COMPREHENSIVE OSTEOPATHIC MEDICAL SELF-ASSESSMENT EXAMINATION
(COMSAE) PHASE 2 FORM 107 COMPLETE PRACTICE EXAM QUESTIONS AND
ANSWERS | VERIFIED SOLUTIONS | UPDATED 2026/2027 STUDY GUIDE
Examiner/Administrator: National Board of Osteopathic Medical Examiners (NBOME)
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPREHENSIVE OSTEOPATHIC MEDICAL
SELF-ASSESSMENT EXAMINATION (COMSAE)
PHASE 2 FORM 107 PRACTICE EXAM
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-ALIGNED CLINICAL COMPETENCY ASSESSMENT || ALIGNED WITH CURRENT
COMLEX-USA LEVEL 2 BLUEPRINTS || INTERNAL MEDICINE || FAMILY MEDICINE ||
PEDIATRICS || OBSTETRICS & GYNECOLOGY || SURGERY || OSTEOPATHIC PRINCIPLES &
PRACTICE || PROFESSIONAL STUDY GUIDE || 100% VERIFIED EDUCATIONAL CONTENT
|| COMPREHENSIVE EXAM PREPARATION || PREPARED FOR CLINICAL LICENSING &
BOARD REVIEW || PROFESSIONAL EXAMINATION USE ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
PROFESSIONAL ACADEMIC EDITION
ADVANCED CLINICAL REVIEW SERIES
PRINT-READY CERTIFICATION FORMAT
,━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Clinical Decision-Making
Q1. A 67-year-old man presents to the emergency department with progressive
dyspnea, orthopnea, and bilateral lower-extremity edema for 2 weeks. His medical
history includes hypertension, type 2 diabetes mellitus, and prior myocardial infarction.
Physical examination reveals elevated jugular venous pressure, bibasilar crackles, and
an S3 gallop. Echocardiography demonstrates an ejection fraction of 30%. Which
medication has been shown to provide the greatest mortality benefit when initiated as
part of guideline-directed therapy in this patient?
A. Furosemide
B. Digoxin
C. Lisinopril
D. Hydrochlorothiazide
Correct Answer: 🔴 C. Lisinopril
Explanation: 🔹 ACE inhibitors such as lisinopril significantly reduce mortality and
hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF).
They decrease afterload, inhibit maladaptive cardiac remodeling, and improve
survival outcomes. Furosemide provides symptomatic relief but does not confer a
mortality benefit. Digoxin may improve symptoms and reduce hospitalization
frequency but does not reduce mortality. Hydrochlorothiazide is not considered
foundational therapy for HFrEF.
Q2. A 24-year-old woman presents with fatigue, arthralgias, oral ulcers, and a
photosensitive rash over her cheeks. Laboratory studies reveal proteinuria and positive
anti-double-stranded DNA antibodies. Which mechanism most directly contributes to
the renal pathology associated with this condition?
A. T-cell mediated destruction of glomeruli
B. Immune complex deposition in the glomerular basement membrane
C. Direct bacterial invasion of renal tissue
D. Amyloid protein accumulation in renal tubules
,Correct Answer: 🔴 B. Immune complex deposition in the glomerular basement
membrane
Explanation: 🔹 Systemic lupus erythematosus causes lupus nephritis through type III
hypersensitivity reactions involving immune complex deposition in glomerular
structures. These complexes activate complement and provoke inflammatory injury.
T-cell destruction is less central to the pathogenesis. Bacterial invasion is unrelated
to lupus nephritis, and amyloid accumulation characterizes amyloidosis rather than
SLE.
Q3. A 58-year-old smoker presents with hematuria and weight loss. CT imaging
demonstrates a renal mass. Laboratory studies reveal elevated hematocrit and
hypercalcemia. Which diagnosis is most likely?
A. Transitional cell carcinoma
B. Renal cell carcinoma
C. Wilms tumor
D. Oncocytoma
Correct Answer: 🔴 B. Renal cell carcinoma
Explanation: 🔹 Renal cell carcinoma classically presents with hematuria, flank pain,
and a renal mass, though the triad is uncommon. Paraneoplastic findings such as
erythrocytosis due to ectopic erythropoietin production and hypercalcemia are
strongly associated with RCC. Transitional cell carcinoma primarily arises from the
renal pelvis and is less associated with these endocrine manifestations. Wilms tumor
is pediatric, and oncocytoma is generally benign.
Q4. A 72-year-old woman with atrial fibrillation suddenly develops severe abdominal
pain that is disproportionate to physical examination findings. Laboratory studies
reveal metabolic acidosis and elevated lactate. Which diagnosis should be considered
most urgently?
A. Acute pancreatitis
B. Mesenteric ischemia
, C. Diverticulitis
D. Small bowel obstruction
Correct Answer: 🔴 B. Mesenteric ischemia
Explanation: 🔹 Acute mesenteric ischemia commonly presents with severe
abdominal pain out of proportion to examination findings, especially in patients with
embolic risk factors such as atrial fibrillation. Elevated lactate reflects tissue
hypoperfusion and ischemia. Pancreatitis usually presents with epigastric pain
radiating to the back and elevated lipase. Diverticulitis causes localized tenderness,
and bowel obstruction often includes distension and vomiting.
Q5. A 45-year-old man presents with episodic headaches, diaphoresis, and
palpitations. Blood pressure is 210/120 mm Hg during attacks. Plasma metanephrines
are markedly elevated. Which tumor is the most likely cause?
A. Adrenal adenoma
B. Pheochromocytoma
C. Aldosteronoma
D. Pituitary adenoma
Correct Answer: 🔴 B. Pheochromocytoma
Explanation: 🔹 Pheochromocytoma is a catecholamine-secreting tumor of
chromaffin cells that causes episodic hypertension, headaches, sweating, and
palpitations. Elevated plasma metanephrines strongly support the diagnosis.
Aldosteronoma primarily causes resistant hypertension with hypokalemia. Adrenal
adenomas are often incidental and hormonally silent. Pituitary adenomas do not
produce this catecholamine syndrome.
Q6. A hospitalized patient receiving unfractionated heparin develops
thrombocytopenia and new-onset leg swelling 7 days after therapy initiation. Which is
the best next step?
A. Continue heparin and monitor platelets
B. Administer platelet transfusion
(COMSAE) PHASE 2 FORM 107 COMPLETE PRACTICE EXAM QUESTIONS AND
ANSWERS | VERIFIED SOLUTIONS | UPDATED 2026/2027 STUDY GUIDE
Examiner/Administrator: National Board of Osteopathic Medical Examiners (NBOME)
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPREHENSIVE OSTEOPATHIC MEDICAL
SELF-ASSESSMENT EXAMINATION (COMSAE)
PHASE 2 FORM 107 PRACTICE EXAM
2026/2027 EDITION
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
COMPLETE PRACTICE EXAM
100 MULTIPLE-CHOICE QUESTIONS
EXACT OFFICIAL COUNT: 100 QUESTIONS
PASSING SCORE: 70%
TESTING TIME: 120 MINUTES
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
NBOME-ALIGNED CLINICAL COMPETENCY ASSESSMENT || ALIGNED WITH CURRENT
COMLEX-USA LEVEL 2 BLUEPRINTS || INTERNAL MEDICINE || FAMILY MEDICINE ||
PEDIATRICS || OBSTETRICS & GYNECOLOGY || SURGERY || OSTEOPATHIC PRINCIPLES &
PRACTICE || PROFESSIONAL STUDY GUIDE || 100% VERIFIED EDUCATIONAL CONTENT
|| COMPREHENSIVE EXAM PREPARATION || PREPARED FOR CLINICAL LICENSING &
BOARD REVIEW || PROFESSIONAL EXAMINATION USE ONLY
━━━━━━━━━━━━━━━━━━━━━━━━━━━━
PROFESSIONAL ACADEMIC EDITION
ADVANCED CLINICAL REVIEW SERIES
PRINT-READY CERTIFICATION FORMAT
,━━━━━━━━━━━━━━━━━━━━━━━━━━━━
Internal Medicine & Clinical Decision-Making
Q1. A 67-year-old man presents to the emergency department with progressive
dyspnea, orthopnea, and bilateral lower-extremity edema for 2 weeks. His medical
history includes hypertension, type 2 diabetes mellitus, and prior myocardial infarction.
Physical examination reveals elevated jugular venous pressure, bibasilar crackles, and
an S3 gallop. Echocardiography demonstrates an ejection fraction of 30%. Which
medication has been shown to provide the greatest mortality benefit when initiated as
part of guideline-directed therapy in this patient?
A. Furosemide
B. Digoxin
C. Lisinopril
D. Hydrochlorothiazide
Correct Answer: 🔴 C. Lisinopril
Explanation: 🔹 ACE inhibitors such as lisinopril significantly reduce mortality and
hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF).
They decrease afterload, inhibit maladaptive cardiac remodeling, and improve
survival outcomes. Furosemide provides symptomatic relief but does not confer a
mortality benefit. Digoxin may improve symptoms and reduce hospitalization
frequency but does not reduce mortality. Hydrochlorothiazide is not considered
foundational therapy for HFrEF.
Q2. A 24-year-old woman presents with fatigue, arthralgias, oral ulcers, and a
photosensitive rash over her cheeks. Laboratory studies reveal proteinuria and positive
anti-double-stranded DNA antibodies. Which mechanism most directly contributes to
the renal pathology associated with this condition?
A. T-cell mediated destruction of glomeruli
B. Immune complex deposition in the glomerular basement membrane
C. Direct bacterial invasion of renal tissue
D. Amyloid protein accumulation in renal tubules
,Correct Answer: 🔴 B. Immune complex deposition in the glomerular basement
membrane
Explanation: 🔹 Systemic lupus erythematosus causes lupus nephritis through type III
hypersensitivity reactions involving immune complex deposition in glomerular
structures. These complexes activate complement and provoke inflammatory injury.
T-cell destruction is less central to the pathogenesis. Bacterial invasion is unrelated
to lupus nephritis, and amyloid accumulation characterizes amyloidosis rather than
SLE.
Q3. A 58-year-old smoker presents with hematuria and weight loss. CT imaging
demonstrates a renal mass. Laboratory studies reveal elevated hematocrit and
hypercalcemia. Which diagnosis is most likely?
A. Transitional cell carcinoma
B. Renal cell carcinoma
C. Wilms tumor
D. Oncocytoma
Correct Answer: 🔴 B. Renal cell carcinoma
Explanation: 🔹 Renal cell carcinoma classically presents with hematuria, flank pain,
and a renal mass, though the triad is uncommon. Paraneoplastic findings such as
erythrocytosis due to ectopic erythropoietin production and hypercalcemia are
strongly associated with RCC. Transitional cell carcinoma primarily arises from the
renal pelvis and is less associated with these endocrine manifestations. Wilms tumor
is pediatric, and oncocytoma is generally benign.
Q4. A 72-year-old woman with atrial fibrillation suddenly develops severe abdominal
pain that is disproportionate to physical examination findings. Laboratory studies
reveal metabolic acidosis and elevated lactate. Which diagnosis should be considered
most urgently?
A. Acute pancreatitis
B. Mesenteric ischemia
, C. Diverticulitis
D. Small bowel obstruction
Correct Answer: 🔴 B. Mesenteric ischemia
Explanation: 🔹 Acute mesenteric ischemia commonly presents with severe
abdominal pain out of proportion to examination findings, especially in patients with
embolic risk factors such as atrial fibrillation. Elevated lactate reflects tissue
hypoperfusion and ischemia. Pancreatitis usually presents with epigastric pain
radiating to the back and elevated lipase. Diverticulitis causes localized tenderness,
and bowel obstruction often includes distension and vomiting.
Q5. A 45-year-old man presents with episodic headaches, diaphoresis, and
palpitations. Blood pressure is 210/120 mm Hg during attacks. Plasma metanephrines
are markedly elevated. Which tumor is the most likely cause?
A. Adrenal adenoma
B. Pheochromocytoma
C. Aldosteronoma
D. Pituitary adenoma
Correct Answer: 🔴 B. Pheochromocytoma
Explanation: 🔹 Pheochromocytoma is a catecholamine-secreting tumor of
chromaffin cells that causes episodic hypertension, headaches, sweating, and
palpitations. Elevated plasma metanephrines strongly support the diagnosis.
Aldosteronoma primarily causes resistant hypertension with hypokalemia. Adrenal
adenomas are often incidental and hormonally silent. Pituitary adenomas do not
produce this catecholamine syndrome.
Q6. A hospitalized patient receiving unfractionated heparin develops
thrombocytopenia and new-onset leg swelling 7 days after therapy initiation. Which is
the best next step?
A. Continue heparin and monitor platelets
B. Administer platelet transfusion
