COMSAE Comprehensive Examination National Board of
Osteopathic Medical Examiners (NBOME) Academic Year
2026/2027 Comprehensive Osteopathic Medical Examination
176 Verified Questions and Correct Answer Rationales
About This Exam Bank
This comprehensive 148-question exam bank is designed to prepare candidates for COMSAE Comprehensive
Examination National Board of Osteopathic Medical Examiners (NBOME) Academic Year 2026/2027
Comprehensive Osteopathic Medical Examination 176 Verified Questions and Correct Answer Rationales. Every
question is aligned with the latest official content outline and includes a detailed, evidence-based rationale, an
explanation of why each remaining option is incorrect, and a supporting reference.
Keywords
COMSAE Comprehensive Examination National Board of Osteopathic Medical Examiners (NBOME) Academic
Year 2026/2027 Comprehensive Osteopathic Medical Examination 176 Verified Questions and Correct Answer
Rationales, exam bank, practice questions, verified answers, detailed rationales, test prep, study guide, review
questions, certification exam, latest update, COMSAE Comprehensive Examination National Board of Osteopathic
Medical Examiners (NBOME) Academic Year 2026/2027 Comprehensive Osteopathic Medical Examination 176
Verified Questions and Correct Answer Rationales, exam bank, practice questions, verified answers, detailed
PART 1: APPLY OSTEOPATHIC PRINCIPLES AND MANIPULATIVE MEDICINE CONCEPTS
TO CLINICAL SCENARIOS
1. During a cranial osteopathic examination, a somatic dysfunction is noted at the sphenobasilar synchondrosis with
restricted motion in flexion. Which of the following best describes the compensatory viscerosomatic reflex most
likely associated with this dysfunction?
A) Increased parasympathetic outflow via the vagus nerve, leading to bronchoconstriction.
B) Facilitated sympathetic outflow at T1-T4, resulting in altered cardiac rate and contractility.
C) Inhibition of the phrenic nerve, causing diaphragmatic paralysis.
D) Enhanced sacral parasympathetic outflow, promoting detrusor contraction.
' Correct Answer: B
Rationale: The sphenobasilar synchondrosis is linked to dural tension affecting the upper thoracic sympathetic
chain (T1-T4), which modulates cardiac function. Choice A is incorrect because vagal outflow is not primarily
influenced by this specific cranial dysfunction. C is anatomically inaccurate; the phrenic nerve arises from C3-C5
and is not directly inhibited by sphenobasilar motion restriction. D involves sacral parasympathetic fibers unrelated
to cranial dysfunction.
2. A 62-year-old patient with chronic kidney disease (eGFR 28 mL/min/1.73 m²) and type 2 diabetes presents with a
non-healing foot ulcer. Which of the following medication adjustments is most appropriate according to the 2025
ADA Standards of Care?
A) Continue metformin at current dose; add empagliflozin for cardiovascular benefit.
B) Discontinue metformin; initiate dapagliflozin if eGFR >25 mL/min/1.73 m².
C) Switch to glyburide to avoid lactic acidosis risk.
D) Start insulin glargine as first-line therapy and stop all oral agents.
' Correct Answer: B
Page 1
,Rationale: The 2025 ADA Standards recommend continuing SGLT2 inhibitors (e.g., dapagliflozin) down to eGFR
25 mL/min/1.73 m² for renal and cardiovascular protection, but metformin should be discontinued when eGFR <30
due to lactic acidosis risk. A is incorrect because metformin is contraindicated at this eGFR. C is wrong because
glyburide risks hypoglycemia in CKD. D is not first-line; SGLT2 inhibitors are preferred.
3. A 45-year-old patient presents with sudden-onset severe headache, neck stiffness, and photophobia. A
non-contrast head CT is negative. Which of the following is the most appropriate next step in management?
A) Initiate empiric antibiotics for bacterial meningitis.
B) Perform lumbar puncture for cerebrospinal fluid analysis.
C) Order MRI brain with gadolinium to rule out aneurysm.
D) Administer sumatriptan for presumed migraine.
' Correct Answer: B
Rationale: In suspected subarachnoid hemorrhage with a negative non-contrast CT, a lumbar puncture is indicated
to assess for xanthochromia, which can persist for up to 2 weeks. A is premature without CSF findings. C is not the
immediate next step; MRI is less sensitive acutely for SAH. D is contraindicated as sumatriptan could worsen
vasospasm if SAH is present.
4. Which of the following best describes the mechanism by which osteopathic manipulative treatment (OMT) may
reduce lymphatic congestion in a patient with lower extremity edema?
A) Stimulation of sympathetic outflow to increase heart rate and perfusion.
B) Activation of the lymphatic pump via thoracic and abdominal diaphragm techniques.
C) Inhibition of the parasympathetic nervous system to reduce capillary permeability.
D) Direct compression of the iliac veins to enhance venous return.
' Correct Answer: B
Rationale: OMT techniques such as the thoracic pump and abdominal diaphragm release enhance lymphatic flow
by creating pressure gradients that move lymph centrally. A is incorrect because sympathetic stimulation would
vasoconstrict and reduce lymphatic drainage. C is false; parasympathetic inhibition does not reduce capillary
permeability. D is not a standard OMT mechanism and could be harmful.
5. A 58-year-old patient with a history of alcohol use disorder is admitted with confusion, ataxia, and
ophthalmoplegia. Which of the following is the most likely underlying pathophysiologic mechanism?
A) Thiamine deficiency leading to impaired oxidative phosphorylation in the mammillary bodies.
B) Vitamin B12 deficiency causing demyelination of the dorsal columns.
C) Niacin deficiency resulting in pellagra with neurodegeneration.
D) Pyridoxine toxicity causing peripheral neuropathy.
' Correct Answer: A
Rationale: The triad of confusion, ataxia, and ophthalmoplegia suggests Wernicke encephalopathy due to thiamine
(B1) deficiency, which impairs oxidative metabolism in vulnerable brain regions like the mammillary bodies. B12
deficiency causes subacute combined degeneration, not ophthalmoplegia. Niacin deficiency causes pellagra with
dermatitis, diarrhea, and dementia. Pyridoxine toxicity causes sensory neuropathy, not this triad.
6. Which of the following findings on a growth chart is most consistent with constitutional delay of growth and
puberty (CDGP) in an adolescent?
A) Height below 3rd percentile with delayed bone age and normal growth velocity.
B) Height at 10th percentile with advanced bone age and rapid growth velocity.
C) Height at 50th percentile with normal bone age and early puberty.
D) Height below 3rd percentile with normal bone age and low IGF-1.
' Correct Answer: A
Page 2
,Rationale: CDGP is characterized by short stature, delayed bone age (typically 2+ years behind chronological age),
and normal growth velocity, often with a family history of late puberty. B suggests precocious puberty. C is normal.
D suggests growth hormone deficiency, which would have low IGF-1 and no bone age delay.
7. A 70-year-old patient with heart failure with reduced ejection fraction (HFrEF) is started on sacubitril/valsartan.
Which of the following laboratory parameters requires the most careful monitoring after initiation?
A) Serum potassium and creatinine.
B) Liver function tests.
C) Thyroid-stimulating hormone.
D) Serum lipase.
' Correct Answer: A
Rationale: Sacubitril/valsartan, like ACE inhibitors and ARBs, can cause hyperkalemia and worsening renal
function, necessitating monitoring of potassium and creatinine. Liver enzymes, TSH, and lipase are not routinely
affected by this medication. B, C, and D are not standard monitoring parameters for ARNI therapy.
8. A 32-year-old patient presents with a painless, firm, fixed mass in the left supraclavicular area. Which of the
following is the most likely underlying malignancy?
A) Lymphoma
B) Gastric adenocarcinoma
C) Breast cancer
D) Thyroid papillary carcinoma
' Correct Answer: B
Rationale: A left supraclavicular mass (Virchow's node) is classically associated with intra-abdominal
malignancies, especially gastric adenocarcinoma, due to lymphatic drainage via the thoracic duct. Lymphoma can
present with lymphadenopathy but is less specifically linked to this location. Breast cancer typically spreads to
axillary nodes. Thyroid cancer spreads to cervical nodes, not typically supraclavicular.
9. Which of the following is the most appropriate initial diagnostic test for a patient with suspected pulmonary
embolism and a low pretest probability?
A) D-dimer assay
B) CT pulmonary angiography
C) V/Q scan
D) Lower extremity venous duplex ultrasound
' Correct Answer: A
Rationale: In patients with low pretest probability for PE, a negative D-dimer can safely rule out PE, avoiding
unnecessary imaging. CT pulmonary angiography is reserved for higher probability or positive D-dimer. V/Q scan is
used when CT is contraindicated. Venous duplex is for DVT, not PE diagnosis.
10. A 28-year-old patient presents with recurrent episodes of hypoglycemia, and diagnostic fasting reveals elevated
insulin and C-peptide levels. Which of the following is the most likely diagnosis?
A) Insulinoma
B) Factitious hypoglycemia due to exogenous insulin
C) Adrenal insufficiency
D) Hepatic failure
' Correct Answer: A
Rationale: Elevated insulin and C-peptide during hypoglycemia indicate endogenous hyperinsulinism, most
commonly an insulinoma. Exogenous insulin use would suppress C-peptide. Adrenal insufficiency and hepatic
failure cause hypoglycemia with low insulin and C-peptide. Thus, A is correct.
Page 3
, 11. A 62-year-old man with chronic atrial fibrillation on warfarin (INR 2.4) presents with sudden-onset severe right
flank pain and gross hematuria. CT angiography demonstrates a left renal artery occlusion with infarction. Which of
the following best explains the embolic source despite therapeutic anticoagulation?
A) Warfarin's inhibition of vitamin K-dependent factors does not prevent platelet-rich thrombus formation on a
ruptured atherosclerotic plaque
B) Left atrial appendage thrombus can persist despite therapeutic INR because anticoagulation reduces but does
not eliminate embolic risk
C) Renal artery occlusion is more commonly due to in situ thrombosis than cardioembolism in atrial fibrillation
D) Warfarin resistance from vitamin K-rich diet is the most likely cause of this embolic event
' Correct Answer: B
Rationale: Even with therapeutic INR, residual left atrial appendage thrombus can embolize; anticoagulation
reduces but does not abolish stroke/systemic embolism risk. Option A describes arterial plaque thrombosis (more
typical of antiplatelet therapy), C is incorrect since cardioembolism is the dominant mechanism in AF, and D is
unlikely without evidence of resistance.
12. A 28-year-old woman with a history of recurrent sinusitis and bronchiectasis has a chest CT showing situs
inversus totalis. Which of the following is the most likely underlying ultrastructural defect?
A) Absent dynein arms on the outer microtubule doublets of cilia
B) Defective alpha-1 antitrypsin secretion from hepatocytes
C) Abnormal CFTR chloride channel function
D) Deficiency of surfactant protein B synthesis
' Correct Answer: A
Rationale: Primary ciliary dyskinesia (Kartagener syndrome) results from absent or dysfunctional dynein arms,
impairing ciliary motility and causing sinusitis, bronchiectasis, and situs inversus. B describes alpha-1 antitrypsin
deficiency (emphysema/liver disease), C describes cystic fibrosis (no situs inversus), and D causes neonatal
respiratory distress.
13. A 45-year-old man presents with episodic hypertension, palpitations, and diaphoresis. Plasma metanephrines are
markedly elevated. Which of the following genetic syndromes is most strongly associated with this presentation?
A) Multiple endocrine neoplasia type 1 (MEN1)
B) Multiple endocrine neoplasia type 2 (MEN2)
C) Von Hippel-Lindau disease
D) Neurofibromatosis type 1
' Correct Answer: B
Rationale: Pheochromocytoma is a hallmark of MEN2 (RET proto-oncogene), often bilateral and associated with
medullary thyroid carcinoma and hyperparathyroidism. MEN1 involves pituitary, parathyroid, and pancreatic
tumors; VHL and NF1 can cause pheochromocytoma but are less strongly associated than MEN2.
14. A 55-year-old woman with type 2 diabetes has an eGFR of 32 mL/min/1.73 m² and albuminuria. Which of the
following medications is most appropriate to slow progression of chronic kidney disease?
A) Empagliflozin
B) Metformin
C) Glimepiride
D) Pioglitazone
' Correct Answer: A
Rationale: SGLT2 inhibitors (e.g., empagliflozin) are recommended in diabetic CKD with eGFR "e20 to reduce
CKD progression and cardiovascular events. Metformin is contraindicated at eGFR <30, glimepiride risks
hypoglycemia in renal impairment, and pioglitazone lacks renal protective benefit.
Page 4
Osteopathic Medical Examiners (NBOME) Academic Year
2026/2027 Comprehensive Osteopathic Medical Examination
176 Verified Questions and Correct Answer Rationales
About This Exam Bank
This comprehensive 148-question exam bank is designed to prepare candidates for COMSAE Comprehensive
Examination National Board of Osteopathic Medical Examiners (NBOME) Academic Year 2026/2027
Comprehensive Osteopathic Medical Examination 176 Verified Questions and Correct Answer Rationales. Every
question is aligned with the latest official content outline and includes a detailed, evidence-based rationale, an
explanation of why each remaining option is incorrect, and a supporting reference.
Keywords
COMSAE Comprehensive Examination National Board of Osteopathic Medical Examiners (NBOME) Academic
Year 2026/2027 Comprehensive Osteopathic Medical Examination 176 Verified Questions and Correct Answer
Rationales, exam bank, practice questions, verified answers, detailed rationales, test prep, study guide, review
questions, certification exam, latest update, COMSAE Comprehensive Examination National Board of Osteopathic
Medical Examiners (NBOME) Academic Year 2026/2027 Comprehensive Osteopathic Medical Examination 176
Verified Questions and Correct Answer Rationales, exam bank, practice questions, verified answers, detailed
PART 1: APPLY OSTEOPATHIC PRINCIPLES AND MANIPULATIVE MEDICINE CONCEPTS
TO CLINICAL SCENARIOS
1. During a cranial osteopathic examination, a somatic dysfunction is noted at the sphenobasilar synchondrosis with
restricted motion in flexion. Which of the following best describes the compensatory viscerosomatic reflex most
likely associated with this dysfunction?
A) Increased parasympathetic outflow via the vagus nerve, leading to bronchoconstriction.
B) Facilitated sympathetic outflow at T1-T4, resulting in altered cardiac rate and contractility.
C) Inhibition of the phrenic nerve, causing diaphragmatic paralysis.
D) Enhanced sacral parasympathetic outflow, promoting detrusor contraction.
' Correct Answer: B
Rationale: The sphenobasilar synchondrosis is linked to dural tension affecting the upper thoracic sympathetic
chain (T1-T4), which modulates cardiac function. Choice A is incorrect because vagal outflow is not primarily
influenced by this specific cranial dysfunction. C is anatomically inaccurate; the phrenic nerve arises from C3-C5
and is not directly inhibited by sphenobasilar motion restriction. D involves sacral parasympathetic fibers unrelated
to cranial dysfunction.
2. A 62-year-old patient with chronic kidney disease (eGFR 28 mL/min/1.73 m²) and type 2 diabetes presents with a
non-healing foot ulcer. Which of the following medication adjustments is most appropriate according to the 2025
ADA Standards of Care?
A) Continue metformin at current dose; add empagliflozin for cardiovascular benefit.
B) Discontinue metformin; initiate dapagliflozin if eGFR >25 mL/min/1.73 m².
C) Switch to glyburide to avoid lactic acidosis risk.
D) Start insulin glargine as first-line therapy and stop all oral agents.
' Correct Answer: B
Page 1
,Rationale: The 2025 ADA Standards recommend continuing SGLT2 inhibitors (e.g., dapagliflozin) down to eGFR
25 mL/min/1.73 m² for renal and cardiovascular protection, but metformin should be discontinued when eGFR <30
due to lactic acidosis risk. A is incorrect because metformin is contraindicated at this eGFR. C is wrong because
glyburide risks hypoglycemia in CKD. D is not first-line; SGLT2 inhibitors are preferred.
3. A 45-year-old patient presents with sudden-onset severe headache, neck stiffness, and photophobia. A
non-contrast head CT is negative. Which of the following is the most appropriate next step in management?
A) Initiate empiric antibiotics for bacterial meningitis.
B) Perform lumbar puncture for cerebrospinal fluid analysis.
C) Order MRI brain with gadolinium to rule out aneurysm.
D) Administer sumatriptan for presumed migraine.
' Correct Answer: B
Rationale: In suspected subarachnoid hemorrhage with a negative non-contrast CT, a lumbar puncture is indicated
to assess for xanthochromia, which can persist for up to 2 weeks. A is premature without CSF findings. C is not the
immediate next step; MRI is less sensitive acutely for SAH. D is contraindicated as sumatriptan could worsen
vasospasm if SAH is present.
4. Which of the following best describes the mechanism by which osteopathic manipulative treatment (OMT) may
reduce lymphatic congestion in a patient with lower extremity edema?
A) Stimulation of sympathetic outflow to increase heart rate and perfusion.
B) Activation of the lymphatic pump via thoracic and abdominal diaphragm techniques.
C) Inhibition of the parasympathetic nervous system to reduce capillary permeability.
D) Direct compression of the iliac veins to enhance venous return.
' Correct Answer: B
Rationale: OMT techniques such as the thoracic pump and abdominal diaphragm release enhance lymphatic flow
by creating pressure gradients that move lymph centrally. A is incorrect because sympathetic stimulation would
vasoconstrict and reduce lymphatic drainage. C is false; parasympathetic inhibition does not reduce capillary
permeability. D is not a standard OMT mechanism and could be harmful.
5. A 58-year-old patient with a history of alcohol use disorder is admitted with confusion, ataxia, and
ophthalmoplegia. Which of the following is the most likely underlying pathophysiologic mechanism?
A) Thiamine deficiency leading to impaired oxidative phosphorylation in the mammillary bodies.
B) Vitamin B12 deficiency causing demyelination of the dorsal columns.
C) Niacin deficiency resulting in pellagra with neurodegeneration.
D) Pyridoxine toxicity causing peripheral neuropathy.
' Correct Answer: A
Rationale: The triad of confusion, ataxia, and ophthalmoplegia suggests Wernicke encephalopathy due to thiamine
(B1) deficiency, which impairs oxidative metabolism in vulnerable brain regions like the mammillary bodies. B12
deficiency causes subacute combined degeneration, not ophthalmoplegia. Niacin deficiency causes pellagra with
dermatitis, diarrhea, and dementia. Pyridoxine toxicity causes sensory neuropathy, not this triad.
6. Which of the following findings on a growth chart is most consistent with constitutional delay of growth and
puberty (CDGP) in an adolescent?
A) Height below 3rd percentile with delayed bone age and normal growth velocity.
B) Height at 10th percentile with advanced bone age and rapid growth velocity.
C) Height at 50th percentile with normal bone age and early puberty.
D) Height below 3rd percentile with normal bone age and low IGF-1.
' Correct Answer: A
Page 2
,Rationale: CDGP is characterized by short stature, delayed bone age (typically 2+ years behind chronological age),
and normal growth velocity, often with a family history of late puberty. B suggests precocious puberty. C is normal.
D suggests growth hormone deficiency, which would have low IGF-1 and no bone age delay.
7. A 70-year-old patient with heart failure with reduced ejection fraction (HFrEF) is started on sacubitril/valsartan.
Which of the following laboratory parameters requires the most careful monitoring after initiation?
A) Serum potassium and creatinine.
B) Liver function tests.
C) Thyroid-stimulating hormone.
D) Serum lipase.
' Correct Answer: A
Rationale: Sacubitril/valsartan, like ACE inhibitors and ARBs, can cause hyperkalemia and worsening renal
function, necessitating monitoring of potassium and creatinine. Liver enzymes, TSH, and lipase are not routinely
affected by this medication. B, C, and D are not standard monitoring parameters for ARNI therapy.
8. A 32-year-old patient presents with a painless, firm, fixed mass in the left supraclavicular area. Which of the
following is the most likely underlying malignancy?
A) Lymphoma
B) Gastric adenocarcinoma
C) Breast cancer
D) Thyroid papillary carcinoma
' Correct Answer: B
Rationale: A left supraclavicular mass (Virchow's node) is classically associated with intra-abdominal
malignancies, especially gastric adenocarcinoma, due to lymphatic drainage via the thoracic duct. Lymphoma can
present with lymphadenopathy but is less specifically linked to this location. Breast cancer typically spreads to
axillary nodes. Thyroid cancer spreads to cervical nodes, not typically supraclavicular.
9. Which of the following is the most appropriate initial diagnostic test for a patient with suspected pulmonary
embolism and a low pretest probability?
A) D-dimer assay
B) CT pulmonary angiography
C) V/Q scan
D) Lower extremity venous duplex ultrasound
' Correct Answer: A
Rationale: In patients with low pretest probability for PE, a negative D-dimer can safely rule out PE, avoiding
unnecessary imaging. CT pulmonary angiography is reserved for higher probability or positive D-dimer. V/Q scan is
used when CT is contraindicated. Venous duplex is for DVT, not PE diagnosis.
10. A 28-year-old patient presents with recurrent episodes of hypoglycemia, and diagnostic fasting reveals elevated
insulin and C-peptide levels. Which of the following is the most likely diagnosis?
A) Insulinoma
B) Factitious hypoglycemia due to exogenous insulin
C) Adrenal insufficiency
D) Hepatic failure
' Correct Answer: A
Rationale: Elevated insulin and C-peptide during hypoglycemia indicate endogenous hyperinsulinism, most
commonly an insulinoma. Exogenous insulin use would suppress C-peptide. Adrenal insufficiency and hepatic
failure cause hypoglycemia with low insulin and C-peptide. Thus, A is correct.
Page 3
, 11. A 62-year-old man with chronic atrial fibrillation on warfarin (INR 2.4) presents with sudden-onset severe right
flank pain and gross hematuria. CT angiography demonstrates a left renal artery occlusion with infarction. Which of
the following best explains the embolic source despite therapeutic anticoagulation?
A) Warfarin's inhibition of vitamin K-dependent factors does not prevent platelet-rich thrombus formation on a
ruptured atherosclerotic plaque
B) Left atrial appendage thrombus can persist despite therapeutic INR because anticoagulation reduces but does
not eliminate embolic risk
C) Renal artery occlusion is more commonly due to in situ thrombosis than cardioembolism in atrial fibrillation
D) Warfarin resistance from vitamin K-rich diet is the most likely cause of this embolic event
' Correct Answer: B
Rationale: Even with therapeutic INR, residual left atrial appendage thrombus can embolize; anticoagulation
reduces but does not abolish stroke/systemic embolism risk. Option A describes arterial plaque thrombosis (more
typical of antiplatelet therapy), C is incorrect since cardioembolism is the dominant mechanism in AF, and D is
unlikely without evidence of resistance.
12. A 28-year-old woman with a history of recurrent sinusitis and bronchiectasis has a chest CT showing situs
inversus totalis. Which of the following is the most likely underlying ultrastructural defect?
A) Absent dynein arms on the outer microtubule doublets of cilia
B) Defective alpha-1 antitrypsin secretion from hepatocytes
C) Abnormal CFTR chloride channel function
D) Deficiency of surfactant protein B synthesis
' Correct Answer: A
Rationale: Primary ciliary dyskinesia (Kartagener syndrome) results from absent or dysfunctional dynein arms,
impairing ciliary motility and causing sinusitis, bronchiectasis, and situs inversus. B describes alpha-1 antitrypsin
deficiency (emphysema/liver disease), C describes cystic fibrosis (no situs inversus), and D causes neonatal
respiratory distress.
13. A 45-year-old man presents with episodic hypertension, palpitations, and diaphoresis. Plasma metanephrines are
markedly elevated. Which of the following genetic syndromes is most strongly associated with this presentation?
A) Multiple endocrine neoplasia type 1 (MEN1)
B) Multiple endocrine neoplasia type 2 (MEN2)
C) Von Hippel-Lindau disease
D) Neurofibromatosis type 1
' Correct Answer: B
Rationale: Pheochromocytoma is a hallmark of MEN2 (RET proto-oncogene), often bilateral and associated with
medullary thyroid carcinoma and hyperparathyroidism. MEN1 involves pituitary, parathyroid, and pancreatic
tumors; VHL and NF1 can cause pheochromocytoma but are less strongly associated than MEN2.
14. A 55-year-old woman with type 2 diabetes has an eGFR of 32 mL/min/1.73 m² and albuminuria. Which of the
following medications is most appropriate to slow progression of chronic kidney disease?
A) Empagliflozin
B) Metformin
C) Glimepiride
D) Pioglitazone
' Correct Answer: A
Rationale: SGLT2 inhibitors (e.g., empagliflozin) are recommended in diabetic CKD with eGFR "e20 to reduce
CKD progression and cardiovascular events. Metformin is contraindicated at eGFR <30, glimepiride risks
hypoglycemia in renal impairment, and pioglitazone lacks renal protective benefit.
Page 4
