COMSAE PHASE 3 FORM 304 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2026 Q&A | LATEST EXAM UPDATE 2026/2027.
Core Domains:
1. Internal Medicine
2. Obstetrics and Gynecology
3. Pediatrics
4. Psychiatry and Behavioral Medicine
5. Surgery and Surgical Subspecialties
6. Emergency Medicine and Acute Care
7. Preventive Medicine and Public Health
8. Medical Ethics and Jurisprudence
9. Pharmacology and Therapeutics
10. Osteopathic Principles and Practice
Introduction
This comprehensive examination is designed to rigorously assess the clinical competence and decision-making
skills of candidates for the COMSAE Phase 3. It evaluates the integration of foundational medical knowledge with
the practical application required for independent, unsupervised practice. The assessment employs a multiple-
choice, scenario-based format that simulates real-world clinical encounters, emphasizing diagnostic acumen,
treatment planning, and patient management. Candidates will be challenged to apply evidence-based guidelines,
navigate complex ethical dilemmas, and demonstrate proficiency in osteopathic principles, ensuring preparedness
for the full scope of responsibilities in a clinical setting.
SECTION ONE: QUESTIONS 1-100
,Question 1
A 72-year-old male with a history of hypertension and type 2 diabetes mellitus presents with a 30-minute
episode of slurred speech and right-sided weakness that completely resolved. He is currently asymptomatic. His
blood pressure is 148/88 mmHg. What is the most appropriate next step in management?
A. Initiate aspirin 81 mg daily
B. Start clopidogrel 75 mg daily
C. Perform a carotid endarterectomy immediately
D. Discontinue metformin and start insulin
🟢 A. Initiate aspirin 81 mg daily
🔴 RATIONALE: This patient experienced a transient ischemic attack (TIA). Immediate management focuses on
secondary stroke prevention. Aspirin is indicated for long-term antiplatelet therapy following a TIA. Carotid
endarterectomy is considered for significant stenosis (>70%) after imaging, not immediately. Clopidogrel may
be used, but aspirin is the standard first-line agent in this setting.
Question 2
A 28-year-old G1P0 at 39 weeks gestation presents with a sudden onset of severe, tearing abdominal pain and
a rigid, board-like abdomen. Fetal heart rate tracing shows late decelerations. What is the most likely diagnosis
and the immediate next step?
A. Placental abruption; prepare for immediate cesarean section
B. Uterine rupture; administer tocolytics
C. Acute pancreatitis; obtain a lipase level
D. Ruptured ectopic pregnancy; perform a pelvic ultrasound
🟢 A. Placental abruption; prepare for immediate cesarean section
🔴 RATIONALE: The acute onset of severe pain and a rigid abdomen with fetal distress in a term pregnancy is
classic for placental abruption. Late decelerations indicate fetal hypoxia, necessitating immediate delivery,
,typically via emergent cesarean section. Uterine rupture is a consideration but less likely without a uterine scar,
and tocolytics are contraindicated.
Question 3
A 6-year-old child presents with a 3-day history of a barking cough, stridor, and hoarseness. Symptoms worsen
at night. On examination, the child is afebrile and in mild respiratory distress with subcostal retractions. What is
the most appropriate next step in management?
A. Administer nebulized racemic epinephrine
B. Obtain a lateral neck X-ray
C. Start oral amoxicillin
D. Perform a direct laryngoscopy
🟢 A. Administer nebulized racemic epinephrine
🔴 RATIONALE: The presentation is consistent with moderate croup (laryngotracheobronchitis). Nebulized
racemic epinephrine is indicated for moderate to severe croup to reduce airway edema. Corticosteroids should
also be given. A lateral neck X-ray is for suspected epiglottitis (not croup) and should not delay treatment.
Question 4
A 45-year-old male with a history of alcohol use disorder is brought to the emergency department by police
after being found confused and disoriented. He is agitated, diaphoretic, and has a tremor. His heart rate is 115
bpm, and blood pressure is 155/95 mmHg. What is the most appropriate initial pharmacological intervention?
A. Haloperidol 5 mg IM
B. Lorazepam 2 mg IV
C. Thiamine 100 mg IV
D. Naloxone 0.4 mg IV
🟢 B. Lorazepam 2 mg IV
🔴 RATIONALE: This patient is presenting with symptoms of alcohol withdrawal, which can progress to delirium
, tremens. Benzodiazepines, such as lorazepam, are the mainstay of treatment to prevent progression.
Haloperidol is not first-line and can lower the seizure threshold. Thiamine is important to prevent Wernicke's
encephalopathy but is not the immediate treatment for acute agitation in this context.
Question 5
A 68-year-old female with a history of COPD presents with increasing shortness of breath and a productive
cough with purulent sputum for the past 3 days. She is on home oxygen at 2 L/min. Her oxygen saturation is
88% on 4 L/min via nasal cannula, respiratory rate is 28/min, and she is using accessory muscles. An arterial
blood gas shows pH 7.31, PaCO2 62 mmHg, PaO2 55 mmHg. What is the most appropriate next step in
management?
A. Administer nebulized albuterol and ipratropium
B. Increase home oxygen to 6 L/min via nasal cannula
C. Start non-invasive positive pressure ventilation (NIPPV)
D. Administer intravenous methylprednisolone
🟢 C. Start non-invasive positive pressure ventilation (NIPPV)
🔴 RATIONALE: This patient has an acute exacerbation of COPD with hypercapnic respiratory failure (pH <7.35,
PaCO2 >45). NIPPV (e.g., BiPAP) is the first-line treatment to improve ventilation and reduce the need for
intubation. While bronchodilators and steroids are part of the treatment regimen, the priority is respiratory
support with NIPPV.
Question 6
A 32-year-old female presents with a 2-week history of a non-productive cough, fever, and night sweats. She
has a history of IV drug use. A chest X-ray reveals a cavitary lesion in the right upper lobe. An acid-fast bacilli
(AFB) smear is positive. Which of the following is the most appropriate initial treatment regimen?
A. Isoniazid, rifampin, pyrazinamide, and ethambutol
B. Isoniazid and rifampin only
RATIONALES 2026 Q&A | LATEST EXAM UPDATE 2026/2027.
Core Domains:
1. Internal Medicine
2. Obstetrics and Gynecology
3. Pediatrics
4. Psychiatry and Behavioral Medicine
5. Surgery and Surgical Subspecialties
6. Emergency Medicine and Acute Care
7. Preventive Medicine and Public Health
8. Medical Ethics and Jurisprudence
9. Pharmacology and Therapeutics
10. Osteopathic Principles and Practice
Introduction
This comprehensive examination is designed to rigorously assess the clinical competence and decision-making
skills of candidates for the COMSAE Phase 3. It evaluates the integration of foundational medical knowledge with
the practical application required for independent, unsupervised practice. The assessment employs a multiple-
choice, scenario-based format that simulates real-world clinical encounters, emphasizing diagnostic acumen,
treatment planning, and patient management. Candidates will be challenged to apply evidence-based guidelines,
navigate complex ethical dilemmas, and demonstrate proficiency in osteopathic principles, ensuring preparedness
for the full scope of responsibilities in a clinical setting.
SECTION ONE: QUESTIONS 1-100
,Question 1
A 72-year-old male with a history of hypertension and type 2 diabetes mellitus presents with a 30-minute
episode of slurred speech and right-sided weakness that completely resolved. He is currently asymptomatic. His
blood pressure is 148/88 mmHg. What is the most appropriate next step in management?
A. Initiate aspirin 81 mg daily
B. Start clopidogrel 75 mg daily
C. Perform a carotid endarterectomy immediately
D. Discontinue metformin and start insulin
🟢 A. Initiate aspirin 81 mg daily
🔴 RATIONALE: This patient experienced a transient ischemic attack (TIA). Immediate management focuses on
secondary stroke prevention. Aspirin is indicated for long-term antiplatelet therapy following a TIA. Carotid
endarterectomy is considered for significant stenosis (>70%) after imaging, not immediately. Clopidogrel may
be used, but aspirin is the standard first-line agent in this setting.
Question 2
A 28-year-old G1P0 at 39 weeks gestation presents with a sudden onset of severe, tearing abdominal pain and
a rigid, board-like abdomen. Fetal heart rate tracing shows late decelerations. What is the most likely diagnosis
and the immediate next step?
A. Placental abruption; prepare for immediate cesarean section
B. Uterine rupture; administer tocolytics
C. Acute pancreatitis; obtain a lipase level
D. Ruptured ectopic pregnancy; perform a pelvic ultrasound
🟢 A. Placental abruption; prepare for immediate cesarean section
🔴 RATIONALE: The acute onset of severe pain and a rigid abdomen with fetal distress in a term pregnancy is
classic for placental abruption. Late decelerations indicate fetal hypoxia, necessitating immediate delivery,
,typically via emergent cesarean section. Uterine rupture is a consideration but less likely without a uterine scar,
and tocolytics are contraindicated.
Question 3
A 6-year-old child presents with a 3-day history of a barking cough, stridor, and hoarseness. Symptoms worsen
at night. On examination, the child is afebrile and in mild respiratory distress with subcostal retractions. What is
the most appropriate next step in management?
A. Administer nebulized racemic epinephrine
B. Obtain a lateral neck X-ray
C. Start oral amoxicillin
D. Perform a direct laryngoscopy
🟢 A. Administer nebulized racemic epinephrine
🔴 RATIONALE: The presentation is consistent with moderate croup (laryngotracheobronchitis). Nebulized
racemic epinephrine is indicated for moderate to severe croup to reduce airway edema. Corticosteroids should
also be given. A lateral neck X-ray is for suspected epiglottitis (not croup) and should not delay treatment.
Question 4
A 45-year-old male with a history of alcohol use disorder is brought to the emergency department by police
after being found confused and disoriented. He is agitated, diaphoretic, and has a tremor. His heart rate is 115
bpm, and blood pressure is 155/95 mmHg. What is the most appropriate initial pharmacological intervention?
A. Haloperidol 5 mg IM
B. Lorazepam 2 mg IV
C. Thiamine 100 mg IV
D. Naloxone 0.4 mg IV
🟢 B. Lorazepam 2 mg IV
🔴 RATIONALE: This patient is presenting with symptoms of alcohol withdrawal, which can progress to delirium
, tremens. Benzodiazepines, such as lorazepam, are the mainstay of treatment to prevent progression.
Haloperidol is not first-line and can lower the seizure threshold. Thiamine is important to prevent Wernicke's
encephalopathy but is not the immediate treatment for acute agitation in this context.
Question 5
A 68-year-old female with a history of COPD presents with increasing shortness of breath and a productive
cough with purulent sputum for the past 3 days. She is on home oxygen at 2 L/min. Her oxygen saturation is
88% on 4 L/min via nasal cannula, respiratory rate is 28/min, and she is using accessory muscles. An arterial
blood gas shows pH 7.31, PaCO2 62 mmHg, PaO2 55 mmHg. What is the most appropriate next step in
management?
A. Administer nebulized albuterol and ipratropium
B. Increase home oxygen to 6 L/min via nasal cannula
C. Start non-invasive positive pressure ventilation (NIPPV)
D. Administer intravenous methylprednisolone
🟢 C. Start non-invasive positive pressure ventilation (NIPPV)
🔴 RATIONALE: This patient has an acute exacerbation of COPD with hypercapnic respiratory failure (pH <7.35,
PaCO2 >45). NIPPV (e.g., BiPAP) is the first-line treatment to improve ventilation and reduce the need for
intubation. While bronchodilators and steroids are part of the treatment regimen, the priority is respiratory
support with NIPPV.
Question 6
A 32-year-old female presents with a 2-week history of a non-productive cough, fever, and night sweats. She
has a history of IV drug use. A chest X-ray reveals a cavitary lesion in the right upper lobe. An acid-fast bacilli
(AFB) smear is positive. Which of the following is the most appropriate initial treatment regimen?
A. Isoniazid, rifampin, pyrazinamide, and ethambutol
B. Isoniazid and rifampin only
