COMSAE PHASE 2 FORM 120+ ACTUAL
QUESTIONS AND COMPLETE
SOLUTIONS — LATEST UPDATE
2026/2027 | GRADED A+ | COMPLETE
EXAM STUDY GUIDE
COMSAE PHASE 2 — EXAM OVERVIEW
Core Domains
Internal Medicine (Cardiovascular, Respiratory, Gastrointestinal,
Endocrine, Renal, Hematology-Oncology, Rheumatology)
Surgery and Perioperative Care
Obstetrics and Gynecology
Pediatrics and Adolescent Medicine
Psychiatry and Behavioral Health
Emergency Medicine and Critical Care
Preventive Medicine and Biostatistics
Osteopathic Principles and Practice (OPP/OMM)
Introduction
The COMSAE Phase 2 is a diagnostic self-assessment examination
developed by the National Board of Osteopathic Medical Examiners
(NBOME) to evaluate an osteopathic medical student's readiness for the
COMLEX-USA Level 2-Cognitive Evaluation (CE). The examination
emphasizes the concepts and principles necessary for making
appropriate medical diagnoses, with content defined by the same
categories as the COMLEX Dimension 1 topics. As of February 2026,
,the COMSAE Phase 2 consists of 160 single-best-answer, multiple-
choice questions divided into four sections of 40 questions each, reduced
from the previous 176 questions. Questions include complex clinical
vignettes and scenario-based items requiring synthesis of information,
critical thinking, and application of evidence-based medicine. This
comprehensive review covers all clinical science domains tested on the
2026/2027 examination cycle.
SECTION ONE: CARDIOVASCULAR MEDICINE (Questions 1–
25)
1. A 68-year-old male with a history of hypertension, type 2 diabetes,
and hyperlipidemia presents to the emergency department with
acute-onset severe substernal chest pain radiating to his jaw and left
arm. He is diaphoretic and nauseous. ECG shows ST-segment
elevation in leads V1-V4. Cardiac enzymes are pending. Which of
the following is the most appropriate immediate management?
A. Administer aspirin 324 mg chewed, nitroglycerin sublingual, and
morphine sulfate IV
B. Administer thrombolytic therapy immediately
C. Administer heparin IV bolus and start heparin drip
D. Administer clopidogrel 600 mg loading dose only
A. Administer aspirin 324 mg chewed, nitroglycerin sublingual, and
morphine sulfate IV
RATIONALE: The immediate management of acute ST-elevation
myocardial infarction includes aspirin (antiplatelet), nitroglycerin
(vasodilator for pain and ischemia), and morphine (analgesic and
,preload reducer). Thrombolytic therapy is indicated only if percutaneous
coronary intervention (PCI) is not available within 90-120 minutes.
2. A 62-year-old man presents with crushing substernal chest pain
that began 45 minutes ago. ECG shows ST-segment elevation in
leads II, III, and aVF. He is diagnosed with an acute inferior wall
myocardial infarction. Which coronary artery is most likely
occluded?
A. Left anterior descending artery
B. Right coronary artery
C. Left circumflex artery
D. Left main coronary artery
B. Right coronary artery
RATIONALE: ST elevations in leads II, III, and aVF indicate an
inferior wall MI, which is most commonly caused by occlusion of the
right coronary artery (RCA). The RCA supplies the inferior wall of the
left ventricle in approximately 80-90% of individuals (right-dominant
circulation).
3. A 57-year-old man with hypertension and type 2 diabetes presents
with acute substernal chest pain radiating to the left arm. ECG
shows ST elevations in leads II, III, and aVF. Which is the most
appropriate next step?
A. Aspirin and immediate PCI
B. Aspirin and IV tPA
C. Aspirin and clopidogrel with medical management
D. Aspirin and urgent CABG
A. Aspirin and immediate PCI
, RATIONALE: The patient is having an acute inferior STEMI.
Immediate reperfusion with percutaneous coronary intervention (PCI)
within 90 minutes of presentation is the treatment of choice. If PCI is not
available within 90-120 minutes, fibrinolysis (tPA) would be considered.
4. A 71-year-old woman with atrial fibrillation on warfarin presents
with sudden onset of left arm weakness and facial droop. Last
known well 70 minutes ago. INR is 1.8. CT head shows no
hemorrhage. Which is the most appropriate next step?
A. IV tPA
B. Aspirin 325 mg
C. Mechanical thrombectomy
D. Heparin drip
A. IV tPA
RATIONALE: The patient presents within the thrombolytic window
(within 4.5 hours) with no hemorrhage on CT. An INR of 1.8 is below
the threshold of 1.7 for exclusion (though guidelines vary), and the
patient is a candidate for IV tPA. Mechanical thrombectomy is reserved
for large vessel occlusions.
5. A 64-year-old man develops substernal chest pressure while
climbing stairs. The pain resolves with rest. Which is the most likely
diagnosis?
A. Unstable angina
B. Stable angina
C. Acute pericarditis
D. Mitral stenosis
B. Stable angina
QUESTIONS AND COMPLETE
SOLUTIONS — LATEST UPDATE
2026/2027 | GRADED A+ | COMPLETE
EXAM STUDY GUIDE
COMSAE PHASE 2 — EXAM OVERVIEW
Core Domains
Internal Medicine (Cardiovascular, Respiratory, Gastrointestinal,
Endocrine, Renal, Hematology-Oncology, Rheumatology)
Surgery and Perioperative Care
Obstetrics and Gynecology
Pediatrics and Adolescent Medicine
Psychiatry and Behavioral Health
Emergency Medicine and Critical Care
Preventive Medicine and Biostatistics
Osteopathic Principles and Practice (OPP/OMM)
Introduction
The COMSAE Phase 2 is a diagnostic self-assessment examination
developed by the National Board of Osteopathic Medical Examiners
(NBOME) to evaluate an osteopathic medical student's readiness for the
COMLEX-USA Level 2-Cognitive Evaluation (CE). The examination
emphasizes the concepts and principles necessary for making
appropriate medical diagnoses, with content defined by the same
categories as the COMLEX Dimension 1 topics. As of February 2026,
,the COMSAE Phase 2 consists of 160 single-best-answer, multiple-
choice questions divided into four sections of 40 questions each, reduced
from the previous 176 questions. Questions include complex clinical
vignettes and scenario-based items requiring synthesis of information,
critical thinking, and application of evidence-based medicine. This
comprehensive review covers all clinical science domains tested on the
2026/2027 examination cycle.
SECTION ONE: CARDIOVASCULAR MEDICINE (Questions 1–
25)
1. A 68-year-old male with a history of hypertension, type 2 diabetes,
and hyperlipidemia presents to the emergency department with
acute-onset severe substernal chest pain radiating to his jaw and left
arm. He is diaphoretic and nauseous. ECG shows ST-segment
elevation in leads V1-V4. Cardiac enzymes are pending. Which of
the following is the most appropriate immediate management?
A. Administer aspirin 324 mg chewed, nitroglycerin sublingual, and
morphine sulfate IV
B. Administer thrombolytic therapy immediately
C. Administer heparin IV bolus and start heparin drip
D. Administer clopidogrel 600 mg loading dose only
A. Administer aspirin 324 mg chewed, nitroglycerin sublingual, and
morphine sulfate IV
RATIONALE: The immediate management of acute ST-elevation
myocardial infarction includes aspirin (antiplatelet), nitroglycerin
(vasodilator for pain and ischemia), and morphine (analgesic and
,preload reducer). Thrombolytic therapy is indicated only if percutaneous
coronary intervention (PCI) is not available within 90-120 minutes.
2. A 62-year-old man presents with crushing substernal chest pain
that began 45 minutes ago. ECG shows ST-segment elevation in
leads II, III, and aVF. He is diagnosed with an acute inferior wall
myocardial infarction. Which coronary artery is most likely
occluded?
A. Left anterior descending artery
B. Right coronary artery
C. Left circumflex artery
D. Left main coronary artery
B. Right coronary artery
RATIONALE: ST elevations in leads II, III, and aVF indicate an
inferior wall MI, which is most commonly caused by occlusion of the
right coronary artery (RCA). The RCA supplies the inferior wall of the
left ventricle in approximately 80-90% of individuals (right-dominant
circulation).
3. A 57-year-old man with hypertension and type 2 diabetes presents
with acute substernal chest pain radiating to the left arm. ECG
shows ST elevations in leads II, III, and aVF. Which is the most
appropriate next step?
A. Aspirin and immediate PCI
B. Aspirin and IV tPA
C. Aspirin and clopidogrel with medical management
D. Aspirin and urgent CABG
A. Aspirin and immediate PCI
, RATIONALE: The patient is having an acute inferior STEMI.
Immediate reperfusion with percutaneous coronary intervention (PCI)
within 90 minutes of presentation is the treatment of choice. If PCI is not
available within 90-120 minutes, fibrinolysis (tPA) would be considered.
4. A 71-year-old woman with atrial fibrillation on warfarin presents
with sudden onset of left arm weakness and facial droop. Last
known well 70 minutes ago. INR is 1.8. CT head shows no
hemorrhage. Which is the most appropriate next step?
A. IV tPA
B. Aspirin 325 mg
C. Mechanical thrombectomy
D. Heparin drip
A. IV tPA
RATIONALE: The patient presents within the thrombolytic window
(within 4.5 hours) with no hemorrhage on CT. An INR of 1.8 is below
the threshold of 1.7 for exclusion (though guidelines vary), and the
patient is a candidate for IV tPA. Mechanical thrombectomy is reserved
for large vessel occlusions.
5. A 64-year-old man develops substernal chest pressure while
climbing stairs. The pain resolves with rest. Which is the most likely
diagnosis?
A. Unstable angina
B. Stable angina
C. Acute pericarditis
D. Mitral stenosis
B. Stable angina
