COMAT Internal Medicine Exam V2 | COMAT
Internal Medicine | Q&A with Rationale (COMAT
Internal Medicine Exam) | National Board of
Osteopathic Medical Examiners (NBOME)
1. A 65-year-old male with a history of hypertension and heart failure with reduced ejection
fraction (HFrEF) presents with worsening shortness of breath and pedal edema. Physical
exam reveals jugular venous distention and bilateral lung crackles. Which of the following is
the most appropriate initial medication to improve symptoms and reduce volume overload?
A. Furosemide
B. Lisinopril
C. Metoprolol succinate
D. Spironolactone
Correct Answer: A
Explanation: This patient is presenting with an acute decompensation of heart failure,
characterized by signs of volume overload. Loop diuretics like furosemide are the first-line
treatment to achieve rapid diuresis and symptom relief. While beta-blockers and ACE
inhibitors are critical for long-term survival in HFrEF, they should not be the primary agent
for immediate fluid removal in the acute setting.
,2. A 42-year-old female presents with acute onset of severe epigastric pain radiating to her
back, accompanied by nausea and vomiting. Laboratory studies show a serum lipase level of
1,200 U/L (normal <160 U/L). What is the most important initial step in the management of
this patient?
A. Urgent ERCP
B. Broad-spectrum antibiotics
C. Aggressive intravenous fluid resuscitation
D. Morphine for pain control
Correct Answer: C
Explanation: Acute pancreatitis requires aggressive early fluid resuscitation to prevent
complications like pancreatic necrosis and organ failure. Serum lipase greater than three
times the upper limit of normal is diagnostic in the setting of characteristic pain. Antibiotics
are not routinely indicated unless there is evidence of infected necrosis or an extra-
pancreatic infection.
3. A 72-year-old male smoker with a history of COPD presents with 3 days of increased cough,
yellow sputum production, and worsening dyspnea. His oxygen saturation is 89% on room air.
In addition to inhaled bronchodilators and oxygen, which of the following should be
prescribed?
A. Systemic corticosteroids and antibiotics
B. Daily maintenance theophylline
,C. Inhaled corticosteroids only
D. Intravenous magnesium sulfate
Correct Answer: A
Explanation: An acute exacerbation of COPD is managed with supplemental oxygen, short-
acting bronchodilators, systemic corticosteroids, and antibiotics if sputum purulence is
present. Corticosteroids reduce recovery time and improve lung function. Antibiotics target
common pathogens like Streptococcus pneumoniae and Haemophilus influenzae, which
often trigger these events.
4. A 30-year-old female presents with heat intolerance, palpitations, and weight loss despite
an increased appetite. Physical exam reveals a smooth, enlarged, non-tender thyroid and
exophthalmos. Which of the following is the most likely laboratory finding?
A. High TSH, High Free T4
B. Low TSH, Low Free T4
C. High TSH, Low Free T4
D. Low TSH, High Free T4
Correct Answer: D
Explanation: The patient’s clinical presentation is classic for Graves’ disease, the most
common cause of hyperthyroidism. Laboratory confirmation typically shows a suppressed
(low) TSH and elevated (high) free T4 or T3 levels. Exophthalmos is a specific finding for
Graves’ disease due to autoimmune-mediated inflammation of the retro-orbital tissues.
, 5. A 55-year-old male with a history of poorly controlled type 2 diabetes presents with a two-
week history of a non-healing ulcer on the plantar surface of his right foot. On exam, the
ulcer is 2 cm, deep, and you can palpate bone with a sterile probe. What is the most likely
diagnosis?
A. Superficial cellulitis
B. Venous stasis ulcer
C. Osteomyelitis
D. Arterial insufficiency
Correct Answer: C
Explanation: The ability to ‘probe to bone’ in a diabetic foot ulcer has a high positive
predictive value for osteomyelitis. Management requires long-term antibiotics and often
surgical debridement of infected bone. Imaging, such as an MRI, is frequently used to
confirm the extent of the infection when the diagnosis is unclear.
6. A 24-year-old college student presents to the emergency department with fever, severe
headache, and neck stiffness. Physical exam reveals a positive Brudzinski sign and a petechial
rash on the lower extremities. What is the most appropriate next step in management?
A. Perform a CT scan of the head
B. Perform a lumbar puncture immediately
C. Administer intravenous antibiotics immediately
D. Obtain blood cultures and wait for results
Internal Medicine | Q&A with Rationale (COMAT
Internal Medicine Exam) | National Board of
Osteopathic Medical Examiners (NBOME)
1. A 65-year-old male with a history of hypertension and heart failure with reduced ejection
fraction (HFrEF) presents with worsening shortness of breath and pedal edema. Physical
exam reveals jugular venous distention and bilateral lung crackles. Which of the following is
the most appropriate initial medication to improve symptoms and reduce volume overload?
A. Furosemide
B. Lisinopril
C. Metoprolol succinate
D. Spironolactone
Correct Answer: A
Explanation: This patient is presenting with an acute decompensation of heart failure,
characterized by signs of volume overload. Loop diuretics like furosemide are the first-line
treatment to achieve rapid diuresis and symptom relief. While beta-blockers and ACE
inhibitors are critical for long-term survival in HFrEF, they should not be the primary agent
for immediate fluid removal in the acute setting.
,2. A 42-year-old female presents with acute onset of severe epigastric pain radiating to her
back, accompanied by nausea and vomiting. Laboratory studies show a serum lipase level of
1,200 U/L (normal <160 U/L). What is the most important initial step in the management of
this patient?
A. Urgent ERCP
B. Broad-spectrum antibiotics
C. Aggressive intravenous fluid resuscitation
D. Morphine for pain control
Correct Answer: C
Explanation: Acute pancreatitis requires aggressive early fluid resuscitation to prevent
complications like pancreatic necrosis and organ failure. Serum lipase greater than three
times the upper limit of normal is diagnostic in the setting of characteristic pain. Antibiotics
are not routinely indicated unless there is evidence of infected necrosis or an extra-
pancreatic infection.
3. A 72-year-old male smoker with a history of COPD presents with 3 days of increased cough,
yellow sputum production, and worsening dyspnea. His oxygen saturation is 89% on room air.
In addition to inhaled bronchodilators and oxygen, which of the following should be
prescribed?
A. Systemic corticosteroids and antibiotics
B. Daily maintenance theophylline
,C. Inhaled corticosteroids only
D. Intravenous magnesium sulfate
Correct Answer: A
Explanation: An acute exacerbation of COPD is managed with supplemental oxygen, short-
acting bronchodilators, systemic corticosteroids, and antibiotics if sputum purulence is
present. Corticosteroids reduce recovery time and improve lung function. Antibiotics target
common pathogens like Streptococcus pneumoniae and Haemophilus influenzae, which
often trigger these events.
4. A 30-year-old female presents with heat intolerance, palpitations, and weight loss despite
an increased appetite. Physical exam reveals a smooth, enlarged, non-tender thyroid and
exophthalmos. Which of the following is the most likely laboratory finding?
A. High TSH, High Free T4
B. Low TSH, Low Free T4
C. High TSH, Low Free T4
D. Low TSH, High Free T4
Correct Answer: D
Explanation: The patient’s clinical presentation is classic for Graves’ disease, the most
common cause of hyperthyroidism. Laboratory confirmation typically shows a suppressed
(low) TSH and elevated (high) free T4 or T3 levels. Exophthalmos is a specific finding for
Graves’ disease due to autoimmune-mediated inflammation of the retro-orbital tissues.
, 5. A 55-year-old male with a history of poorly controlled type 2 diabetes presents with a two-
week history of a non-healing ulcer on the plantar surface of his right foot. On exam, the
ulcer is 2 cm, deep, and you can palpate bone with a sterile probe. What is the most likely
diagnosis?
A. Superficial cellulitis
B. Venous stasis ulcer
C. Osteomyelitis
D. Arterial insufficiency
Correct Answer: C
Explanation: The ability to ‘probe to bone’ in a diabetic foot ulcer has a high positive
predictive value for osteomyelitis. Management requires long-term antibiotics and often
surgical debridement of infected bone. Imaging, such as an MRI, is frequently used to
confirm the extent of the infection when the diagnosis is unclear.
6. A 24-year-old college student presents to the emergency department with fever, severe
headache, and neck stiffness. Physical exam reveals a positive Brudzinski sign and a petechial
rash on the lower extremities. What is the most appropriate next step in management?
A. Perform a CT scan of the head
B. Perform a lumbar puncture immediately
C. Administer intravenous antibiotics immediately
D. Obtain blood cultures and wait for results
