COMSAE Phase 2 Form 114: 200+ Practice Questions &
Answers with Explantion | NBOME Osteopathic Exam
Prep Newest 2025/2026 Instant downoad pdf.
Question 1
A 68 year old man with history of heart failure presents with acute dyspnea and pink
frothy sputum. Lung auscultation reveals diffuse crackles. Blood pressure is 150/90 mm
Hg and heart rate 110 bpm. What is the most appropriate immediate intervention
A) IV furosemide
B) IV nitroglycerin
C) IV morphine
D) Noninvasive positive pressure ventilation
Answer: D
Explanation: Noninvasive positive pressure ventilation (NIPPV) provides immediate
improvement in oxygenation and reduces preload and afterload in acute cardiogenic
pulmonary edema. While furosemide, nitroglycerin, and morphine are all used, NIPPV is
the most rapidly effective intervention for severe respiratory distress.
Question 2
A 45 year old woman presents with episodic headaches, palpitations, and sweating. Her
blood pressure is 190/110 mm Hg during an episode. Which laboratory test is most
helpful in confirming the diagnosis
A) Plasma metanephrines
B) Serum aldosterone to renin ratio
C) Urinary free cortisol
D) Serum calcium
,Answer: A
Explanation: Episodic hypertension with headache, palpitations, and diaphoresis suggests
pheochromocytoma. Plasma metanephrines or urinary fractionated metanephrines are the
best screening tests due to high sensitivity. Aldosterone to renin ratio is for primary
hyperaldosteronism, and urinary free cortisol for Cushing syndrome.
Question 3
A 72 year old woman with osteoporosis presents with acute onset severe back pain after
lifting a heavy box. She is unable to stand. What is the most appropriate next imaging
study
A) MRI spine without contrast
B) CT spine without contrast
C) X ray spine
D) Bone scan
Answer: A
Explanation: Acute severe back pain in an osteoporotic patient after lifting suggests
vertebral compression fracture. MRI without contrast is best to differentiate acute fracture
from malignancy or infection and to assess for cord or nerve root compromise. X ray may
miss acute fractures without edema.
Question 4
A newborn has respiratory distress, absent breath sounds on the left, and a scaphoid
abdomen. What is the most likely diagnosis
A) Congenital diaphragmatic hernia
B) Pneumothorax
,C) Meconium aspiration syndrome
D) Tracheoesophageal fistula
Answer: A
Explanation: The combination of respiratory distress, absent breath sounds on one side,
and a scaphoid abdomen in a newborn is classic for congenital diaphragmatic hernia,
usually a Bochdalek hernia. Abdominal contents herniate into the chest, compressing the
lung and causing a scaphoid abdomen from reduced abdominal contents.
Question 5
A 30 year old man has fatigue, weight gain, cold intolerance, and constipation. TSH is 25
mIU/L (normal 0.4-4.0) and free T4 is 0.5 ng/dL (normal 0.8-1.8). What is the most
appropriate treatment
A) Levothyroxine 25 mcg daily
B) Levothyroxine 100 mcg daily
C) Methimazole
D) Observation with repeat TSH in 6 weeks
Answer: B
*Explanation: This patient has overt primary hypothyroidism based on elevated TSH and
low free T4. The usual starting dose of levothyroxine for a young healthy adult is 1.6
mcg/kg/day, approximately 100-150 mcg daily. Low dose 25 mcg is used for elderly or
those with cardiac disease. Methimazole treats hyperthyroidism.*
Question 6
A 55 year old man with cirrhosis presents with confusion, asterixis, and elevated
ammonia. What medication is first line for reducing ammonia levels in hepatic
, encephalopathy
A) Rifaximin
B) Lactulose
C) Neomycin
D) Lactobacillus
Answer: B
Explanation: Lactulose is first line for hepatic encephalopathy. It works by acidifying the
colon, converting ammonia to ammonium ion which cannot be absorbed, and promoting
bacterial incorporation of nitrogen. Rifaximin is an add-on agent for recurrent
encephalopathy. Neomycin is less preferred due to nephrotoxicity.
Question 7
A 28 year old pregnant woman at 32 weeks gestation has asymptomatic bacteriuria on a
routine urine culture. Which of the following antibiotics is safe and appropriate for
treatment in pregnancy
A) Nitrofurantoin
B) Ciprofloxacin
C) Doxycycline
D) Trimethoprim-sulfamethoxazole
Answer: A
Explanation: Nitrofurantoin is safe and effective for asymptomatic bacteriuria in
pregnancy (except near term due to possible hemolysis in the newborn). Fluoroquinolones
like ciprofloxacin are avoided in pregnancy due to cartilage toxicity risk. Doxycycline is
teratogenic and causes tooth discoloration. TMP-SMX is avoided in third trimester due to
kernicterus risk.
Answers with Explantion | NBOME Osteopathic Exam
Prep Newest 2025/2026 Instant downoad pdf.
Question 1
A 68 year old man with history of heart failure presents with acute dyspnea and pink
frothy sputum. Lung auscultation reveals diffuse crackles. Blood pressure is 150/90 mm
Hg and heart rate 110 bpm. What is the most appropriate immediate intervention
A) IV furosemide
B) IV nitroglycerin
C) IV morphine
D) Noninvasive positive pressure ventilation
Answer: D
Explanation: Noninvasive positive pressure ventilation (NIPPV) provides immediate
improvement in oxygenation and reduces preload and afterload in acute cardiogenic
pulmonary edema. While furosemide, nitroglycerin, and morphine are all used, NIPPV is
the most rapidly effective intervention for severe respiratory distress.
Question 2
A 45 year old woman presents with episodic headaches, palpitations, and sweating. Her
blood pressure is 190/110 mm Hg during an episode. Which laboratory test is most
helpful in confirming the diagnosis
A) Plasma metanephrines
B) Serum aldosterone to renin ratio
C) Urinary free cortisol
D) Serum calcium
,Answer: A
Explanation: Episodic hypertension with headache, palpitations, and diaphoresis suggests
pheochromocytoma. Plasma metanephrines or urinary fractionated metanephrines are the
best screening tests due to high sensitivity. Aldosterone to renin ratio is for primary
hyperaldosteronism, and urinary free cortisol for Cushing syndrome.
Question 3
A 72 year old woman with osteoporosis presents with acute onset severe back pain after
lifting a heavy box. She is unable to stand. What is the most appropriate next imaging
study
A) MRI spine without contrast
B) CT spine without contrast
C) X ray spine
D) Bone scan
Answer: A
Explanation: Acute severe back pain in an osteoporotic patient after lifting suggests
vertebral compression fracture. MRI without contrast is best to differentiate acute fracture
from malignancy or infection and to assess for cord or nerve root compromise. X ray may
miss acute fractures without edema.
Question 4
A newborn has respiratory distress, absent breath sounds on the left, and a scaphoid
abdomen. What is the most likely diagnosis
A) Congenital diaphragmatic hernia
B) Pneumothorax
,C) Meconium aspiration syndrome
D) Tracheoesophageal fistula
Answer: A
Explanation: The combination of respiratory distress, absent breath sounds on one side,
and a scaphoid abdomen in a newborn is classic for congenital diaphragmatic hernia,
usually a Bochdalek hernia. Abdominal contents herniate into the chest, compressing the
lung and causing a scaphoid abdomen from reduced abdominal contents.
Question 5
A 30 year old man has fatigue, weight gain, cold intolerance, and constipation. TSH is 25
mIU/L (normal 0.4-4.0) and free T4 is 0.5 ng/dL (normal 0.8-1.8). What is the most
appropriate treatment
A) Levothyroxine 25 mcg daily
B) Levothyroxine 100 mcg daily
C) Methimazole
D) Observation with repeat TSH in 6 weeks
Answer: B
*Explanation: This patient has overt primary hypothyroidism based on elevated TSH and
low free T4. The usual starting dose of levothyroxine for a young healthy adult is 1.6
mcg/kg/day, approximately 100-150 mcg daily. Low dose 25 mcg is used for elderly or
those with cardiac disease. Methimazole treats hyperthyroidism.*
Question 6
A 55 year old man with cirrhosis presents with confusion, asterixis, and elevated
ammonia. What medication is first line for reducing ammonia levels in hepatic
, encephalopathy
A) Rifaximin
B) Lactulose
C) Neomycin
D) Lactobacillus
Answer: B
Explanation: Lactulose is first line for hepatic encephalopathy. It works by acidifying the
colon, converting ammonia to ammonium ion which cannot be absorbed, and promoting
bacterial incorporation of nitrogen. Rifaximin is an add-on agent for recurrent
encephalopathy. Neomycin is less preferred due to nephrotoxicity.
Question 7
A 28 year old pregnant woman at 32 weeks gestation has asymptomatic bacteriuria on a
routine urine culture. Which of the following antibiotics is safe and appropriate for
treatment in pregnancy
A) Nitrofurantoin
B) Ciprofloxacin
C) Doxycycline
D) Trimethoprim-sulfamethoxazole
Answer: A
Explanation: Nitrofurantoin is safe and effective for asymptomatic bacteriuria in
pregnancy (except near term due to possible hemolysis in the newborn). Fluoroquinolones
like ciprofloxacin are avoided in pregnancy due to cartilage toxicity risk. Doxycycline is
teratogenic and causes tooth discoloration. TMP-SMX is avoided in third trimester due to
kernicterus risk.
