2026 Comprehensive Osteopathic Medical
Self-Assessment Examination (COMSAE) Phase
2 – Assessment Series B Form 115i | Complete
High-Yield Practice Exam | Advanced Clinical
Scenarios | Detailed Rationales | COMLEX
Level 2–Style Board Review
Question 1
A 68-year-old man presents with fever, productive cough,
confusion, and hypotension. His blood pressure is 84/50 mm Hg
despite receiving 3 L of isotonic saline. Chest radiography
demonstrates a right lower lobe infiltrate. Serum lactate is 5.4
mmol/L.
Which intervention should be performed next?
A. Begin norepinephrine infusion
B. Administer sodium bicarbonate
C. Start dopamine infusion
D. Repeat chest radiography
Answer: A. Begin norepinephrine infusion
,Rationale: Septic shock is defined by persistent hypotension
despite adequate fluid resuscitation requiring vasopressors to
maintain MAP ≥65 mm Hg. Norepinephrine is the first-line
vasopressor because it increases vascular tone with fewer
arrhythmias than dopamine. Sodium bicarbonate is generally
not indicated unless severe acidemia is present.
Question 2
A 23-year-old woman develops sudden pleuritic chest pain and
dyspnea 4 days postpartum. She is tachycardic and hypoxic.
What is the most appropriate initial diagnostic study?
A. D-dimer
B. CT pulmonary angiography
C. Chest MRI
D. Exercise stress test
Answer: B. CT pulmonary angiography
Rationale: Pregnancy and the postpartum period markedly
increase venous thromboembolism risk. In a hemodynamically
stable patient, CT pulmonary angiography is generally the
preferred diagnostic test after initial evaluation.
,Question 3
A 55-year-old diabetic presents with fever, flank pain,
hypotension, and leukocytosis. CT demonstrates an obstructing
9-mm proximal ureteral stone with hydronephrosis.
The next best management is:
A. Oral ciprofloxacin
B. Immediate extracorporeal shock-wave lithotripsy
C. Emergent urinary decompression
D. Observation
Answer: C. Emergent urinary decompression
Rationale: Obstructed infected urinary systems are urologic
emergencies. Immediate decompression with ureteral stent or
percutaneous nephrostomy plus IV antibiotics prevents
progression to septic shock.
Question 4
A patient develops severe chest pain radiating to the back.
Blood pressure is 200/110 mm Hg in the left arm and 170/90
mm Hg in the right arm.
Which medication should be administered first?
, A. Nicardipine
B. Esmolol
C. Hydralazine
D. Nitroprusside alone
Answer: B. Esmolol
Rationale: Acute aortic dissection requires reduction of shear
stress before vasodilation. Beta-blockade should precede
vasodilators to prevent reflex tachycardia.
Question 5
A 29-year-old woman presents with unilateral headache, ptosis,
and miosis following chiropractic neck manipulation.
Most likely diagnosis?
A. Cluster headache
B. Vertebral artery dissection
C. Carotid artery dissection
D. Trigeminal neuralgia
Answer: C. Carotid artery dissection
Self-Assessment Examination (COMSAE) Phase
2 – Assessment Series B Form 115i | Complete
High-Yield Practice Exam | Advanced Clinical
Scenarios | Detailed Rationales | COMLEX
Level 2–Style Board Review
Question 1
A 68-year-old man presents with fever, productive cough,
confusion, and hypotension. His blood pressure is 84/50 mm Hg
despite receiving 3 L of isotonic saline. Chest radiography
demonstrates a right lower lobe infiltrate. Serum lactate is 5.4
mmol/L.
Which intervention should be performed next?
A. Begin norepinephrine infusion
B. Administer sodium bicarbonate
C. Start dopamine infusion
D. Repeat chest radiography
Answer: A. Begin norepinephrine infusion
,Rationale: Septic shock is defined by persistent hypotension
despite adequate fluid resuscitation requiring vasopressors to
maintain MAP ≥65 mm Hg. Norepinephrine is the first-line
vasopressor because it increases vascular tone with fewer
arrhythmias than dopamine. Sodium bicarbonate is generally
not indicated unless severe acidemia is present.
Question 2
A 23-year-old woman develops sudden pleuritic chest pain and
dyspnea 4 days postpartum. She is tachycardic and hypoxic.
What is the most appropriate initial diagnostic study?
A. D-dimer
B. CT pulmonary angiography
C. Chest MRI
D. Exercise stress test
Answer: B. CT pulmonary angiography
Rationale: Pregnancy and the postpartum period markedly
increase venous thromboembolism risk. In a hemodynamically
stable patient, CT pulmonary angiography is generally the
preferred diagnostic test after initial evaluation.
,Question 3
A 55-year-old diabetic presents with fever, flank pain,
hypotension, and leukocytosis. CT demonstrates an obstructing
9-mm proximal ureteral stone with hydronephrosis.
The next best management is:
A. Oral ciprofloxacin
B. Immediate extracorporeal shock-wave lithotripsy
C. Emergent urinary decompression
D. Observation
Answer: C. Emergent urinary decompression
Rationale: Obstructed infected urinary systems are urologic
emergencies. Immediate decompression with ureteral stent or
percutaneous nephrostomy plus IV antibiotics prevents
progression to septic shock.
Question 4
A patient develops severe chest pain radiating to the back.
Blood pressure is 200/110 mm Hg in the left arm and 170/90
mm Hg in the right arm.
Which medication should be administered first?
, A. Nicardipine
B. Esmolol
C. Hydralazine
D. Nitroprusside alone
Answer: B. Esmolol
Rationale: Acute aortic dissection requires reduction of shear
stress before vasodilation. Beta-blockade should precede
vasodilators to prevent reflex tachycardia.
Question 5
A 29-year-old woman presents with unilateral headache, ptosis,
and miosis following chiropractic neck manipulation.
Most likely diagnosis?
A. Cluster headache
B. Vertebral artery dissection
C. Carotid artery dissection
D. Trigeminal neuralgia
Answer: C. Carotid artery dissection
