythrocytes to oxidative damage from
sulfa drugs, antimalarials, and infections. Bite cells result from splenic macrophage
removal of Heinz body-containing erythrocytes. Hereditary spherocytosis produces
spherocytes rather than bite cells. Pyruvate kinase deficiency causes chronic
hemolysis but is not classically triggered by oxidant stress. Autoimmune hemolytic
anemia produces positive Coombs testing and spherocytes.
Q4. A hospitalized patient receiving unfractionated heparin develops
thrombocytopenia and digital ischemia 7 days after initiation of therapy. Which
mechanism best explains this complication?
A. Direct platelet toxicity
B. Autoantibody formation against platelet factor 4 complexes
C. Vitamin K depletion
D. Disseminated intravascular coagulation activation
Correct Answer: 🔴 B. Autoantibody formation against platelet factor 4 complexes
Explanation: 🔹 Heparin-induced thrombocytopenia (HIT) is caused by IgG
antibodies directed against heparin-platelet factor 4 complexes, resulting in
paradoxical thrombosis despite thrombocytopenia. Direct platelet toxicity is not the
, mechanism. Vitamin K depletion is associated with warfarin therapy. DIC may
produce thrombocytopenia but is not the primary pathophysiologic process in HIT.
Q5. A 44-year-old woman presents with episodic headaches, diaphoresis, and
palpitations. Her blood pressure is persistently elevated. Plasma metanephrines are
markedly elevated. Prior to surgical intervention, which medication should be
administered first?
A. Propranolol
B. Hydrochlorothiazide
C. Phenoxybenzamine
D. Lisinopril
Correct Answer: 🔴 C. Phenoxybenzamine
Explanation: 🔹 Pheochromocytoma requires alpha blockade before beta blockade to
avoid unopposed alpha-adrenergic vasoconstriction and hypertensive crisis.
Phenoxybenzamine is a nonselective irreversible alpha blocker used preoperatively.
Beta blockers such as propranolol should only be added after adequate alpha
blockade. Hydrochlorothiazide and lisinopril do not address catecholamine excess.
Q6. A 72-year-old smoker presents with hematuria and weight loss. CT scan reveals a
renal mass. Laboratory studies demonstrate elevated hematocrit and hypercalcemia.
Which diagnosis is most likely?
A. Transitional cell carcinoma
B. Wilms tumor
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 may also produce paraneoplastic syndromes including
erythropoietin-mediated polycythemia and PTHrP-mediated hypercalcemia.
Transitional cell carcinoma arises from the renal pelvis and is less associated with
