COMSAE PHASE 3 FORM 312 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) PLUS RATIONALES
2026 Q&A | LATEST EXAM UPDATE 2026/2027.
Core Domains
Internal Medicine: Cardiology, Pulmonology, Gastroenterology, Endocrinology, Nephrology.
Surgery: Preoperative and Postoperative Care, Trauma, Wound Management, Surgical Complications.
Pediatrics: Growth and Development, Pediatric Infectious Disease, Neonatology.
Obstetrics and Gynecology: Antepartum Care, Intrapartum Care, Postpartum Care, Gynecologic Oncology.
Psychiatry: Mood Disorders, Psychotic Disorders, Substance Use Disorders, Anxiety Disorders.
Emergency Medicine: Triage, Acute Coronary Syndrome, Stroke, Toxicological Emergencies.
Preventive Medicine and Public Health: Screening Guidelines, Immunizations, Biostatistics, Epidemiology.
Ethics and Professionalism: Patient Autonomy, Informed Consent, Confidentiality, End-of-Life Care, Medical-
Legal Issues.
Musculoskeletal and Rheumatology: Arthritis, Fractures, Back Pain, Autoimmune Disorders.
Introduction
This comprehensive assessment is designed to rigorously evaluate a candidate's readiness for the COMSAE Phase 3
examination. It measures the application of foundational medical knowledge, clinical reasoning, and decision-
making skills essential for safe and effective osteopathic medical practice. The exam utilizes a multiple-choice and
scenario-based structure to simulate the challenges encountered in a clinical setting. Emphasis is placed on the
integration of biomedical and clinical sciences, regulatory compliance, ethical standards, and the practical
,management of complex patient cases. This tool serves as a critical measure of preparedness for the next stage of
medical training.
SECTION ONE: QUESTIONS 1 - 100
Question 1
A 72-year-old male with a history of hypertension and type 2 diabetes presents with a 30-minute episode of
transient monocular blindness (amaurosis fugax) in his right eye, which has now completely resolved. His blood
pressure is 148/88 mmHg, and his heart rate is 78 bpm. Carotid ultrasound reveals a 75% stenosis of the right
internal carotid artery. Which of the following is the most appropriate next step in management?
A. Initiate clopidogrel therapy and schedule for carotid endarterectomy within 2 weeks.
B. Start aspirin and atorvastatin, and optimize glycemic control.
C. Perform a computed tomography angiography (CTA) of the head and neck.
D. Administer intravenous alteplase (tPA) immediately.
🟢A
🔴 RATIONALE: This patient has symptomatic carotid stenosis (>70%) following a transient ischemic attack
(TIA). The standard of care for patients with symptomatic high-grade stenosis is carotid endarterectomy (CEA),
which should ideally be performed within 2 weeks of the index event to maximize benefit. Option B represents
medical management which is secondary to surgical intervention in this symptomatic patient. Option C is not
needed if a carotid ultrasound has already clearly defined the stenosis. Option D is incorrect because the
patient's symptoms have resolved, making tPA inappropriate.
,Question 2
A 45-year-old female with a history of systemic lupus erythematosus (SLE) presents with progressive shortness
of breath and pleuritic chest pain. A chest X-ray shows a left-sided pleural effusion. A diagnostic thoracentesis is
performed, and the fluid is exudative with a glucose level of 45 mg/dL. Which of the following is the most likely
underlying cause for this presentation?
A. Pleuropulmonary lupus
B. Parapneumonic effusion
C. Tuberculous pleuritis
D. Malignant effusion
🟢A
🔴 RATIONALE: In a patient with SLE, a unilateral pleural effusion with exudative characteristics and low glucose
is highly suggestive of pleuropulmonary lupus. SLE is a common cause of exudative pleural effusions. While
tuberculosis (C) and malignancy (D) can cause exudative effusions, the presence of an underlying autoimmune
disease makes A the most likely. A parapneumonic effusion (B) would be less likely without evidence of an
active infection.
Question 3
A 3-week-old male infant is brought to the clinic with jaundice that has persisted since birth. He is otherwise
feeding well, and his stools are pale and chalky. On physical examination, the liver is palpated 3 cm below the
costal margin. Which of the following diagnostic tests is most critical for establishing the diagnosis?
A. Liver biopsy
B. Direct serum bilirubin level
C. Abdominal ultrasound
D. Hepatobiliary scintigraphy (HIDA scan)
, 🟢B
🔴 RATIONALE: The presentation of persistent jaundice, pale stools, and hepatomegaly in a newborn is
concerning for biliary atresia. To diagnose this, it is critical to first confirm that the hyperbilirubinemia is direct
(conjugated), as this differentiates it from benign indirect hyperbilirubinemia. A direct bilirubin level > 2.0
mg/dL is a hallmark of biliary atresia and warrants further urgent imaging and surgical consultation. While C, D,
and A are part of the diagnostic workup, establishing a diagnosis of direct hyperbilirubinemia is the most critical
initial step.
Question 4
A 68-year-old male presents with sudden onset of severe, sharp pain in his right lower quadrant, which began 2
hours ago. He reports that the pain is constant and radiating to his right flank. He has nausea and is afebrile. On
physical exam, he is in significant distress. There is no rebound tenderness or guarding. His white blood cell
count is 10,500 cells/mm³, and his urinalysis reveals microscopic hematuria. Which of the following is the most
likely diagnosis?
A. Acute appendicitis
B. Ruptured abdominal aortic aneurysm (AAA)
C. Diverticulitis
D. Renal colic
🟢D
🔴 RATIONALE: Acute onset of severe, colicky flank pain radiating to the groin (though in this case flank)
associated with microscopic hematuria is classic for a ureteral stone, causing renal colic. The absence of
peritoneal signs (rebound, guarding) and fever makes appendicitis (A) and diverticulitis (C) less likely. A ruptured
AAA (B) would present with profound, pulsatile abdominal pain, hemodynamic instability, and often a palpable
pulsatile mass, which are not described here.
2026 Q&A | LATEST EXAM UPDATE 2026/2027.
Core Domains
Internal Medicine: Cardiology, Pulmonology, Gastroenterology, Endocrinology, Nephrology.
Surgery: Preoperative and Postoperative Care, Trauma, Wound Management, Surgical Complications.
Pediatrics: Growth and Development, Pediatric Infectious Disease, Neonatology.
Obstetrics and Gynecology: Antepartum Care, Intrapartum Care, Postpartum Care, Gynecologic Oncology.
Psychiatry: Mood Disorders, Psychotic Disorders, Substance Use Disorders, Anxiety Disorders.
Emergency Medicine: Triage, Acute Coronary Syndrome, Stroke, Toxicological Emergencies.
Preventive Medicine and Public Health: Screening Guidelines, Immunizations, Biostatistics, Epidemiology.
Ethics and Professionalism: Patient Autonomy, Informed Consent, Confidentiality, End-of-Life Care, Medical-
Legal Issues.
Musculoskeletal and Rheumatology: Arthritis, Fractures, Back Pain, Autoimmune Disorders.
Introduction
This comprehensive assessment is designed to rigorously evaluate a candidate's readiness for the COMSAE Phase 3
examination. It measures the application of foundational medical knowledge, clinical reasoning, and decision-
making skills essential for safe and effective osteopathic medical practice. The exam utilizes a multiple-choice and
scenario-based structure to simulate the challenges encountered in a clinical setting. Emphasis is placed on the
integration of biomedical and clinical sciences, regulatory compliance, ethical standards, and the practical
,management of complex patient cases. This tool serves as a critical measure of preparedness for the next stage of
medical training.
SECTION ONE: QUESTIONS 1 - 100
Question 1
A 72-year-old male with a history of hypertension and type 2 diabetes presents with a 30-minute episode of
transient monocular blindness (amaurosis fugax) in his right eye, which has now completely resolved. His blood
pressure is 148/88 mmHg, and his heart rate is 78 bpm. Carotid ultrasound reveals a 75% stenosis of the right
internal carotid artery. Which of the following is the most appropriate next step in management?
A. Initiate clopidogrel therapy and schedule for carotid endarterectomy within 2 weeks.
B. Start aspirin and atorvastatin, and optimize glycemic control.
C. Perform a computed tomography angiography (CTA) of the head and neck.
D. Administer intravenous alteplase (tPA) immediately.
🟢A
🔴 RATIONALE: This patient has symptomatic carotid stenosis (>70%) following a transient ischemic attack
(TIA). The standard of care for patients with symptomatic high-grade stenosis is carotid endarterectomy (CEA),
which should ideally be performed within 2 weeks of the index event to maximize benefit. Option B represents
medical management which is secondary to surgical intervention in this symptomatic patient. Option C is not
needed if a carotid ultrasound has already clearly defined the stenosis. Option D is incorrect because the
patient's symptoms have resolved, making tPA inappropriate.
,Question 2
A 45-year-old female with a history of systemic lupus erythematosus (SLE) presents with progressive shortness
of breath and pleuritic chest pain. A chest X-ray shows a left-sided pleural effusion. A diagnostic thoracentesis is
performed, and the fluid is exudative with a glucose level of 45 mg/dL. Which of the following is the most likely
underlying cause for this presentation?
A. Pleuropulmonary lupus
B. Parapneumonic effusion
C. Tuberculous pleuritis
D. Malignant effusion
🟢A
🔴 RATIONALE: In a patient with SLE, a unilateral pleural effusion with exudative characteristics and low glucose
is highly suggestive of pleuropulmonary lupus. SLE is a common cause of exudative pleural effusions. While
tuberculosis (C) and malignancy (D) can cause exudative effusions, the presence of an underlying autoimmune
disease makes A the most likely. A parapneumonic effusion (B) would be less likely without evidence of an
active infection.
Question 3
A 3-week-old male infant is brought to the clinic with jaundice that has persisted since birth. He is otherwise
feeding well, and his stools are pale and chalky. On physical examination, the liver is palpated 3 cm below the
costal margin. Which of the following diagnostic tests is most critical for establishing the diagnosis?
A. Liver biopsy
B. Direct serum bilirubin level
C. Abdominal ultrasound
D. Hepatobiliary scintigraphy (HIDA scan)
, 🟢B
🔴 RATIONALE: The presentation of persistent jaundice, pale stools, and hepatomegaly in a newborn is
concerning for biliary atresia. To diagnose this, it is critical to first confirm that the hyperbilirubinemia is direct
(conjugated), as this differentiates it from benign indirect hyperbilirubinemia. A direct bilirubin level > 2.0
mg/dL is a hallmark of biliary atresia and warrants further urgent imaging and surgical consultation. While C, D,
and A are part of the diagnostic workup, establishing a diagnosis of direct hyperbilirubinemia is the most critical
initial step.
Question 4
A 68-year-old male presents with sudden onset of severe, sharp pain in his right lower quadrant, which began 2
hours ago. He reports that the pain is constant and radiating to his right flank. He has nausea and is afebrile. On
physical exam, he is in significant distress. There is no rebound tenderness or guarding. His white blood cell
count is 10,500 cells/mm³, and his urinalysis reveals microscopic hematuria. Which of the following is the most
likely diagnosis?
A. Acute appendicitis
B. Ruptured abdominal aortic aneurysm (AAA)
C. Diverticulitis
D. Renal colic
🟢D
🔴 RATIONALE: Acute onset of severe, colicky flank pain radiating to the groin (though in this case flank)
associated with microscopic hematuria is classic for a ureteral stone, causing renal colic. The absence of
peritoneal signs (rebound, guarding) and fever makes appendicitis (A) and diverticulitis (C) less likely. A ruptured
AAA (B) would present with profound, pulsatile abdominal pain, hemodynamic instability, and often a palpable
pulsatile mass, which are not described here.
