2026 Comprehensive Osteopathic Medical
Self-Assessment Examination (COMSAE) Phase
2 – Assessment Series B Form 118 | Complete
Clinical Practice Question Bank | High-Yield
Board Review | Detailed Rationales | COMLEX
Level 2–Style Preparation Question 1
1.A 67-year-old man presents with crushing substernal chest
pain radiating to his left arm for 50 minutes. ECG demonstrates
ST-segment elevation in leads II, III, and aVF. Blood pressure is
82/56 mmHg. Lung examination reveals clear breath sounds
bilaterally. Which intervention should be avoided initially?
A. Intravenous normal saline
B. Emergent coronary angiography
C. Sublingual nitroglycerin
D. Aspirin 325 mg
Answer: C. Sublingual nitroglycerin
Rationale: Inferior STEMI with hypotension and clear lungs
strongly suggests right ventricular infarction. Right ventricular
,preload is essential for maintaining cardiac output.
Nitroglycerin decreases preload and can precipitate profound
hypotension. Initial management includes aspirin, IV fluids,
urgent reperfusion, and avoidance of preload-reducing
medications until right ventricular involvement is excluded.
Question 2
A 29-year-old woman presents with fever, dysuria, flank pain,
nausea, and vomiting for two days. Temperature is 39.2°C
(102.6°F). Urinalysis demonstrates numerous WBCs, positive
leukocyte esterase, and WBC casts. Which diagnosis is most
likely?
A. Acute cystitis
B. Acute pyelonephritis
C. Interstitial cystitis
D. Nephrolithiasis
Answer: B. Acute pyelonephritis
Rationale: Flank pain, fever, systemic illness, and WBC casts
indicate infection involving the renal parenchyma. Acute cystitis
usually lacks fever and flank tenderness. Interstitial cystitis
causes chronic pelvic pain without systemic infection.
Nephrolithiasis causes hematuria and colicky pain but not WBC
, casts unless complicated by infection.
Question 3
A 72-year-old woman is admitted with fever, productive cough,
and confusion. Blood pressure is 82/48 mmHg despite receiving
2 L of intravenous crystalloid. Serum lactate is 5.1 mmol/L.
Which is the most appropriate next step?
A. Begin norepinephrine infusion
B. Administer furosemide
C. Obtain CT scan of the chest before treatment
D. Start sodium bicarbonate infusion
Answer: A. Begin norepinephrine infusion
Rationale: This patient has septic shock because hypotension
persists despite adequate fluid resuscitation and lactate is
elevated. Norepinephrine is the first-line vasopressor after
appropriate fluid administration. Imaging should never delay
treatment, bicarbonate is generally not indicated unless severe
acidemia is present, and diuretics would worsen hypotension.
Question 4
A 26-year-old woman develops sudden pleuritic chest pain and
dyspnea 5 days after knee surgery. Heart rate is 122/min,
Self-Assessment Examination (COMSAE) Phase
2 – Assessment Series B Form 118 | Complete
Clinical Practice Question Bank | High-Yield
Board Review | Detailed Rationales | COMLEX
Level 2–Style Preparation Question 1
1.A 67-year-old man presents with crushing substernal chest
pain radiating to his left arm for 50 minutes. ECG demonstrates
ST-segment elevation in leads II, III, and aVF. Blood pressure is
82/56 mmHg. Lung examination reveals clear breath sounds
bilaterally. Which intervention should be avoided initially?
A. Intravenous normal saline
B. Emergent coronary angiography
C. Sublingual nitroglycerin
D. Aspirin 325 mg
Answer: C. Sublingual nitroglycerin
Rationale: Inferior STEMI with hypotension and clear lungs
strongly suggests right ventricular infarction. Right ventricular
,preload is essential for maintaining cardiac output.
Nitroglycerin decreases preload and can precipitate profound
hypotension. Initial management includes aspirin, IV fluids,
urgent reperfusion, and avoidance of preload-reducing
medications until right ventricular involvement is excluded.
Question 2
A 29-year-old woman presents with fever, dysuria, flank pain,
nausea, and vomiting for two days. Temperature is 39.2°C
(102.6°F). Urinalysis demonstrates numerous WBCs, positive
leukocyte esterase, and WBC casts. Which diagnosis is most
likely?
A. Acute cystitis
B. Acute pyelonephritis
C. Interstitial cystitis
D. Nephrolithiasis
Answer: B. Acute pyelonephritis
Rationale: Flank pain, fever, systemic illness, and WBC casts
indicate infection involving the renal parenchyma. Acute cystitis
usually lacks fever and flank tenderness. Interstitial cystitis
causes chronic pelvic pain without systemic infection.
Nephrolithiasis causes hematuria and colicky pain but not WBC
, casts unless complicated by infection.
Question 3
A 72-year-old woman is admitted with fever, productive cough,
and confusion. Blood pressure is 82/48 mmHg despite receiving
2 L of intravenous crystalloid. Serum lactate is 5.1 mmol/L.
Which is the most appropriate next step?
A. Begin norepinephrine infusion
B. Administer furosemide
C. Obtain CT scan of the chest before treatment
D. Start sodium bicarbonate infusion
Answer: A. Begin norepinephrine infusion
Rationale: This patient has septic shock because hypotension
persists despite adequate fluid resuscitation and lactate is
elevated. Norepinephrine is the first-line vasopressor after
appropriate fluid administration. Imaging should never delay
treatment, bicarbonate is generally not indicated unless severe
acidemia is present, and diuretics would worsen hypotension.
Question 4
A 26-year-old woman develops sudden pleuritic chest pain and
dyspnea 5 days after knee surgery. Heart rate is 122/min,
