COMPREHENSIVE OSTEOPATHIC MEDICAL LICENSING EXAMINATION
(COMSAE) 2025”2026 REAL EXAM 150 QUESTIONS AND DETAILED
ANSWERS WITH RATIONALES COVERING THE RECENT TESTED
QUESTIONS GUARANTEE A+ GRADE
1. A 45-year-old man presents with crushing chest pain radiating to his left arm and jaw. ECG
shows ST-segment elevation in leads II, III, and aVF. Which artery is most likely occluded?
A. Left anterior descending artery
B. Circumflex artery
C. ☑ Right coronary artery
D. Left main coronary artery
Rationale: Inferior MI (leads II, III, aVF) is usually caused by right coronary artery occlusion.
2. A 32-year-old woman presents with fatigue, pallor, and spoon-shaped nails. Lab results: Hb
9 g/dL, MCV 70 fL, ferritin 10 ng/mL. What is the most likely diagnosis?
A. Vitamin B12 deficiency
B. Thalassemia
C. ☑ Iron-deficiency anemia
D. Aplastic anemia
Rationale: Microcytic anemia with low ferritin indicates iron-deficiency anemia, often due to
chronic blood loss or poor dietary intake.
3. A 60-year-old man has progressive shortness of breath on exertion. Exam: bibasilar
crackles, elevated JVP, pedal edema. BNP is elevated. What is the most appropriate next
step?
A. Chest X-ray
B. ECG
C. ☑ Initiate diuretics and optimize heart failure therapy
D. Echocardiogram in 6 months
Rationale: Elevated BNP with clinical signs of fluid overload indicates heart failure;
management includes diuretics and guideline-directed therapy.
4. A 24-year-old man presents with acute right knee pain after twisting it while playing
soccer. Exam: positive anterior drawer test. Most likely injury?
A. MCL tear
B. LCL tear
C. ☑ ACL tear
,D. Meniscus tear
Rationale: Positive anterior drawer test indicates ACL tear.
5. A 65-year-old man presents with sudden-onset tearing chest pain radiating to the back. BP:
180/100 in right arm, 150/90 in left arm. Most likely diagnosis?
A. Myocardial infarction
B. Pulmonary embolism
C. ☑ Aortic dissection
D. Pericarditis
Rationale: BP difference between arms with tearing chest pain is classic for aortic dissection.
6. A 28-year-old woman presents with palpitations, heat intolerance, weight loss, and
exophthalmos. Labs: suppressed TSH, elevated T4. Diagnosis?
A. Hashimoto thyroiditis
B. Subacute thyroiditis
C. ☑ Graves disease
D. Toxic multinodular goiter
Rationale: Hyperthyroidism with diffuse goiter and exophthalmos is consistent with Graves
disease.
7. A 50-year-old man presents with progressive difficulty urinating, weak stream, and
nocturia. DRE: smooth, enlarged prostate. Most likely diagnosis?
A. Prostate cancer
B. Urethral stricture
C. ☑ Benign prostatic hyperplasia
D. Bladder cancer
Rationale: Lower urinary tract symptoms with smooth, enlarged prostate indicate BPH.
8. A 55-year-old man with diabetes presents with fever, productive cough, and lobar
consolidation on chest X-ray. Most likely pathogen?
A. Mycoplasma pneumoniae
B. ☑ Streptococcus pneumoniae
C. Legionella pneumophila
D. Influenza virus
Rationale: Sudden onset fever, productive cough, lobar consolidation suggests S.
pneumoniae.
,9. A 35-year-old man presents with fever, malaise, and a painless ulcer on his penis. Darkfield
microscopy shows spirochetes. Diagnosis?
A. Herpes simplex virus
B. Chancroid
C. ☑ Primary syphilis
D. Gonorrhea
Rationale: Painless chancre with spirochetes indicates primary syphilis.
10. A 40-year-old woman presents with weight gain, cold intolerance, fatigue, and dry skin.
Labs: elevated TSH, low T4. Most likely diagnosis?
A. Graves disease
B. Subacute thyroiditis
C. ☑ Primary hypothyroidism
D. Secondary hypothyroidism
Rationale: High TSH and low T4 indicate primary hypothyroidism, most commonly from
Hashimoto thyroiditis.
11. A 25-year-old woman presents with fever, dysuria, and urgency. Urinalysis shows WBCs
and positive nitrites. Most appropriate initial treatment?
A. IV vancomycin
B. ☑ Oral antibiotics like nitrofurantoin or TMP-SMX
C. IV ceftriaxone only
D. Observation
Rationale: Uncomplicated UTI in a young woman can be treated with oral antibiotics.
12. A 60-year-old man presents with right upper quadrant pain, fever, and jaundice. Labs:
elevated ALP and bilirubin. Imaging shows common bile duct dilation. Most likely diagnosis?
A. Acute hepatitis
B. Cholecystitis
C. ☑ Choledocholithiasis
D. Pancreatitis
Rationale: Charcot triad (RUQ pain, fever, jaundice) and CBD dilation indicate
choledocholithiasis.
, 13. A 70-year-old woman presents with sudden-onset left-sided weakness and slurred
speech. CT: ischemic stroke in right MCA territory. Best initial management?
A. Observation
B. Aspirin only
C. Heparin infusion
D. ☑ IV thrombolysis if within 4.5 hours
Rationale: Acute ischemic stroke within the therapeutic window is treated with IV tPA.
14. A 45-year-old man presents with chronic cough, night sweats, and weight loss. Chest X-
ray: cavitary lesion in upper lobe. Most likely pathogen?
A. Streptococcus pneumoniae
B. Mycoplasma pneumoniae
C. ☑ Mycobacterium tuberculosis
D. Legionella
Rationale: Upper lobe cavitary lesion with chronic symptoms is classic for pulmonary TB.
15. A 6-year-old boy presents with fever, sore throat, and a sandpaper-like rash on the trunk.
Diagnosis?
A. Measles
B. Rubella
C. ☑ Scarlet fever
D. Varicella
Rationale: Fever, pharyngitis, and sandpaper rash suggest Scarlet fever (Group A strep).
16. A 50-year-old woman presents with a painless breast lump. Mammogram shows a
spiculated mass. Most likely diagnosis?
A. Fibroadenoma
B. Cyst
C. ☑ Breast carcinoma
D. Mastitis
Rationale: Spiculated mass in a woman >40 years is highly suggestive of breast cancer.
17. A 22-year-old college student presents with sudden severe headache, neck stiffness, and
photophobia. CSF shows gram-negative diplococci. Most likely organism?
A. Streptococcus pneumoniae
B. Haemophilus influenzae
(COMSAE) 2025”2026 REAL EXAM 150 QUESTIONS AND DETAILED
ANSWERS WITH RATIONALES COVERING THE RECENT TESTED
QUESTIONS GUARANTEE A+ GRADE
1. A 45-year-old man presents with crushing chest pain radiating to his left arm and jaw. ECG
shows ST-segment elevation in leads II, III, and aVF. Which artery is most likely occluded?
A. Left anterior descending artery
B. Circumflex artery
C. ☑ Right coronary artery
D. Left main coronary artery
Rationale: Inferior MI (leads II, III, aVF) is usually caused by right coronary artery occlusion.
2. A 32-year-old woman presents with fatigue, pallor, and spoon-shaped nails. Lab results: Hb
9 g/dL, MCV 70 fL, ferritin 10 ng/mL. What is the most likely diagnosis?
A. Vitamin B12 deficiency
B. Thalassemia
C. ☑ Iron-deficiency anemia
D. Aplastic anemia
Rationale: Microcytic anemia with low ferritin indicates iron-deficiency anemia, often due to
chronic blood loss or poor dietary intake.
3. A 60-year-old man has progressive shortness of breath on exertion. Exam: bibasilar
crackles, elevated JVP, pedal edema. BNP is elevated. What is the most appropriate next
step?
A. Chest X-ray
B. ECG
C. ☑ Initiate diuretics and optimize heart failure therapy
D. Echocardiogram in 6 months
Rationale: Elevated BNP with clinical signs of fluid overload indicates heart failure;
management includes diuretics and guideline-directed therapy.
4. A 24-year-old man presents with acute right knee pain after twisting it while playing
soccer. Exam: positive anterior drawer test. Most likely injury?
A. MCL tear
B. LCL tear
C. ☑ ACL tear
,D. Meniscus tear
Rationale: Positive anterior drawer test indicates ACL tear.
5. A 65-year-old man presents with sudden-onset tearing chest pain radiating to the back. BP:
180/100 in right arm, 150/90 in left arm. Most likely diagnosis?
A. Myocardial infarction
B. Pulmonary embolism
C. ☑ Aortic dissection
D. Pericarditis
Rationale: BP difference between arms with tearing chest pain is classic for aortic dissection.
6. A 28-year-old woman presents with palpitations, heat intolerance, weight loss, and
exophthalmos. Labs: suppressed TSH, elevated T4. Diagnosis?
A. Hashimoto thyroiditis
B. Subacute thyroiditis
C. ☑ Graves disease
D. Toxic multinodular goiter
Rationale: Hyperthyroidism with diffuse goiter and exophthalmos is consistent with Graves
disease.
7. A 50-year-old man presents with progressive difficulty urinating, weak stream, and
nocturia. DRE: smooth, enlarged prostate. Most likely diagnosis?
A. Prostate cancer
B. Urethral stricture
C. ☑ Benign prostatic hyperplasia
D. Bladder cancer
Rationale: Lower urinary tract symptoms with smooth, enlarged prostate indicate BPH.
8. A 55-year-old man with diabetes presents with fever, productive cough, and lobar
consolidation on chest X-ray. Most likely pathogen?
A. Mycoplasma pneumoniae
B. ☑ Streptococcus pneumoniae
C. Legionella pneumophila
D. Influenza virus
Rationale: Sudden onset fever, productive cough, lobar consolidation suggests S.
pneumoniae.
,9. A 35-year-old man presents with fever, malaise, and a painless ulcer on his penis. Darkfield
microscopy shows spirochetes. Diagnosis?
A. Herpes simplex virus
B. Chancroid
C. ☑ Primary syphilis
D. Gonorrhea
Rationale: Painless chancre with spirochetes indicates primary syphilis.
10. A 40-year-old woman presents with weight gain, cold intolerance, fatigue, and dry skin.
Labs: elevated TSH, low T4. Most likely diagnosis?
A. Graves disease
B. Subacute thyroiditis
C. ☑ Primary hypothyroidism
D. Secondary hypothyroidism
Rationale: High TSH and low T4 indicate primary hypothyroidism, most commonly from
Hashimoto thyroiditis.
11. A 25-year-old woman presents with fever, dysuria, and urgency. Urinalysis shows WBCs
and positive nitrites. Most appropriate initial treatment?
A. IV vancomycin
B. ☑ Oral antibiotics like nitrofurantoin or TMP-SMX
C. IV ceftriaxone only
D. Observation
Rationale: Uncomplicated UTI in a young woman can be treated with oral antibiotics.
12. A 60-year-old man presents with right upper quadrant pain, fever, and jaundice. Labs:
elevated ALP and bilirubin. Imaging shows common bile duct dilation. Most likely diagnosis?
A. Acute hepatitis
B. Cholecystitis
C. ☑ Choledocholithiasis
D. Pancreatitis
Rationale: Charcot triad (RUQ pain, fever, jaundice) and CBD dilation indicate
choledocholithiasis.
, 13. A 70-year-old woman presents with sudden-onset left-sided weakness and slurred
speech. CT: ischemic stroke in right MCA territory. Best initial management?
A. Observation
B. Aspirin only
C. Heparin infusion
D. ☑ IV thrombolysis if within 4.5 hours
Rationale: Acute ischemic stroke within the therapeutic window is treated with IV tPA.
14. A 45-year-old man presents with chronic cough, night sweats, and weight loss. Chest X-
ray: cavitary lesion in upper lobe. Most likely pathogen?
A. Streptococcus pneumoniae
B. Mycoplasma pneumoniae
C. ☑ Mycobacterium tuberculosis
D. Legionella
Rationale: Upper lobe cavitary lesion with chronic symptoms is classic for pulmonary TB.
15. A 6-year-old boy presents with fever, sore throat, and a sandpaper-like rash on the trunk.
Diagnosis?
A. Measles
B. Rubella
C. ☑ Scarlet fever
D. Varicella
Rationale: Fever, pharyngitis, and sandpaper rash suggest Scarlet fever (Group A strep).
16. A 50-year-old woman presents with a painless breast lump. Mammogram shows a
spiculated mass. Most likely diagnosis?
A. Fibroadenoma
B. Cyst
C. ☑ Breast carcinoma
D. Mastitis
Rationale: Spiculated mass in a woman >40 years is highly suggestive of breast cancer.
17. A 22-year-old college student presents with sudden severe headache, neck stiffness, and
photophobia. CSF shows gram-negative diplococci. Most likely organism?
A. Streptococcus pneumoniae
B. Haemophilus influenzae
