COMSAE PHASE 2 – FORM 109 PRACTICE EXAM QUESTIONS AND ANSWERS | VERIFIED AND
WELL DETAILED ANSWERS | PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM UPDATE
Core Domains
1. Internal Medicine
2. Obstetrics and Gynecology
3. Pediatrics
4. Psychiatry and Behavioral Health
5. Surgery and Surgical Subspecialties
6. Emergency Medicine and Acute Care
7. Osteopathic Principles and Practice (OPP)
8. Preventive Medicine and Public Health
9. Ethics, Jurisprudence, and Patient Safety
10. Pharmacology and Therapeutics
Introduction
This comprehensive examination is designed to rigorously assess the knowledge and clinical reasoning
skills expected of a second-year osteopathic medical student preparing for the COMSAE Phase 2. The
exam evaluates a candidate's ability to synthesize foundational biomedical concepts, apply them to
complex clinical scenarios, and demonstrate sound professional judgment. The assessment is
structured using multiple-choice and clinical vignette-based questions that emphasize real-world
application, diagnostic acumen, and therapeutic decision-making. This practice exam serves as a vital
tool for identifying strengths and areas needing further study, ensuring candidates are well-prepared
for the challenges of clinical practice and the licensing examination. It is intended to be a definitive,
high-yield preparation resource.
SECTION ONE: QUESTIONS 1-100
1. A 65-year-old male with a history of hypertension and type 2 diabetes presents to the clinic
with a chief complaint of progressive shortness of breath and swelling in his lower extremities
over the past two weeks. He reports sleeping with three pillows to breathe comfortably. On
examination, his blood pressure is 150/90 mmHg, heart rate is 95 bpm, and respiratory rate is
22/min. Jugular venous distension is noted at 12 cm H2O, and he has pitting edema in both legs
up to the knees. An S3 gallop is auscultated at the apex. An echocardiogram is ordered. Which
of the following is the most likely finding on this patient's echocardiogram?
A. Severe aortic stenosis
B. Dilated left ventricle with globally reduced ejection fraction
C. Concentric left ventricular hypertrophy with a hyperdynamic ejection fraction
D. Normal left ventricle with evidence of constrictive pericarditis
🟢B
🔴 Explanation: This patient is presenting with classic signs of acute decompensated heart failure
(ADHF) with a reduced ejection fraction (HFrEF). The orthopnea, elevated JVP, peripheral edema,
and S3 gallop are hallmark signs of volume overload and decreased cardiac output. An S3 gallop is
a strong indicator of a failing, volume-overloaded ventricle. Dilated cardiomyopathy, characterized
,by a thin, dilated left ventricle and reduced ejection fraction, is the most common finding in HFrEF.
Severe aortic stenosis typically presents with a systolic ejection murmur and syncope, while
constrictive pericarditis involves pericardial thickening and symptoms of right-sided heart failure
without marked LV dilation. Concentric hypertrophy is more characteristic of hypertensive heart
disease and HFpEF.
2. A 28-year-old woman at 39 weeks gestation presents to the labor and delivery unit with
regular, painful uterine contractions occurring every 3-4 minutes. Her cervix is 5 cm dilated, 90%
effaced, and the fetus is in the vertex position at station 0. Fetal heart rate tracing shows
moderate variability and no decelerations. The patient requests an epidural for pain control.
What is the most critical step to perform prior to administering the epidural in this patient?
A. Place an indwelling Foley catheter
B. Obtain a baseline fetal heart rate tracing
C. Administer a 500 mL bolus of intravenous fluids
D. Assess the patient's platelet count
🟢D
🔴 Explanation: The single most important contraindication to neuraxial (epidural) anesthesia is a
coagulopathy. Administering an epidural in the presence of a low platelet count or other clotting
abnormalities places the patient at high risk for an epidural hematoma, which can lead to
permanent paralysis. A platelet count is a mandatory part of the pre-procedural evaluation to
ensure the patient's bleeding risk is within acceptable limits for the procedure. While IV fluids (C), a
Foley catheter (A), and a baseline FHR tracing (B) are all important components of managing a
patient in labor and preparing for an epidural, the assessment of hemostasis is the most critical
safety step that must be performed immediately before the procedure.
3. A 4-year-old child is brought to the emergency room by his mother due to a sudden onset of
a high-pitched, barking cough that began last night. The mother states the child was playing and
eating grapes just before bedtime. The child is now sitting upright, leaning forward, and is
drooling. He is afebrile, but his heart rate is 140 bpm and respiratory rate is 34/min. On
examination, he is stridorous at rest and is visibly anxious. What is the most appropriate next
step in managing this child?
A. Perform a chest X-ray
B. Prepare the child for direct laryngoscopy in the operating room
C. Administer a nebulized racemic epinephrine
D. Obtain a lateral neck X-ray
🟢B
🔴 Explanation: This child's acute presentation of stridor, drooling, inability to handle secretions,
and the classic "tripod" or "sniffing" position is highly suspicious for a foreign body aspiration in the
airway, likely a grape, causing a high-grade obstruction. This is a life-threatening emergency. A
foreign body causing significant respiratory distress and stridor requires immediate removal by
direct laryngoscopy or bronchoscopy in the operating room by an otolaryngologist or
anesthesiologist. Waiting to perform imaging studies (A, D) would be a dangerous delay. Nebulized
racemic epinephrine (C) is the treatment for croup, which presents with a "barking" cough but is
usually accompanied by fever and preceded by symptoms of an upper respiratory infection, and
does not typically present with drooling or an inability to handle secretions.
,4. A 55-year-old male presents to his primary care physician for an annual physical. He has no
complaints. His past medical history is significant for hyperlipidemia and well-controlled
hypertension. He has a 20-pack-year smoking history and quit five years ago. His father had a
myocardial infarction at age 58. His laboratory results show a total cholesterol of 220 mg/dL, an
LDL of 150 mg/dL, an HDL of 40 mg/dL, and a triglyceride level of 180 mg/dL. According to the
2019 ACC/AHA guidelines on the primary prevention of cardiovascular disease, which of the
following is the most appropriate next step in his management?
A. Initiate high-intensity statin therapy
B. Initiate moderate-intensity statin therapy
C. Recommend lifestyle modifications and recheck lipids in 3-6 months
D. Initiate a PCSK9 inhibitor
🟢B
🔴 Explanation: This patient has multiple risk factors: age (male > 45), hypertension,
hyperlipidemia, and a strong family history of premature ASCVD. His calculated 10-year ASCVD risk
is estimated to be >7.5% and <20% based on the provided risk factors. The 2018/2019 ACC/AHA
guidelines recommend moderate-intensity statin therapy (e.g., atorvastatin 10-20mg or
rosuvastatin 5-10mg) for patients with a 10-year ASCVD risk of 7.5% to 20%. High-intensity statin
therapy (A) is reserved for those with a 10-year ASCVD risk >20% or those with clinical ASCVD.
PCSK9 inhibitors (D) are used in patients with very high-risk ASCVD or familial hypercholesterolemia
who are not at goal on maximally tolerated statin therapy.
5. A 32-year-old woman comes to the clinic with a 3-day history of burning pain during
urination, frequency, and urgency. She has had two similar episodes in the past year. She reports
no vaginal discharge or itching. Her temperature is 37.2°C (99.0°F). Urinalysis reveals positive
leukocyte esterase and nitrites, and microscopic examination shows 50-75 WBCs/hpf and 5-10
RBCs/hpf. A urine culture is sent. Which of the following is the most appropriate first-line
antibiotic for the empiric treatment of her uncomplicated cystitis, considering local resistance
patterns are unknown?
A. Ciprofloxacin
B. Trimethoprim-sulfamethoxazole
C. Nitrofurantoin
D. Amoxicillin-clavulanate
🟢C
🔴 Explanation: Nitrofurantoin is a first-line antibiotic for the empiric treatment of uncomplicated
cystitis in otherwise healthy, non-pregnant women. It has excellent efficacy against the most
common uropathogens, particularly E. coli, and is associated with a low rate of resistance.
Trimethoprim-sulfamethoxazole (B) is also a first-line agent, but resistance rates among E. coli are
often high (>20%), and local resistance patterns should be <20% to use it empirically. Ciprofloxacin
(A) is a fluoroquinolone and is reserved for more complicated infections or pyelonephritis due to
concerns about adverse effects and emerging resistance. Amoxicillin-clavulanate (D) is not a first-
line empiric agent for uncomplicated cystitis and has higher rates of E. coli resistance.
6. A 70-year-old man with a history of benign prostatic hyperplasia presents with a 4-week
history of low back pain that is constant, worse at night, and not relieved by rest. He has lost 10
pounds unintentionally over the last two months. His PSA level is 32 ng/mL. A digital rectal exam
reveals a hard, nodular prostate. A bone scan shows multiple areas of increased uptake in the
, lumbar spine and pelvis. A CT-guided biopsy of a lumbar lesion is performed. The pathology
report is most likely to show:
A. Prostatic adenocarcinoma
B. Transitional cell carcinoma
C. Osteosarcoma
D. Metastatic lung adenocarcinoma
🟢A
🔴 Explanation: This is a classic presentation of metastatic prostate cancer. The patient's elevated
PSA, hard nodular prostate on DRE, bone pain that is characteristic of malignancy (constant, worse
at night), and the bone scan findings of multiple areas of increased uptake (which are characteristic
of osteoblastic metastases) are highly suspicious for prostate adenocarcinoma that has
metastasized to the bone. Prostatic adenocarcinoma is the most common type of prostate cancer
and frequently metastasizes to the axial skeleton (vertebrae, pelvis). A biopsy of the bone lesion
would confirm the diagnosis and show metastatic prostatic adenocarcinoma.
7. A 24-year-old woman with a history of asthma is brought to the emergency room with an
acute asthma exacerbation. She has been using her albuterol inhaler every 2 hours without relief.
On arrival, she is unable to speak in full sentences, has a respiratory rate of 28/min, heart rate of
115 bpm, and oxygen saturation of 90% on room air. Her peak expiratory flow rate is 40% of her
personal best. What is the most appropriate initial treatment for this patient?
A. Administer a high-dose inhaled corticosteroid
B. Begin continuous nebulized albuterol and ipratropium, and systemic corticosteroids
C. Administer a single dose of IV magnesium sulfate
D. Prepare for immediate endotracheal intubation
🟢B
🔴 Explanation: This patient is in a severe asthma exacerbation, as evidenced by her inability to
speak in full sentences, tachycardia, tachypnea, and a PEFR of <50% of her personal best. The
standard of care for a severe exacerbation is aggressive therapy with continuous nebulized
albuterol combined with ipratropium, along with early administration of systemic corticosteroids
(e.g., oral or IV) to reduce airway inflammation. While IV magnesium (C) may be considered in
severe cases that do not respond to initial therapy, it is not the most initial step. Endotracheal
intubation (D) is a last resort for impending respiratory failure. Inhaled corticosteroids (A) are a
maintenance therapy and are not effective for acute symptom relief.
8. A 45-year-old female presents to the clinic with a complaint of fatigue, weight gain, cold
intolerance, and constipation for the past 6 months. Physical examination reveals dry skin,
periorbital edema, and a bradycardia of 52 bpm. A thyroid-stimulating hormone (TSH) level is
ordered and returns at 12.5 mIU/L (normal 0.5-4.5 mIU/L). A free T4 level is low. What is the
most likely diagnosis and its underlying pathophysiological mechanism?
A. Hashimoto's thyroiditis; destruction of the thyroid gland by autoantibodies
B. Graves' disease; stimulation of the thyroid gland by thyroid-stimulating immunoglobulins
C. Subacute granulomatous thyroiditis; viral inflammation of the thyroid
D. Pituitary adenoma; overproduction of TSH
🟢A
🔴 Explanation: The patient's symptoms of hypothyroidism (fatigue, weight gain, cold intolerance,
WELL DETAILED ANSWERS | PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM UPDATE
Core Domains
1. Internal Medicine
2. Obstetrics and Gynecology
3. Pediatrics
4. Psychiatry and Behavioral Health
5. Surgery and Surgical Subspecialties
6. Emergency Medicine and Acute Care
7. Osteopathic Principles and Practice (OPP)
8. Preventive Medicine and Public Health
9. Ethics, Jurisprudence, and Patient Safety
10. Pharmacology and Therapeutics
Introduction
This comprehensive examination is designed to rigorously assess the knowledge and clinical reasoning
skills expected of a second-year osteopathic medical student preparing for the COMSAE Phase 2. The
exam evaluates a candidate's ability to synthesize foundational biomedical concepts, apply them to
complex clinical scenarios, and demonstrate sound professional judgment. The assessment is
structured using multiple-choice and clinical vignette-based questions that emphasize real-world
application, diagnostic acumen, and therapeutic decision-making. This practice exam serves as a vital
tool for identifying strengths and areas needing further study, ensuring candidates are well-prepared
for the challenges of clinical practice and the licensing examination. It is intended to be a definitive,
high-yield preparation resource.
SECTION ONE: QUESTIONS 1-100
1. A 65-year-old male with a history of hypertension and type 2 diabetes presents to the clinic
with a chief complaint of progressive shortness of breath and swelling in his lower extremities
over the past two weeks. He reports sleeping with three pillows to breathe comfortably. On
examination, his blood pressure is 150/90 mmHg, heart rate is 95 bpm, and respiratory rate is
22/min. Jugular venous distension is noted at 12 cm H2O, and he has pitting edema in both legs
up to the knees. An S3 gallop is auscultated at the apex. An echocardiogram is ordered. Which
of the following is the most likely finding on this patient's echocardiogram?
A. Severe aortic stenosis
B. Dilated left ventricle with globally reduced ejection fraction
C. Concentric left ventricular hypertrophy with a hyperdynamic ejection fraction
D. Normal left ventricle with evidence of constrictive pericarditis
🟢B
🔴 Explanation: This patient is presenting with classic signs of acute decompensated heart failure
(ADHF) with a reduced ejection fraction (HFrEF). The orthopnea, elevated JVP, peripheral edema,
and S3 gallop are hallmark signs of volume overload and decreased cardiac output. An S3 gallop is
a strong indicator of a failing, volume-overloaded ventricle. Dilated cardiomyopathy, characterized
,by a thin, dilated left ventricle and reduced ejection fraction, is the most common finding in HFrEF.
Severe aortic stenosis typically presents with a systolic ejection murmur and syncope, while
constrictive pericarditis involves pericardial thickening and symptoms of right-sided heart failure
without marked LV dilation. Concentric hypertrophy is more characteristic of hypertensive heart
disease and HFpEF.
2. A 28-year-old woman at 39 weeks gestation presents to the labor and delivery unit with
regular, painful uterine contractions occurring every 3-4 minutes. Her cervix is 5 cm dilated, 90%
effaced, and the fetus is in the vertex position at station 0. Fetal heart rate tracing shows
moderate variability and no decelerations. The patient requests an epidural for pain control.
What is the most critical step to perform prior to administering the epidural in this patient?
A. Place an indwelling Foley catheter
B. Obtain a baseline fetal heart rate tracing
C. Administer a 500 mL bolus of intravenous fluids
D. Assess the patient's platelet count
🟢D
🔴 Explanation: The single most important contraindication to neuraxial (epidural) anesthesia is a
coagulopathy. Administering an epidural in the presence of a low platelet count or other clotting
abnormalities places the patient at high risk for an epidural hematoma, which can lead to
permanent paralysis. A platelet count is a mandatory part of the pre-procedural evaluation to
ensure the patient's bleeding risk is within acceptable limits for the procedure. While IV fluids (C), a
Foley catheter (A), and a baseline FHR tracing (B) are all important components of managing a
patient in labor and preparing for an epidural, the assessment of hemostasis is the most critical
safety step that must be performed immediately before the procedure.
3. A 4-year-old child is brought to the emergency room by his mother due to a sudden onset of
a high-pitched, barking cough that began last night. The mother states the child was playing and
eating grapes just before bedtime. The child is now sitting upright, leaning forward, and is
drooling. He is afebrile, but his heart rate is 140 bpm and respiratory rate is 34/min. On
examination, he is stridorous at rest and is visibly anxious. What is the most appropriate next
step in managing this child?
A. Perform a chest X-ray
B. Prepare the child for direct laryngoscopy in the operating room
C. Administer a nebulized racemic epinephrine
D. Obtain a lateral neck X-ray
🟢B
🔴 Explanation: This child's acute presentation of stridor, drooling, inability to handle secretions,
and the classic "tripod" or "sniffing" position is highly suspicious for a foreign body aspiration in the
airway, likely a grape, causing a high-grade obstruction. This is a life-threatening emergency. A
foreign body causing significant respiratory distress and stridor requires immediate removal by
direct laryngoscopy or bronchoscopy in the operating room by an otolaryngologist or
anesthesiologist. Waiting to perform imaging studies (A, D) would be a dangerous delay. Nebulized
racemic epinephrine (C) is the treatment for croup, which presents with a "barking" cough but is
usually accompanied by fever and preceded by symptoms of an upper respiratory infection, and
does not typically present with drooling or an inability to handle secretions.
,4. A 55-year-old male presents to his primary care physician for an annual physical. He has no
complaints. His past medical history is significant for hyperlipidemia and well-controlled
hypertension. He has a 20-pack-year smoking history and quit five years ago. His father had a
myocardial infarction at age 58. His laboratory results show a total cholesterol of 220 mg/dL, an
LDL of 150 mg/dL, an HDL of 40 mg/dL, and a triglyceride level of 180 mg/dL. According to the
2019 ACC/AHA guidelines on the primary prevention of cardiovascular disease, which of the
following is the most appropriate next step in his management?
A. Initiate high-intensity statin therapy
B. Initiate moderate-intensity statin therapy
C. Recommend lifestyle modifications and recheck lipids in 3-6 months
D. Initiate a PCSK9 inhibitor
🟢B
🔴 Explanation: This patient has multiple risk factors: age (male > 45), hypertension,
hyperlipidemia, and a strong family history of premature ASCVD. His calculated 10-year ASCVD risk
is estimated to be >7.5% and <20% based on the provided risk factors. The 2018/2019 ACC/AHA
guidelines recommend moderate-intensity statin therapy (e.g., atorvastatin 10-20mg or
rosuvastatin 5-10mg) for patients with a 10-year ASCVD risk of 7.5% to 20%. High-intensity statin
therapy (A) is reserved for those with a 10-year ASCVD risk >20% or those with clinical ASCVD.
PCSK9 inhibitors (D) are used in patients with very high-risk ASCVD or familial hypercholesterolemia
who are not at goal on maximally tolerated statin therapy.
5. A 32-year-old woman comes to the clinic with a 3-day history of burning pain during
urination, frequency, and urgency. She has had two similar episodes in the past year. She reports
no vaginal discharge or itching. Her temperature is 37.2°C (99.0°F). Urinalysis reveals positive
leukocyte esterase and nitrites, and microscopic examination shows 50-75 WBCs/hpf and 5-10
RBCs/hpf. A urine culture is sent. Which of the following is the most appropriate first-line
antibiotic for the empiric treatment of her uncomplicated cystitis, considering local resistance
patterns are unknown?
A. Ciprofloxacin
B. Trimethoprim-sulfamethoxazole
C. Nitrofurantoin
D. Amoxicillin-clavulanate
🟢C
🔴 Explanation: Nitrofurantoin is a first-line antibiotic for the empiric treatment of uncomplicated
cystitis in otherwise healthy, non-pregnant women. It has excellent efficacy against the most
common uropathogens, particularly E. coli, and is associated with a low rate of resistance.
Trimethoprim-sulfamethoxazole (B) is also a first-line agent, but resistance rates among E. coli are
often high (>20%), and local resistance patterns should be <20% to use it empirically. Ciprofloxacin
(A) is a fluoroquinolone and is reserved for more complicated infections or pyelonephritis due to
concerns about adverse effects and emerging resistance. Amoxicillin-clavulanate (D) is not a first-
line empiric agent for uncomplicated cystitis and has higher rates of E. coli resistance.
6. A 70-year-old man with a history of benign prostatic hyperplasia presents with a 4-week
history of low back pain that is constant, worse at night, and not relieved by rest. He has lost 10
pounds unintentionally over the last two months. His PSA level is 32 ng/mL. A digital rectal exam
reveals a hard, nodular prostate. A bone scan shows multiple areas of increased uptake in the
, lumbar spine and pelvis. A CT-guided biopsy of a lumbar lesion is performed. The pathology
report is most likely to show:
A. Prostatic adenocarcinoma
B. Transitional cell carcinoma
C. Osteosarcoma
D. Metastatic lung adenocarcinoma
🟢A
🔴 Explanation: This is a classic presentation of metastatic prostate cancer. The patient's elevated
PSA, hard nodular prostate on DRE, bone pain that is characteristic of malignancy (constant, worse
at night), and the bone scan findings of multiple areas of increased uptake (which are characteristic
of osteoblastic metastases) are highly suspicious for prostate adenocarcinoma that has
metastasized to the bone. Prostatic adenocarcinoma is the most common type of prostate cancer
and frequently metastasizes to the axial skeleton (vertebrae, pelvis). A biopsy of the bone lesion
would confirm the diagnosis and show metastatic prostatic adenocarcinoma.
7. A 24-year-old woman with a history of asthma is brought to the emergency room with an
acute asthma exacerbation. She has been using her albuterol inhaler every 2 hours without relief.
On arrival, she is unable to speak in full sentences, has a respiratory rate of 28/min, heart rate of
115 bpm, and oxygen saturation of 90% on room air. Her peak expiratory flow rate is 40% of her
personal best. What is the most appropriate initial treatment for this patient?
A. Administer a high-dose inhaled corticosteroid
B. Begin continuous nebulized albuterol and ipratropium, and systemic corticosteroids
C. Administer a single dose of IV magnesium sulfate
D. Prepare for immediate endotracheal intubation
🟢B
🔴 Explanation: This patient is in a severe asthma exacerbation, as evidenced by her inability to
speak in full sentences, tachycardia, tachypnea, and a PEFR of <50% of her personal best. The
standard of care for a severe exacerbation is aggressive therapy with continuous nebulized
albuterol combined with ipratropium, along with early administration of systemic corticosteroids
(e.g., oral or IV) to reduce airway inflammation. While IV magnesium (C) may be considered in
severe cases that do not respond to initial therapy, it is not the most initial step. Endotracheal
intubation (D) is a last resort for impending respiratory failure. Inhaled corticosteroids (A) are a
maintenance therapy and are not effective for acute symptom relief.
8. A 45-year-old female presents to the clinic with a complaint of fatigue, weight gain, cold
intolerance, and constipation for the past 6 months. Physical examination reveals dry skin,
periorbital edema, and a bradycardia of 52 bpm. A thyroid-stimulating hormone (TSH) level is
ordered and returns at 12.5 mIU/L (normal 0.5-4.5 mIU/L). A free T4 level is low. What is the
most likely diagnosis and its underlying pathophysiological mechanism?
A. Hashimoto's thyroiditis; destruction of the thyroid gland by autoantibodies
B. Graves' disease; stimulation of the thyroid gland by thyroid-stimulating immunoglobulins
C. Subacute granulomatous thyroiditis; viral inflammation of the thyroid
D. Pituitary adenoma; overproduction of TSH
🟢A
🔴 Explanation: The patient's symptoms of hypothyroidism (fatigue, weight gain, cold intolerance,
